Health professionals' education related to people with intellectual and developmental disabilities: A scoping review

BACKGROUND

People with intellectual and developmental disabilities are among the most underserved in an inequitable healthcare system.

METHODS

Using Arksey and O'Malley's methodology and a social determinants of health framework, we conducted a scoping review of literature on the state of practice in education of healthcare professionals in the health and healthcare needs of this population.

RESULTS

Searches found 4948 articles, with 182 included in the final review. Themes identified included gaps of not being informed by workforce needs, continued use of the medical model of care, not addressing intersectionality with racial/ethnic and other discriminations, and lack of involvement of the population in developing/evaluating programs and promising trends of development of competency-based interprofessional programs with experiential learning.

CONCLUSION

We provide recommendations for best practices in a concerted effort to educate a healthcare workforce equipped with the knowledge and skills to address the health needs of this population.

Presentation of Depressive Symptoms in Autism Spectrum Disorders

BACKGROUND

Depressive disorders are frequently mis- and underdiagnosed in individuals with autism spectrum disorders (ASD).

OBJECTIVE

Our objective was to identify and synthesize current knowledge regarding (1) the presentation of depressive symptoms and (2) the use of self-reports in assessing depressive symptoms in individuals with ASD and comparisons between self-reported and observer-reported symptoms. A scoping review was conducted to capture the full range of literature on the topic and to identify research gaps.

METHODS

Articles were identified through a search of academic literature and screened for relevance to the aims of the review.

RESULTS

In addition to typical depression symptoms, individuals with ASD may demonstrate atypical symptoms such as changes in autistic symptoms, self-injurious behavior, and psychomotor changes. Moreover, the review revealed a bias toward observer-reports of symptoms. Self-reports frequently were not included or were ascribed less weight than observer-reports. Self-reports typically differed from reports given by parents or other caregivers, but a consistent pattern in these differences has not been established.

CONCLUSIONS

Further research on the use of self-reports in assessing depressive symptoms in individuals with ASD is needed. Self-reports may provide information not obtainable through observer-reports, and integrating both self- and observer-reports in psychiatric evaluations may produce more comprehensive and accurate assessments.

Fractional order PID for tracking control of a parallel robotic manipulator type delta

This paper presents the tracking control for a robotic manipulator type delta employing fractional order PID controllers with computed torque control strategy. It is contrasted with an integer order PID controller with computed torque control strategy. The mechanical structure, kinematics and dynamic models of the delta robot are descripted. A SOLIDWORKS/MSC-ADAMS/MATLAB cosimulation model of the delta robot is built and employed for the stages of identification, design, and validation of control strategies. Identification of the dynamic model of the robot is performed using the least squares algorithm. A linearized model of the robotic system is obtained employing the computed torque control strategy resulting in a decoupled double integrating system. From the linearized model of the delta robot, fractional order PID and integer order PID controllers are designed, analyzing the dynamical behavior for many evaluation trajectories. Controllers robustness is evaluated against external disturbances employing performance indexes for the joint and spatial error, applied torque in the joints and trajectory tracking. Results show that fractional order PID with the computed torque control strategy has a robust performance and active disturbance rejection when it is applied to parallel robotic manipulators on tracking tasks.

Fissure Seal or Fluoride Varnish? A Randomized Trial of Relative Effectiveness

Fissure sealant (FS) and fluoride varnish (FV) are effective in preventing dental caries when compared with a no-treatment control. However, the relative clinical effectiveness of these interventions is uncertain. The objective of the study was to compare the clinical effectiveness of FS and FV in preventing dental caries in first permanent molars (FPMs) in 6- to 7-y-olds. The study design was a randomized clinical trial, with 2 parallel arms. The setting was a targeted-population program that used mobile dental clinics in schools located within areas of high social and economic deprivation in South Wales. A total of 1,016 children were randomized 1:1 to receive either FS or FV. Resin-based FS was applied to caries-free FPMs and maintained at 6-mo intervals. FV was applied at baseline and at 6-mo intervals for 3 y. The main outcome measures were the proportion of children developing caries into dentine (D_4-6MFT) on any 1 of up to 4 treated FPMs after 36 mo. At 36 mo, 835 (82%) children remained: 417 in the FS arm and 418 in the FV arm. A smaller proportion of children who received FV ( n = 73, 17.5%) versus FS ( n = 82, 19.6%) developed caries into dentine on at least 1 FPM (odds ratio [OR] = 0.84; 95% CI, 0.59 to 1.21; P = 0.35), a nonstatistically significant difference between FS and FV treatments. The results were similar when the number of newly decayed teeth (OR = 0.86; 95% CI, 0.60 to 1.22) and tooth surfaces (OR = 0.85; 95% CI, 0.59 to 1.21) were examined. In a community oral health program, semiannual application of FV resulted in caries prevention that was not significantly different from that obtained by applying and maintaining FS after 36 mo (EudraCT: 2010-023476-23; ISRCTN: ISRCTN17029222).

WITHDRAWN: Dieting to reduce body weight for controlling hypertension in adults

BACKGROUND

As early as the 1920's, researchers noted a relationship between caloric restriction, weight loss and a decreased incidence of hypertension (Terry 1922, Preble 1923, Bauman 1928, Master 1929). In 1988 a meta-analysis of aggregate data from 12 prospective studies, including 5 randomized controlled trials (RCTs), found that on average each 1 kilogram decrease in body weight in obese hypertensive patients was associated with a 2.4 mm Hg systolic and 1.5 mm Hg diastolic decrease in blood pressure (Staessen 1988). Blood pressure reductions were not dependent upon degree of baseline obesity.This review aims to: 1) update the work of Staessen (Staessen 1988) looking specifically at randomized controlled trials, and 2) assess whether any of the trials assess effects of weight-reducing diets on clinical outcomes such as quality of life, morbidity or mortality.

OBJECTIVES

Evaluate whether weight-loss diets are more effective than regular diets or other antihypertensive therapies in controlling blood pressure and preventing morbidity and mortality in hypertensive adults.

SEARCH STRATEGY

MEDLINE and The Cochrane Library were searched through November 1997. Trials known to experts in the field were included through June 1998.

SELECTION CRITERIA

For inclusion in the review, trials were required to meet each of the following criteria: 1) randomized controlled trials with one group assigned to a weight-loss diet and the other group assigned to either normal diet or antihypertensive therapy; 2) ambulatory adults with a mean blood pressure of at least 140 mm Hg systolic and/or 90 mm Hg diastolic; 3) active intervention consisting of a calorie-restricted diet intended to produce weight loss (excluded studies simultaneously implementing multiple lifestyle interventions where the effects of weight loss could not be disaggregated); and 4) outcome measures included weight loss and blood pressure.

DATA COLLECTION AND ANALYSIS

Studies were dual abstracted by two independent reviewers using a standardized form designed specifically for this review. The primary mode of analysis was qualitative; graphs of effect sizes for individual studies were also used.

MAIN RESULTS

Eighteen trials were found. Only one small study of inadequate power reported morbidity and mortality outcomes. None addressed quality of life or general well being issues. In general, participants assigned to weight-reduction groups lost weight compared to control groups.Six trials involving 361 participants assessed a weight-reducing diet versus a normal diet. The data suggested weight loss in the range of 4% to 8% of body weight was associated with a decrease in blood pressure in the range of 3 mm Hg systolic and diastolic. Three trials involving 363 participants assessed a weight-reducing diet versus treatment with antihypertensive medications. These suggested that a stepped-care approach with antihypertensive medications produced greater decreases in blood pressure (in the range of 6/5 mm Hg systolic/diastolic) than did a weight-loss diet. Trials that allowed adjustment of participants' antihypertensive regimens suggested that patients required less intensive antihypertensive drug therapy if they followed a weight-reducing diet. Data was insufficient to determine the relative efficacy of weight-reduction versus changes in sodium or potassium intake or exercise.

AUTHORS' CONCLUSIONS

Weight-reducing diets in overweight hypertensive persons can affect modest weight loss in the range of 3-9% of body weight and are probably associated with modest blood pressure decreases of roughly 3 mm Hg systolic and diastolic. Weight-reducing diets may decrease dosage requirements of persons taking antihypertensive medications.

Cecal diverticulitis: a case report and review of the current literature

We report a case of a female patient with a picture of "atypical appendicitis," with 3 days of abdominal pain, localized to the right lower quadrant with no nausea, vomiting, diarrhea, or anorexia. On examination she was febrile to 38.4 degrees C, had tenderness at McBurney's point, and a leukocyte count of 11,200. A computerized axial tomography (CAT) scan was obtained showing changes consistent with appendicitis. On laparoscopic exploration the patient was found to have cecal masses. Definitive surgical treatment was deferred until after adequate evaluation of the colon. Postoperative colonoscopy demonstrated cecal diverticulitis. Management of cecal diverticulitis found during laparotomy for presumed appendicitis has included right hemicolectomy, ileocolic resection or appendectomy, and conservative treatment with antibiotics. The laparoscopic approach in a patient with an equivocal history and physical examination allows for definitive workup of inflammatory cecal masses found during surgery for appendicitis.

Dieting to reduce body weight for controlling hypertension in adults

OBJECTIVES

Evaluate whether weight-loss diets are more effective than regular diets or other antihypertensive therapies in controlling blood pressure and preventing morbidity and mortality in hypertensive adults.

SEARCH STRATEGY

MEDLINE and The Cochrane Library were searched through November 1997. Trials known to experts in the field were included through June 1998.

SELECTION CRITERIA

For inclusion in the review, trials were required to meet each of the following criteria: 1) randomized controlled trials with one group assigned to a weight-loss diet and the other group assigned to either normal diet or antihypertensive therapy; 2) ambulatory adults with a mean blood pressure of at least 140 mm Hg systolic and/or 90 mm Hg diastolic; 3) active intervention consisting of a calorie-restricted diet intended to produce weight loss (excluded studies simultaneously implementing multiple lifestyle interventions where the effects of weight loss could not be disaggregated); and 4) outcome measures included weight loss and blood pressure.

DATA COLLECTION AND ANALYSIS

Studies were dual abstracted by two independent reviewers using a standardized form designed specifically for this review. The primary mode of analysis was qualitative; graphs of effect sizes for individual studies were also used.

MAIN RESULTS

Eighteen trials were found. Only one small study of inadequate power reported morbidity and mortality outcomes. None addressed quality of life or general well being issues. In general, participants assigned to weight-reduction groups lost weight compared to control groups. Six trials involving 361 participants assessed a weight-reducing diet versus a normal diet. The data suggested weight loss in the range of 4% to 8% of body weight was associated with a decrease in blood pressure in the range of 3 mm Hg systolic and diastolic. Three trials involving 363 participants assessed a weight-reducing diet versus treatment with antihypertensive medications. These suggested that a stepped-care approach with antihypertensive medications produced greater decreases in blood pressure (in the range of 6/5 mm Hg systolic/diastolic) than did a weight-loss diet. Trials that allowed adjustment of participants' antihypertensive regimens suggested that patients required less intensive antihypertensive drug therapy if they followed a weight-reducing diet. Data was insufficient to determine the relative efficacy of weight-reduction versus changes in sodium or potassium intake or exercise.

REVIEWER'S CONCLUSIONS

Weight-reducing diets in overweight hypertensive persons can affect modest weight loss in the range of 3-9% of body weight and are probably associated with modest blood pressure decreases of roughly 3 mm Hg systolic and diastolic. Weight-reducing diets may decrease dosage requirements of persons taking antihypertensive medications.

Speckle photography with different pupils in a multiple-exposure scheme

The use of different multiple-aperture pupils for recording each image in speckle photography is proposed. The introduction of suitable spatial frequency carriers, by internally modulating imaged speckles, allows one to selectively isolate or combine the spectral content of different images into spatially separated regions in the Fourier plane. Theoretical and experimental results extend the speckle photography technique to the depiction of several specklegrams of multiple uniform in-plane displacements. In this case, because different pupils are considered for recording, the cross-correlation functions for the amplitudes and intensities in the image plane are calculated on the basis of the statistical properties of the object. Also, the ensemble-average intensity in the Fourier plane is analytically derived, and fringe visibility is investigated.

Bronchiolitis Obliterans

Bronchiolitis obliterans (BO) is a fibrotic lung disease involving the small conducting airways. BO may be classified by etiology and underlying disease or, more commonly, by histopathological pattern. The two major histopathological categories are (1) BO organizing pneumonia (BOOP) and proliferative bronchiolitis and (2) constrictive bronchiolitis. The former is often idiopathic in nature and may also be associated with connective tissue diseases and inhalation injury. Characteristic findings on chest imaging include alveolar infiltrates and ground glass opacities and pulmonary function tests (PFTs) usually reveal restrictive dysfunction. Constrictive bronchiolitis is associated with organ transplantation, infections, connective tissue diseases, inhalation injury, and drugs and may also have an idiopathic origin. The radiographic characteristic is a mosaic pattern on high-resolution computed tomography (HRCT) and PFTs most often reveal obstructive dysfunction. This article will attempt to review constrictive BO, including histopathology, clinical presentation, radiographic appearance, and physiological findings, for both idiopathic diseases, as well as specific clinical-associated entities.

A low incidence of posttransplant lymphoproliferative disorder in 109 lung transplant recipients

STUDY OBJECTIVES

The incidence of posttransplant lymphoproliferative disorder (PTLD) has been reported to range from 6.4 to 20% in lung transplant (LT) recipients. Postulated contributing factors include Epstein-Barr virus (EBV) infection and the use of immunosuppression, particularly muromonab-CD3 (OKT3)(Orthoclone OKT-3; Ortho Biotech; Raritan, NJ). We sought to examine these PTLD risk factors in 109 LT recipients at our institution who survived > 1 month.

DESIGN

Retrospective review of EBV serology of all LT recipients at our institution. Our standard transplant protocol includes OKT3 for induction and refractory rejection, as well as lifelong acyclovir for herpes prophylaxis. We do not perform EBV donor-recipient matching.

SETTING

A university-based LT center.

RESULTS

We found that 5 of 109 patients were serologically negative for EBV prior to lung transplantation, and all of these patients converted following lung transplantation. The mean time to conversion was 151 days (range, 11 to 365 days). One fatal case of PTLD was documented in an EBV seroconverter (one of five patients) 12 weeks status posttransplantation for lymphangioleiomyomatosis. One nonfatal extrathoracic PTLD was documented in a seropositive patient (1 of 104 patients) 33 months posttransplantation.

CONCLUSIONS

We conclude the following: (1) PTLD in LT recipients may have a lower incidence (2 of 109 patients; 1.8%) than previously reported, despite an aggressive immunosuppressive regimen; and (2) the incidence of PTLD is higher in patients with primary EBV infection (20% vs 1%).

Opioid agonists and antagonists. 6-Desoxy-6-substituted lactone, epoxide, and glycidate ester derivatives of naltrexone and oxymorphone

Synthesis and opioid radioreceptor assay data on analogues closely related to 6-desoxy-6-spiro-alpha-methylene-gamma-lactone 5a, a compound with irreversible activity in this assay, are reported. Saturated lactones (7a,b), endocyclic alpha, beta-unsaturated gamma-lactones (8a,b and 9a), and 6 alpha,7 alpha-fused alpha-methylene-gamma-lactones (10a and 11a) were prepared. Related 6-desoxy-6-methylene 6 beta- and 6 alpha-oxides (12a,b and 13a) and glycidate esters 14a,b and 15a,b were also prepared with use of naltrexone (1a) and oxymorphone (1b) as starting material. Compounds in the N-cyclopropylmethyl (N-CPM) series were more potent than those in the N-Me series in displacing [3H]naltrexone in the opioid radioreceptor assay, usually by 2-16-fold in the absence of Na ion. The most potent N-CPM analogues were epoxides 12a and 13a and glycidate esters 14a and 15a, showing IC50's of 2-6 nM, similar to that of 5a. Of the N-Me analogues, 6 beta-oxide 12b was most active, with an IC50 of 8 nM in the absence of Na ion. For the N-CPM analogues, the Na ion ratios were generally less than 1, with two exceptions. The N-Me analogues showed expected larger Na ion effects of 7 or greater. None of the lactone analogues had irreversible effects when preincubated in the rat brain membrane preparation, even at 37 degrees C for 30 min, i.e., washing restored [3H]naltrexone binding to control levels. These results clearly show that the alpha-methylene-gamma-lactone moiety of 5a is required for irreversible effects, consistent with it serving as a conjugate addition acceptor of a nucleophilic group from a ligand at or near the receptor. The epoxides and glycidate esters also had no irreversible activity, indicating more electrophilic functional groups are needed and/or these electrophiles are not properly aligned to react with nucleophilic groups at or near the opioid receptor.

Diastereomeric 6-desoxy-6-spiro-alpha-methylene-gamma-butyrolactone derivatives of naltrexone and oxymorphone. Selective irreversible inhibition of naltrexone binding in an opioid receptor preparation by a conformationally restricted michael acceptor ligand

The diastereomeric 6-desoxy-6-spiro-alpha-methylene-gamma-butyrolactone derivatives of naltrexone (4a and 5a) and of oxymorphone (4b and 5b) were prepared from their parent ketones. Diastereomers 4a and 4b were obtained from the 3,14-diacetate derivatives of naltrexone (6a) and oxymorphone (6b) by reaction with the Reformatsky reagent prepared from methyl alpha-(bromomethyl)acrylate. Deacetylation with methanol completed the synthesis. Diastereomers 5a and 5b were obtained from oxiranes 8a and 8b, respectively. The oxiranes were allowed to react with the sodium salt of ethyl acetoacetate, followed by methenation and deprotection to complete the synthesis of 5a and 5b, respectively. Compound 5a was the most potent agent tested in competition against [3H]naltrexone in the opioid radioreceptor assay. At a concentration of 5 nM this compound produced a 50% inhibition of binding. The majority of this inhibition (30%) was irreversible, i.e., it remained even after extensive washing of the membrane preparation in the presence and absence of Na+. Naloxone protected against this irreversible effect. The data suggest a receptor nucleophile, perhaps a sulfhydryl group, is located where it can add to the alpha, beta-unsaturated carbonyl system of 5a.

Evidence from opiate binding studies that heroin acts through its metabolites

The relative affinity to opiate receptors of heroin, 6-acetylmorphine and morphine was estimated by determining their ability to displace specifically bound 3H-naltrexone from rat brain opiate binding sites. In vitro hydrolysis of heroin to 6-acetylmorphine was monitored in the binding assay filtrate by use of a quantitative HPLC procedure. The rate of heroin hydrolysis was significantly slower at 0 degrees C than at 37 degrees C. The displacement of 1 nM 3H-naltrexone by unlabeled ligand at concentrations ranging from 7 to 500 nM was measured at 0 degrees C for 120 minutes, yielding IC50 values of heroin = 483 nM, 6-acetylmorphine = 73 nM and morphine = 53 nM. When the binding data for heroin were recalculated to include the displacement that could be attributed to the 6-acetylmorphine derived from heroin degradation during the incubation, all of the apparent heroin binding was accounted for by the 6-acetylmorphine. These results are consistent with previous reports of the low binding affinity of morphine congeners (e.g., codeine) that lack a free phenolic 3-hydroxyl group and support the view that heroin is a prodrug which serves to determine the distribution of its intrinsically active metabolites, 6-acetylmorphine and morphine.