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.

Oral health of adults with intellectual disabilities: a systematic review

BACKGROUND

There have been several past reports that adults with intellectual disabilities experience poor oral health (tooth loss, periodontal health and untreated dental caries). Loss of a functional dentition has serious consequences, including problems with chewing, swallowing, nutrition, speech, temporomandibular joint osteoarthritis and pain and systemic health conditions. Poor oral health is largely preventable through proactive oral care support. In recent years, social care provision for adults has changed, with deinstitutionalisation and home-based personalised care now being the typical provision in high income countries. Hence, oral health inequalities might be reducing. However, there is limited recent evidence-synthesis on the topic. We aimed to address this.

METHOD

PROSPERO registration number: CRD42018089880. We conducted a preferred reporting items for systematic reviews and meta-analyses systematic review of publications since 2008. Four databases were searched with a clear search strategy, strict inclusion criteria for selection of papers, double scoring (two raters), systematic data extraction and quality appraisal of included papers.

RESULTS

A total of 33/3958 retrieved articles were included, of which 14 were drawn from dental service users and 10 from Special Olympic athletes, therefore not necessarily being representative of the wider population with intellectual disabilities. Despite this limitation, adults with intellectual disabilities were still shown to experience poor oral health. High levels of poor oral hygiene and gingivitis were found, with many also affected by periodontitis and untreated dental decay. There is clear unmet need relating to both periodontal (gum) and tooth health, leading to tooth loss.

CONCLUSIONS

Despite reports in the past of poor oral health amongst adults with intellectual disabilities, and despite it being preventable, there remains a high burden of poor oral health. This highlights the need to raise awareness, and for polices on effective daily oral care, and appropriate service provision. The importance of oral health and its possible negative sequelae needs to be elevated amongst carers and professionals.

Neurodevelopmental multimorbidity and educational outcomes of 766,244 Scottish schoolchildren

Background

Neurodevelopmental conditions commonly co-exist in children but, in comparison with adults, childhood multimorbidity has attracted less attention in research and clinical practice.

Methods

Record linkage of five Scotland-wide databases produced a cohort of 766,244 children attending Scottish schools between 2009 and 2013. Autistic spectrum disorder (ASD) and intellectual disabilities were ascertained from records of special educational need in the annual Pupil Census and attention deficit hyperactivity disorder (ADHD) and depression through relevant encashed prescriptions.

Results

Neurodevelopmental multimorbidity (≥2 conditions) was identified in 4,789 (0·6%) children; with ASD and ADHD the most common combination. Multimorbidity was associated with significantly increased risk of school absenteeism (adjusted IRR 1·23, 95% CI 1·20-1·28), school exclusion (adjusted IRR 3·04, 95% CI 2·74-3·38), low attainment (adjusted OR 12·07, 95% CI 9·15-15·94) and unemployment (adjusted OR 2·11, 95% CI 1·83-2·45) with clear dose relationships evident between number of conditions (0, 1, ≥2) and the last three outcomes. The associations with multimorbidity were stronger in girls than boys. Co-existence of depression was the strongest driver of absenteeism and co-existence of ADHD the strongest driver of exclusion. Low attainment and unemployment were, in part, mediated by absence and attainment respectively, and were not driven by specific conditions but rather multimorbidity from any cause.

Conclusions

Structuring clinical practice and training around single conditions may disadvantage children with multimorbidity who are at significantly increased risk of adverse outcomes if their complex needs are not recognised and managed.

Key messages

Neurodevelopmental multimorbidity can have significant impacts on children’s education. A holistic healthcare approach is needed to reduce the address their needs and reduce the risk of adverse outcomes.

Embedding routine health checks for adults with intellectual disabilities in primary care: practice nurse perceptions

BACKGROUND

Adults with intellectual disabilities (IDs) have consistently poorer health outcomes than the general population. There is evidence that routine health checks in primary care may improve outcomes. We conducted a randomised controlled trial of practice nurse led health checks. Here, we report findings from the nested qualitative study.

AIM

To explore practice nurse perceptions and experience of delivering an anticipatory health check for adults with IDs.

DESIGN AND SETTING

Qualitative study in General Practices located in NHS Greater Glasgow and Clyde, Scotland, UK.

METHOD

Eleven practice nurses from 11 intervention practices participated in a semi-structured interview. Analysis was guided by a framework approach.

RESULTS

Practice nurses reported initially feeling 'swamped' and 'baffled' by the prospect of the intervention, but early misgivings were not realised. Health checks were incorporated into daily routines with relative ease, but this was largely contingent on existing patient engagement. The intervention was thought most successful with patients already well known to the practice. Chronic disease management models are commonly used by practice nurses and participants tailored health checks to existing practice. It emerged that few of the nurses utilised the breadth of the check instead modifying the check to respond to individual patients' needs. As such, already recognised 'problems' or issues dominated the health check process. Engaging with the health checks in this way appeared to increase the acceptability and feasibility of the check for nurses. There was universal support for the health check ethos, although some questioned whether all adults with IDs would access the health checks, and as a consequence, the long-term benefits of checks.

CONCLUSION

While the trial found the intervention to be dominant over standard health care, the adjustments nurses made may not have maximised potential benefits to patients. Increasing training could further improve the benefits that health checks provide for people with IDs.

Reducing Stability of Support Structure for a Target Does Not Alter Reach Kinematics among Younger Adults

Investigation into the reach-to-grasp movement has indicated that this movement sequence is composed of two distinct movement components, independently influenced by the characteristics of the target. It remains undetermined whether properties other than those conveyed by the target also influence the strategy used to complete the task successfully. Here, we explored whether characteristics of the support structure influence reaching kinematics among younger adults. The purpose of the study was to assess whether support structure stability affected movement kinematics of the transport phase. Subjects were required to reach for a full glass of water on a stable or an unstable support structure. Kinematic measures of interest included transport time, peak transport velocity, peak transport acceleration, and timing of kinematic peaks. Analysis showed that reducing the stability of the support structure did not significantly affect any of the measures of interest. The results imply that stability of support structure does not influence transport kinematics among younger adults.

Efficacy of disintegrating aspirin in two different models for acute mild-to-moderate pain: sore throat pain and dental pain

A recently developed fast-release aspirin tablet formulation has been evaluated in two different pain models. The dental impaction pain model and the sore throat pain model are widely used for assessing analgesia, including acute mild-to-moderate pain. Both studies were double-blind, randomized, parallel group and compared a single dose of 1000 mg aspirin with 1000 mg paracetamol and with placebo and investigated the onset and overall time course of pain relief. Speed of onset was measured by the double-stopwatch method for time to meaningful pain relief and time to first perceptible pain relief. Pain intensity and pain relief were rated subjectively over a 6-h (dental pain) and 2-h (sore throat pain) time period. In both models fast-release aspirin and commercial paracetamol were statistically significantly different from placebo for onset of action, summed pain intensity differences and total pain relief. Meaningful pain relief was achieved within a median of 42.3 and 42.9 min for aspirin and paracetamol, respectively, in the dental pain model. The corresponding numbers in sore throat pain were 48.0 and 40.4 min. All treatments in both studies were safe and well tolerated. No serious adverse events were reported and no subject was discontinued due to an adverse event. Overall the two studies clearly demonstrated efficacy over placebo in the two pain models and a comparable efficacy and safety profile between aspirin and an equivalent dose of paracetamol under the conditions of acute dental pain and acute sore throat pain.

Trial registration These trials were registered with ClinicalTrials.gov, registration number: NCT01420094, registration date: July 27, 2011 and registration number: NCT01453400, registration date: October 13, 2011.

Recruitment to intellectual disability research: a qualitative study

BACKGROUND

Difficulties in the recruitment of adults with intellectual disability (ID) to research studies are well described but little studied. The aim of this study was to investigate the difficulties in recruiting to a specific research project, in order to inform future recruitment to ID research.

METHODS

Individual semi-structured interviews were held between September 2009 and May 2010 with people who had been involved as intermediaries in recruitment to the research project. These were transcribed verbatim and were independently analysed by two researchers using the Framework approach, who then agreed upon the key emerging themes.

RESULTS

Ten interviews were analysed. A number of themes arose, including participant factors (interview anxiety, difficulties in understanding the concept of research, worry about negative feedback), the importance of the researcher (using a personal approach, meeting potential participants prior to recruitment) and motivators [enjoyment of the research interview (participant), obtaining a medical assessment (carer)]. The themes were then used to generate strategies to improve recruitment to ID research: these include the research team applying a more personal approach, developing the recruitment process to allow for multiple meetings with potential participants, and considering motivators for both participants and carers.

CONCLUSIONS

This study has used the experiences of intermediaries to identify strategies for improving recruitment to future ID research. This has implications in terms of both time and money. However, successful recruitment is essential to ID research, and we hope that the study will be used by ID researchers to review and improve their recruitment processes.

Evaluation of onset of pain relief from micronized aspirin in a dental pain model

A new formulation of a micronized acetylsalicylic acid swallowable tablet with an effervescent component (FR-aspirin) was evaluated in two independent studies using the dental impaction pain model. These clinical studies were performed to confirm the results of preclinical dissolution studies and human pharmacokinetic studies, which indicated an improved onset of analgesia without compromising duration of effect or safety. Study 1 evaluated a 650-mg dose of aspirin and Study 2 evaluated a 1,000-mg dose of aspirin. Both studies were double-blinded, parallel group and compared to regular aspirin (R-aspirin) and placebo. Speed of onset was measured by the double stopwatch method for time to both first perceptible relief and meaningful relief. In both studies, the FR-aspirin was significantly faster (p<0.038-0.001) than both R-aspirin and placebo for both onset measures. There were no significant differences between FR-aspirin and R-aspirin for peak or total effects and both treatments were significantly better than placebo. For first perceptible relief, FR-aspirin onset was 19.8 and 16.3 min for 650 mg and 1,000 mg, respectively, compared to 23.7 and 20.0 for R-aspirin. For meaningful relief, FR-aspirin onset was 48.9 and 49.4 min for 650 mg and 1,000 mg, respectively, compared to 119.2 and 99.2 for R-aspirin. These efficacy studies clearly demonstrate that the onset of analgesic efficacy is dramatically improved by adding an effervescent component and micronized active ingredient to the swallowable tablet aspirin formulation. The enhanced onset did not adversely impact either the peak effect or duration of effect or tolerability compared to regular aspirin.

Diagnosing variant Creutzfeldt-Jakob disease: a retrospective analysis of the first 150 cases in the UK

INTRODUCTION

Establishing an early clinical diagnosis in variant Creutzfeldt-Jakob disease (vCJD) can be difficult, resulting in extended periods of uncertainty for many families and sometimes a view that patients have been subjected to unnecessary investigations. This issue is accentuated by the progressive nature of vCJD and by the difficulty in achieving a confident clinical diagnosis before an advanced stage of illness. Although diagnostic delay may be a result of the non-specific early clinical features, a systematic analysis of the process of diagnosis was undertaken, with the aim of trying to achieve earlier diagnosis of vCJD.

METHODS

Retrospective case file analysis was undertaken of the first 150 definite and clinically probable cases of vCJD identified by the UK surveillance system.

RESULTS

There is a significant interval between illness onset and presentation to a primary care physician, which is influenced by the nature of the initial clinical features. Neurological review is invariably sought following the development of clinical signs and a diagnosis is then established relatively quickly. Despite the progressive clinical course, a confident clinical diagnosis is not usually achieved until a relatively advanced stage of illness (mean time to diagnosis 10.5 months) with a more rapid clinical progression accounting for those cases diagnosed earlier after symptom onset.

CONCLUSIONS

Early clinical diagnosis in vCJD is not possible in the great majority of cases because of non-specific initial symptoms. Once neurological signs develop, a diagnosis is usually made promptly but this is often at a relatively advanced stage of illness. The inherent delays in the diagnosis of vCJD have implications for those involved in both public health and therapeutics.

Oxidative stress contributes to pulmonary hypertension in the transgenic (mRen2)27 rat

The transgenic (mRen2)27 (Ren2) rat overexpresses mouse renin in extrarenal tissues, causing increased local synthesis of ANG II, oxidative stress, and hypertension. However, little is known about the role of oxidative stress induced by the tissue renin-angiotensin system (RAS) as a contributing factor in pulmonary hypertension (PH). Using male Ren2 rats, we test the hypothesis that lung tissue RAS overexpression and resultant oxidative stress contribute to PH and pulmonary vascular remodeling. Mean arterial pressure (MAP), right ventricular systolic pressure (RVSP), and wall thickness of small pulmonary arteries (PA), as well as intrapulmonary NADPH oxidase activity and subunit protein expression and reactive oxygen species (ROS), were compared in age-matched Ren2 and Sprague-Dawley (SD) rats pretreated with the SOD/catalase mimetic tempol for 21 days. In placebo-treated Ren2 rats, MAP and RVSP, as well as intrapulmonary NADPH oxidase activity and subunits (Nox2, p22phox, and Rac-1) and ROS, were elevated compared with placebo-treated SD rats (P < 0.05). Tempol decreased RVSP (P < 0.05), but not MAP, in Ren2 rats. Tempol also reduced intrapulmonary NADPH oxidase activity, Nox2, p22phox, and Rac-1 protein expression, and ROS in Ren2 rats (P < 0.05). Compared with SD rats, the cross-sectional surface area of small PA was 38% greater (P < 0.001) and luminal surface area was 54% less (P < 0.001) in Ren2 rats. Wall surface area was reduced and luminal area was increased in tempol-treated SD and Ren2 rats compared with untreated controls (P < 0.05). Collectively, the results of this investigation support a seminal role for enhanced tissue RAS/oxidative stress as factors in development of PH and pulmonary vascular remodeling.

Anxiety-mediated gait adaptations reduce errors of obstacle negotiation among younger and older adults: implications for fall risk

The purpose of this study was to determine if anxiety-mediated gait adaptations can reduce the risk for falling among younger and older adults. Fourteen younger adults (23.14+/-3.08 years) and 14 older adults (69.28+/-5.41 years) participated in this study. Participants were asked to walk the length of a 7.20m walkway and avoid contact with an obstacle that appeared suddenly underfoot at either 25% or 75% of the gait cycle duration. Testing was conducted in four conditions of postural threat. The obstacle was presented as a light beam and did not jeopardize balance when contacted. Fall risk was inferred from the frequency of obstacle contacts. Our findings indicated that obstacle contact frequency decreased when conservative gait patterns emerged. These findings imply that anxiety-mediated gait adaptations are beneficial in reducing the risk for falling among older adults and present the possibility that fear of falling may offer protective benefits for postural control. One possibility is that the beneficial effects of anxiety can only be realized among older adults who do not fear falling.

Sporadic Creutzfeldt-Jakob disease with cerebellar ataxia at onset in the UK

OBJECTIVE

To determine the frequency, in the UK, of sporadic Creutzfeldt-Jakob Disease (sCJD) with a cerebellar ataxic onset, and to describe the clinical features of the syndrome.

METHODS

A retrospective review of autopsy-proved cases of sCJD cases in the UK, 1990-2005, identifying those presenting with cerebellar features without early cognitive decline.

RESULTS

29 of 618 (5%) patients with sCJD had an isolated cerebellar onset. Mean illness duration was 9 months. Subsequently, 21 (72%) developed myoclonus and 23 (79%) developed pyramidal features. Magnetic resonance imaging showed high signal in the basal ganglia in 11 of 14 (79%) patients. 7 of 15 (47%) patients were valine homozygotic at prion protein gene (PRNP)-129. Only 8 (28%) cases were referred to the surveillance unit after death.

CONCLUSION

A better definition of sCJD presenting with an isolated cerebellar syndrome might improve future case recognition and contribute to the determination of its cause.

Isolated visual symptoms at onset in sporadic Creutzfeldt-Jakob disease: the clinical phenotype of the "Heidenhain variant"

BACKGROUND

The Heidenhain variant of sporadic Creutzfeldt-Jakob disease (sCJD) is commonly understood to represent cases with early, prominent visual complaints. The term is clarified to represent those who present with isolated visual symptoms. This group may pose diagnostic difficulties and often present to ophthalmologists where they may undergo needless invasive procedures.

METHOD

A retrospective review of 594 pathologically proved sCJD cases referred to the UK National CJD Surveillance Unit over a 15 year period to identify Heidenhain cases.

RESULTS

22 cases had isolated visual symptoms at onset with a mean illness duration of 4 months. The mean age at disease onset was 67 years. Most displayed myoclonus, pyramidal signs, and a delay in the onset of dementia for some weeks. 17 (77%) were referred initially to ophthalmology. Two underwent cataract extraction before diagnosis. All tested cases were homozygous for methionine at codon 129 of the prion protein gene.

CONCLUSIONS

This rare, but clinically distinct, group of patients with sCJD may cause diagnostic difficulties. Because ocular intervention carries with it the risk of onward transmission awareness of this condition among ophthalmologists is important.

Caring for the older person: an exploration of perceptions using personal construct theory

BACKGROUND

There is a reluctance among nurses to enter elderly care.

OBJECTIVE

To discover nurses' perceptions of the elderly patients in their care.

METHOD

After a period of participant observation, we selected 26 nurses from among those working in two elderly-care rehabilitation hospitals. Interpersonal perceptions were investigated using personal construct theory. We elicited personal constructs, produced repertory grids and rated patients according to popularity.

RESULTS AND CONCLUSIONS

The most common way of perceiving patients was in terms of mental or physical dependence. Health-care assistants were more likely than staff nurses to perceive patients in terms of their personality. Nurses tended to have simplified ways of perceiving their patients. Popular patients were always mentally intact.

Metal-containing lymph nodes following prosthetic replacement of osseous malignancy: potential role of MR imaging in characterisation

The identification of regional lymphadenopathy in patients with bone malignancy treated by excision and insertion of a prosthesis usually indicates metastatic disease. We present two cases in which the lymphadenopathy was due to an uncommon but well-recognized foreign body reaction. This is secondary to the lymphatic uptake of metal debris shed by the prosthesis. In one case the metal within the excised lymph node could be demonstrated on in vitro MR imaging and in retrospect on the original in vivo scans. This condition should be considered when undertaking an MR examination in patients with bone malignancy treated by prosthetic replacement in whom there is a clinical suspicion of metastatic spread to the regional lymph nodes.

Ibuprofen liquigel for oral surgery pain

BACKGROUND

Ibuprofen liquigel is a solubilized potassium ibuprofen 200-mg gelatin capsule formulation that was approved for over-the-counter use in 1995.

OBJECTIVE

This study compared the analgesic efficacy and tolerability of ibuprofen liquigel 200 mg, ibuprofen liquigel 400 mg, acetaminophen caplets 1000 mg, and placebo in patients experiencing moderate or severe pain after surgical removal of impacted third molars.

METHODS

This randomized, double-blind, parallel-group, 6-hour study was conducted in 210 patients experiencing moderate or severe postoperative pain. Ratings of pain intensity and pain relief were recorded every 15 minutes for the first hour, at 90 and 120 minutes, and then hourly through hour 6. The onsets of first perceptible relief and meaningful relief were recorded using 2 stopwatches. An analysis of variance model was employed to test for significant differences (P < or = 0.05) between treatment groups with respect to pain relief, pain intensity difference, total pain relief (TOTPAR), and summed pain intensity difference (SPID). Stopwatch measures were analyzed using the Cox proportional hazards model. Drug tolerability was assessed by monitoring the occurrence of adverse events.

RESULTS

During the first 2 hours of the study (TOTPAR 2 and SPID 2), all active treatments were significantly more efficacious than placebo (P < 0.001), with ibuprofen liquigel 200 and 400 mg significantly more efficacious than acetaminophen 1000 mg (P < 0.05 and P < 0.01, respectively). For the entire duration of the study (TOTPAR 6 and SPID 6), only the 2 doses of ibuprofen liquigel were significantly more efficacious than placebo (P < 0.001). Ibuprofen liquigel 200 and 400 mg were also significantly more efficacious than acetaminophen 1000 mg on the summary measures TOTPAR 6 and SPID 6 (P < 0.01 and P < 0.001, respectively). Analysis of the stopwatch data revealed that all active treatments displayed significantly more rapid onsets to confirmed first perceptible relief (P < 0.001 to < 0.05) and meaningful relief (P < 0.001 to < 0.01) than did placebo, with ibuprofen liquigel 400 mg displaying a significantly more rapid onset to meaningful relief than acetaminophen 1000 mg (P < 0.05) and a significantly more rapid onset to confirmed first perceptible relief than acetaminophen 1000 mg (P < 0.001) and ibuprofen liquigel 200 mg (P < 0.01). All adverse events were considered mild or moderate, with an overall incidence of 11.5% in the ibuprofen liquigel 200-mg group, 6.8% in the ibuprofen liquigel 400-mg group, 19.0% in the acetaminophen 1000-mg group, and 25.9% in the placebo group.

CONCLUSIONS

Ibuprofen liquigel provided greater peak and overall analgesic effects and a more rapid onset to analgesia than did acetaminophen 1000 mg.

Analgesic efficacy of intranasal butorphanol (Stadol NS) in the treatment of pain after dental impaction surgery

PURPOSE

This study evaluated the safety and efficacy of increasing doses of intranasal butorphanol (Stadol NS, Bristol-Myers Squibb, New York, NY) compared with placebo in controlling moderate to severe pain after removal of bony impacted third molars.

PATIENTS AND METHODS

This single-dose, double-blind, parallel-group, dose-response trial compared the efficacy and safety of 4 doses of intranasally administered butorphanol tartrate and placebo in controlling moderate to severe pain after the removal of impacted third molars in 151 patients. The study was conducted at 2 sites. The patients were randomly assigned to receive 1 dose of butorphanol tartrate: 0.25 mg (n = 31), 0.5 mg (n = 29), 1.0 mg (n = 30), 2.0 mg (n = 30), or placebo (n = 31). Medication was administered with a metered-dose spray pump. Patients rated pain intensity (PI), pain relief (PAR), pain half gone (PHG), and adverse events at 0.25, 0.5, 1, 2, 3, 4, 5, and 6 hours after treatment. At the end of the study period or before rescue medication (ibuprofen, 400 mg, or acetaminophen, 1,000 mg), patients provided an overall assessment (GLOBAL).

RESULTS

A linear dose-response regression (P < or = .05) was observed for the means of pain intensity difference (PID), PAR, and PHG at 0.25, 0.5, and 1 hour, and for sum of pain intensity differences (SPID), sum of pain relief (TOTPAR), peak PID and PAR, and GLOBAL evaluation. The 1.0- and 2.0-mg groups experienced greater pain relief compared with placebo (P = .05) during the first hour after drug administration. The 1.0- and 2.0-mg groups had significantly better GLOBAL evaluations than the placebo group, but were not significantly different from placebo for time until remedication (TREMED). Incidence and severity of the most common adverse events were dose-related. Two severe adverse events (drowsiness and dizziness) occurred after the 2.0-mg dose.

CONCLUSION

Intranasal butorphanol effectively relieved postsurgical dental pain, with a rapid onset within 15 minutes, and seems to be a promising addition to the current armamentarium of opioid analgesics. As with other opioids, it should be used cautiously in an outpatient setting.

Evaluation of a novel solubilized formulation of ibuprofen in the treatment of migraine headache: a randomized, double-blind, placebo-controlled, dose-ranging study

A total of 729 migraine sufferers with moderate to severe baseline pain evaluated a single 200, 400 or 600 mg dose of a new liquigel formulation of ibuprofen over 8 h. Ibuprofen liquigels were significantly superior to placebo for cumulative headache response (pain reduced to mild or none) from 0.5 (600 mg) or 1 h (200 and 400 mg) to 8 h. At 2 h, respective headache response rates for ibuprofen 200, 400 and 600 mg and placebo were 64%, 72%, 72% and 50%. All three doses were also significantly superior to placebo for 2-h pain-free (25%, 28%, 29% and 13%, respectively) and for proportions with mild or no limitation of activity (2-8 h). Ibuprofen liquigels were generally superior to placebo for reducing photophobia, phonophobia, or nausea (1-4 h) and for global evaluation. All doses were well tolerated. These data demonstrate that ibuprofen liquigels relieve the pain, ancillary symptoms, and limitation of activity, of migraine.

Conventional and extended-release etodolac for postsurgical dental pain

This double-masked, parallel-group, randomized study compared the analgesic efficacy and tolerability of a single investigational 1200-mg dose of extended-release etodolac with those of a single 400-mg dose of extended-release etodolac and twice-daily doses of conventional etodolac 200 and 400 mg and placebo given 8 hours apart in 237 patients with moderate or severe postoperative pain following surgical removal of > or = 2 impacted third molars. Both doses of conventional etodolac and the 1200-mg dose of extended-release etodolac were significantly more effective on all summary analgesic measures than placebo (P < 0.05). Conventional etodolac had an onset of analgesic activity within 45 (400 mg) to 60 (200 mg) minutes and an analgesic duration of 5 to 6 hours. Extended-release etodolac 1200 mg had an onset of action within 60 minutes and an analgesic duration of 12 to 24 hours. At hours 2 and 3, conventional etodolac 400 mg was significantly more effective than the other treatments; from hours 6 through 12, extended-release etodolac 1200 mg was significantly more effective than the other treatments (both, P < 0.05). No serious adverse events were observed in this study, with an incidence of side effects in the active etodolac groups no different than that with placebo. Extended-release etodolac 1200 mg has a prolonged analgesic duration and an acceptable side-effect profile in the oral surgery pain model.

The safety profile of nonprescription ibuprofen in multiple-dose use: a meta-analysis

A meta-analysis was performed to compare the incidence of adverse experiences (AEs) during the multiple-dose use of nonprescription ibuprofen to a placebo. Eight studies, with doses ranging from 800 to 1200 mg/day and durations of 1 to 10 days, met the criteria for inclusion. AEs were classified according to COSTART, except that "abdominal pain" was conservatively reassigned to the digestive system. In each study, the overall AE frequency among ibuprofen-treated subjects (n = 1094) was numerically less than or equal to the placebo (n = 1093). Pooled across all studies, placebo subjects reported AEs significantly (p = 0.018) more often (31.7%) than ibuprofen subjects (27.4%). The frequency of digestive system AEs was comparable (p = 0.420) for the placebo (11.0%) and ibuprofen (12.1%); there was no significant difference for any specific digestive system AE. AE frequency in the "body-as-a-whole" category was significantly higher (p < 0.001) in the placebo (20.4%) than in ibuprofen (14.8%). The number of severe AEs in all of these categories was lower for ibuprofen than for the placebo. These data indicate that nonprescription ibuprofen has an excellent side effect profile in multiple-dose use, with a frequency of gastrointestinal AEs comparable to a placebo.

The relationship between psychiatric and physical health in elderly people with intellectual disability

Elderly people with intellectual disability have high rates of both psychiatric and physical disorders. In the elderly general population, these disorders are known to be associated. Whether such an association exists amongst elderly people with intellectual disability is unclear, but the resolution of this question is of clinical as well as academic importance. Psychiatric and physical assessments were completed on 134 people with intellectual disability aged 65 years and over (93.7% of the ascertained population living in Leicestershire, UK). The relationship between the two disorders was statistically examined. The number of physical disorders, age, level of intellectual disability and smoking status were retained in the logistic regression equation which predicted caseness for dementia in 79.9%. Similar statistical modelling for psychiatric disorders (other than dementia) retained the level of intellectual disability as the only explanatory variable in the equation. These results differ from the elderly general population, but are in keeping with the one previous intellectual disability study. In view of the poor use of general medical services by elderly people with intellectual disability, knowledge of such comorbidity should alert psychiatrists to the need for physical assessments in order to optimize health.

Affective psychosis and Prader-Willi syndrome

Previous studies have demonstrated that maladaptive behaviours are common amongst adults with Prader-Willi syndrome (PWS). Case reports have also previously demonstrated that psychosis can occur amongst adults with PWS. The present study was undertaken in order to gain a better understanding of the psychopathology of the psychosis of PWS. Twenty-three out of 25 adults identified with PWS living in Northamptonshire, UK, agreed to participate. Comprehensive psychiatric assessments (using the PPS-LD), and measures of adaptive and maladaptive behaviours (using the AAMR-ABS) were completed. Comparisons were made for the prevalence of psychiatric disorders against those from a previous epidemiological study of adults with intellectual disability of other aetiologies from a neighbouring county. The PWS group was found to have higher rates of affective disorders (a point prevalence of 17.4%), in which psychotic symptoms were common, but similar rates of schizophrenia/delusional disorders (4.3%) compared with the comparison group. Behaviour disorders were also common. Surprisingly, none of the PWS group was found to have generalized anxiety or phobic disorders. The diagnostic criteria for the episodes including psychotic symptoms are explored. The high rates of affective disorders is of clinical (i.e. treatment) importance as well as being of academic interest with regard to the genetics of psychiatric disorders.

Epidemiology of self-injurious behaviour in adults with learning disabilities

BACKGROUND

There have been few epidemiological studies of the disabling and poorly understood disorder self-injurious behaviour among adults with learning disabilities.

METHOD

Interviews were undertaken with the carers of adults known to the Leicestershire Learning Disabilities Register (n = 2277). The Disability Assessment Schedule was used and information was also collected on demographic characteristics, developmental and physical status.

RESULTS

Self-injurious behaviour was present in 17.4% of the population. In 1.7% self-injurious behaviour occurred frequently and was severe. There was no gender difference between those with and without self-injurious behaviour. Both the chronological age and developmental quotient of individuals with self-injurious behaviour were lower than those of individuals without self-injurious behaviour. Autistic symptoms were more common among those with self-injurious behaviour. The association of self-injurious behaviour with a wide range of other maladaptive behaviours was highly significant. Logistic regression analysis retained age, developmental quotient, hearing status, immobility and number of autistic symptoms as explanatory variables for self-injurious behaviour.

CONCLUSIONS

Self-injurious behaviour is a prevalent and disabling disorder among adults with learning disabilities.

Maladaptive behaviours and symptoms of dementia in adults with Down's syndrome compared with adults with intellectual disability of other aetiologies

Dementia commonly occurs in elderly people with intellectual disability, especially those with Down's syndrome. The non-cognitive symptoms of dementia can be of greater significance to individuals and carers than the cognitive changes caused by this condition. It is not known whether there are differences between people with Down's syndrome and those with intellectual disability of other causes with regard to the prevalence of such symptoms. The present study was undertaken to draw a comparison between a group with Down's syndrome and dementia (n = 19), and a group with intellectual disability of other causes and dementia (n = 26). Maladaptive behaviours and psychiatric symptomatology were assessed in both groups. The group with Down's syndrome had a higher prevalence of low mood, restlessness/excessive overactivity, disturbed sleep, being excessively uncooperative and auditory hallucinations. Aggression occurred with greater frequency in those subjects with intellectual disability of other causes. These findings are of epidemiological importance in terms of service planning and understanding psychiatric presentation.

Immunity to T cell receptor peptides in multiple sclerosis. III. Preferential immunogenicity of complementarity-determining region 2 peptides from disease-associated T cell receptor BV genes

Vaccination with synthetic TCR peptides from the BV5S2 complementarity-determining region 2 (CDR2) can boost significantly the frequency of circulating CD4+ peptide-specific Th2 cells in multiple sclerosis (MS) patients, with an associated decrease in the frequency of myelin basic protein (MBP)-reactive Th1 cells and possible clinical benefit. To evaluate the immunogenicity of CDR2 vs other regions of the TCR, we vaccinated seven MS patients with overlapping BV5S2 peptides spanning amino acids 1-94. Six patients responded to at least one of three overlapping or substituted CDR2 peptides possessing a core epitope of residues 44-52, and one patient also responded to a CDR1 peptide. Of the CDR2 peptides, the substituted (Y49T)BV5S2-38-58 peptide was the most immunogenic but cross-reacted with the native sequence and had the strongest binding affinity for MS-associated HLA-DR2 alleles, suggesting that position 49 is an MHC rather than a TCR contact residue. Two MS patients who did not respond to BV5S2 peptides were immunized successfully with CDR2 peptides from different BV gene families overexpressed by their MBP-specific T cells. Taken together, these results suggest that a widely active vaccine for MS might well involve a limited set of slightly modified CDR2 peptides from BV genes involved in T cell recognition of MBP.

A dose-ranging study of bromfenac sodium in oral surgery pain

OBJECTIVE

The purpose of this study was to evaluate the analgesic efficacy and safety of five graded doses of bromfenac sodium in patients experiencing moderate to severe pain after the surgical removal of impacted third molar teeth.

STUDY DESIGN

The study employed a randomized, double-blind, single-dose, 8-hour, inpatient evaluation period. The treatment groups included placebo (n = 21) and bromfenac (n = 102) at dosage strengths of 5 mg (n = 21), 25 mg (n = 20), 50 mg (n = 20), 100 mg (n = 20), and 200 mg (n = 21). Patients ingested a dose of study medication when their postsurgical pain reached a moderate or severe intensity. Pain intensity and pain relief were rated at 15, 30, 60, 90, and 120 minutes and then hourly for the remaining 6 hours. Efficacy and safety variables were analyzed by means of analysis of variance and chi-squared tests where appropriate.

RESULTS

At all doses, bromfenac exhibited statistical superiority (p < 0.05) to placebo, with all but the 5-mg dose being significantly more efficacious for every summary analgesic measure (3- and 8-hour sum pain intensity difference and sum pain analog intensity difference, total pain relief, peak effects, sum of pain half gone, and global evaluation). Peak analgesic effects did not increase beyond those provided by the 25-mg dose of bromfenac, although both the 100- and 200-mg bromfenac doses provided a more rapid onset and a longer duration of analgesia than either the 25- or 50-mg dosage strengths. The most common side effects reported were headache, nausea, dizziness, and drowsiness; the incidence in the bromfenac group was no different from that in the placebo group.

CONCLUSIONS

Bromfenac is a safe and efficacious analgesic, with a threshold dose of 5 mg and a positive dose-response up to 25 mg for peak effects and 100 mg for total analgesic activity.

Clinical study of the effects of age on the physical health of adults with mental retardation

Physical disorders and pharmacotherapy for all 134 people with mental retardation ages 65 years and over living in Leicestershire, United Kingdom, were examined. Results were compared with a randomly selected group of 73 younger adults with mental retardation. Group comparisons revealed higher rates of urinary incontinence, immobility, hearing impairments, arthritis, hypertension, and cerebrovascular disease among the older group. The younger group had higher rates of dermatological disorders; congenital heart disease; ear, nose, and throat (ENT) disorders; and neurological disorders (excluding Parkinson disease). The older group took more drugs for physical illness. The effect of ageing on physical morbidity outweighs the effect of people with more severe mental retardation dying younger: Older people with mental retardation have significant physical health needs.

Analgesic efficacy and safety of (R)- ketoprofen in postoperative dental pain

This double-blind, randomized, parallel-group study compared the analgesic efficacy and safety of single doses of (R)- ketoprofen 25 mg and 100 mg to that of acetaminophen 1,000 mg and placebo in 177 patients experiencing moderate to severe pain after surgical removal of their impacted third molars. Both (R)- ketoprofen 100 mg and acetaminophen 1,000 mg were significantly (P < 0.05) more efficacious than placebo for all summary analgesic measures. Other than a more rapid analgesic onset (45 minutes versus 60 minutes) for acetaminophen 1,000 mg, (R)- ketoprofen 100 mg and acetaminophen 1,000 mg were statistically equivalent to each other. The 25 mg dose of (R)- ketoprofen appeared to approach the analgesic threshold dose, being numerically but not statistically superior to placebo for all summary measures. There were no serious adverse events observed in this study, with the overall incidence of side effects being somewhat less in the (R)- ketoprofen groups than in the acetaminophen 1,000 mg group. (R)- Ketoprofen possesses analgesic activity and an acceptable side-effect profile in the oral surgery pain model.

The Leicester 500 Project. Social support and the development of postnatal depressive symptoms, a prospective cohort survey

BACKGROUND

A prospective epidemiology study evaluated the role of specific social and psychological variables in the prediction of depressive symptomatology and disorders following childbirth in a community sample. Measures of social support used previously in clinically depressed populations facilitated further comparison.

METHODS

Nulliparous pregnant women (N = 507) were interviewed during pregnancy with the Interview Measure of Social Relationships (IMSR) and a contextual assessment of pregnancy-related support and adversity and 427 were followed up at 3 months postpartum with the 30-item GHQ, including six depression items. To establish the clinical representativeness of the GHQ, high GHQ scorers and a random subsample of low scorers were interviewed using the SCAN. Regression models were developed using the GHQ Depression scale (GHQ-D), the IMSR and other risk factor data.

RESULTS

GHQ-D after childbirth was predicted by lack of perceived support from members of the woman's primary group and lack of support in relation to the event becoming pregnant; this held even after controlling for antenatal depression, neuroticism, family and personal psychiatric history and adversity. Informant-rated deficits in provision of social support also predicted later depression. The size of the primary social network group previously found to be related to depression in women, did not predict depressive symptom development.

CONCLUSION

Predictors of depressive symptom development differ from predictors of recovery from clinical depression in women. Interventions should be designed to reduce specific deficits in social support observed in particular study populations.

Depression and porphyria: Safe use of fluoxetine in a woman with learning disabilities

Many antipsychotic and antidepressant drugs can precipitate life-threatening porphyric crisis in individuals with the underlying condition. However, when people with porphyria develop mental illness, they require treatment in order to maintain their quality of life. For this reason, although the condition is rare, psychiatrists need information regarding the safety profile of psychotropic drugs when used in people with porphyria. This case report describes the safe use of fluoxetine to treat depression in a woman with severe learning disabilities and porphyria, who failed to respond to non-pharmacological approaches.

Behaviour phenotype for Down's syndrome

BACKGROUND

For more than a century, the idea of particular personality/behavioural characteristics being associated with people with Down's syndrome has been explored, but with inconclusive results.

METHOD

The Disability Assessment Schedule was used to ascertain the behavioural profiles of 360 adults with Down's syndrome and 1829 adults with learning disabilities of other aetiologies, who were the whole identified population within a defined geographical area. Comparison was made between the two total groups and additionally for the subgroups aged < 35 years and aged > or = 35 years. Comparison was also made with regards to cluster analysis findings.

RESULTS

Despite an equal age and developmental quotient, the Down's syndrome group were less likely to demonstrate maladaptive behaviours. The behaviour characteristics of the adults with Down's syndrome remained constant in the younger and older age groups. Cluster analysis demonstrated adults with Down's syndrome to have an increased prevalence in cluster groupings with lower rates of maladaptive behaviours.

CONCLUSIONS

This study confirms there to be a behaviour phenotype among adults with Down's syndrome. The reasons for this (e.g. genetic/psychological/social) require further research. Such research may establish a better understanding of the aetiologies of maladaptive behaviours among people with learning disabilities in general.

A population-based health survey of maladaptive behaviours associated with dementia in elderly people with learning disabilities

Maladaptive behaviours are known to present as a feature of dementia amongst people from the general population, but there has been little research to examine whether this has implications for people with learning disabilities who develop dementia. Out of 143 people with learning disabilities aged 65 years and over living in Leicestershire, England, 134 (93.7%) participated in the study. Twenty-nine people diagnosed as having dementia were compared against 99 people without dementia; six people with possible dementia were excluded from the analysis. Comparisons were made on the results of a checklist of maladaptive behaviours. Seventeen out of the 22 maladaptive behaviours examined were found to be more prevalent amongst the people with dementia. The behaviours which were significantly more prevalent in the group with dementia included lack of energy, lack of sense of danger, sleep disturbance, agitation, incontinence, excessively uncooperative, mealtime/feeding problem, irritability and aggression. Dementia is becoming more prevalent amongst people with learning disabilities because of their increasing life span. Maladaptive behaviours are commonly associated with dementia. This can cause a significant burden for individuals and their carers, which may influence the viability of a person's residential placement.

Deficient health and social services for elderly people with learning disabilities

Elderly people with learning disabilities have greater psychiatric morbidity than younger individuals, but a previous report has suggested that the majority of the former do not receive treatment. All people with learning disabilities aged 65 years and over living in Leicestershire, England (n = 134), and a random sample of adults with learning disabilities aged between 20 and 64 years (n = 73) were assessed for psychiatric disorders and service use. Elderly people received less day care, less respite care and were less likely to have a social worker and receive input from most health services than the younger group. Chiropody was an exception. Those receiving psychiatric services did so through the learning disabilities specialist services only. Those with an additional psychiatric disorder were more likely to receive services, but results still favoured the younger group. Services were better accessed by those living in residential care. Failure to access services may relate to carers attitudes and beliefs: in learning disability settings, morbidity was attributed to 'it's just old age; in the elderly settings, morbidity was attributed to 'it's because s/he has learning disabilities'. The specialist health and social services need to take the lead in health promotion and education.

Psychiatric symptoms of dementia among elderly people with learning disabilities

OBJECTIVE

To determine the rate of psychiatric symptoms among elderly people with learning disabilities who have dementia.

DESIGN

Survey.

SETTING

The general community of a county in the UK.

PARTICIPANTS

The whole population of people with learning disabilities who were 65 years or over. The total population was 143, of whom 134 participated (93.7%). From the total population, those with dementia were determined (N = 29).

MEASURES

Description of psychopathology, using a semi-structured psychiatric rating scale.

RESULTS

Psychotic symptoms occurred in 27.6%, with the most common types being delusions of thefts, other persecutory delusions and visual hallucinations of strangers in the house. The onset of other psychiatric symptoms as part of the dementia was also common, in particular changed sleep pattern, loss of concentration, worry, reduced quantity of speech, change in appetite and onset of or increase in aggression.

CONCLUSIONS

People with leaming disabilities are living longer, and so the number with dementia is rising. Psychiatric symptoms occur commonly in dementia, can cause significant distress and require recognition, understanding and the development of effective managements.

Adverse effects of summer amongst people with learning disabilities: neuroleptic malignant syndrome

The existing literature regarding neuroleptic malignant syndrome (NMS) amongst people with learning disabilities is limited. We describe three case reports of people with learning disabilities from the same geographical area who developed NMS within 3 weeks of each other. This was during the hottest part of a very hot summer. The presentation of NMS is discussed. The importance of carers attending to adequate hydration for people with learning disabilities and poor communication skills during the summer months is stressed.

Bromfenac sodium, acetaminophen/oxycodone, ibuprofen, and placebo for relief of postoperative pain

The objective of this double-masked, parallel-group, multicenter, inpatient study was to compare bromfenac with an acetaminophen/oxycodone combination and ibuprofen in patients who had pain due to abdominal gynecologic surgery. In the 8-hour, single-dose phase, 238 patients received single oral doses of bromfenac (50 or 100 mg), acetaminophen 650 mg/oxycodone 10 mg, ibuprofen 400 mg, or placebo. In the multiple-dose phase, 204 patients received bromfenac, acetaminophen/oxycodone, or ibuprofen for up to 5 days. In the single-dose phase, both bromfenac doses produced peak analgesic responses equivalent to acetaminophen/oxycodone, but the responses to bromfenac were longer lasting. Bromfenac produced significantly better overall (8-hour) analgesic summed scores than acetaminophen/oxycodone. Ibuprofen was less efficacious than the other analgesics. The remedication rate was lower in both bromfenac groups than in the other treatment groups. The acetaminophen/oxycodone group reported more somnolence and vomiting. Single doses of bromfenac provided analgesia at least equivalent to that of the acetaminophen/oxycodone combination, with a longer duration of action. Both doses of bromfenac and acetaminophen/oxycodone were superior to ibuprofen in this study.

High prevalence of dementia among people with learning disabilities not attributable to Down's syndrome

BACKGROUND

For many years, it has been known that dementia can occur in people with learning disabilities, but there have been few research studies. Studies that do quote rates for dementia show these to be high, but this important fact has received remarkably little attention.

METHOD

Comprehensive psychiatric and medical assessments were undertaken on the whole population (ascertained as far as is possible) of people with learning disabilities aged 65 years and over living in Leicestershire, UK (N = 134), in order to ascertain rates of DCR defined dementia, and associated factors.

RESULTS

Dementia was diagnosed in 21.6%, against an expected prevalence of 5.7%, for a group with this age structure. The rate of dementia increased in successive age cohorts: 15.6% aged 65-74 years; 23.5% aged 65-84 years; and 70.0% aged 85-94 years. People with dementia tended to be older, female, with more poorly controlled epilepsy, a larger number of additional physical disorders, less likely to be smokers and had lower adaptive behaviour scores than did the elderly people without dementia. They were more likely to live in health service accommodation.

CONCLUSIONS

Dementia occurs at a much higher rate among elderly people with learning disabilities than it does among the general population; this is independent of the association between dementia and Down's syndrome. Whether this relates aetiologically to genetics, lack of brain 'reserve' or history of brain damage is yet to be determined.

Epidemiology of psychiatric disorders in elderly compared with younger adults with learning disabilities

BACKGROUND

The literature regarding psychiatric illness among elderly people with learning disabilities is limited and conflicting because of methodological differences. There have been no recent studies comparing psychiatric epidemiology between younger and older adults with learning disabilities, using the same methodology and definitions.

METHOD

Comprehensive psychiatric examination using a semi-structured rating scale was undertaken on everyone with learning disabilities, aged 65 years or over (n = 134), living in a defined geographical area. Comparison was made with a randomly selected control group of adults with learning disabilities aged 20-65 years (n = 73) drawn from the same geographical area.

RESULTS

Elderly people with learning disabilities have a greater prevalence of psychiatric morbidity than younger controls (68.7 v. 47.9%). Rates for depression and anxiety disorders are high, and dementia is common: there are equal rates for schizophrenia/delusional disorders, autism and behaviour disorders in the two groups.

CONCLUSIONS

The higher psychiatric morbidity among elderly (compared with younger) people with learning disabilities has not previously received adequate recognition. This warrants further investigation by service planners and clinicians.

The current provision of specialist health services to people with learning disabilities in England and Wales

Considerable change has taken place in the provision of specialist health services to people with learning disabilities with the move away from institutions and an emphasis on care in the community. There is diversity between services in different parts of the country, but no existing source of information by which NHS Trusts can benchmark their own services against the national norm. This project was undertaken in order to ascertain the current provision of specialist health services in England and Wales. A questionnaire was returned by 83.9% of 161 NHS Trusts, who quantified their service in terms of in-patient and community resources. Results were analysed and presented where possible as cumulative frequencies, to facilitate benchmarking.

Ketoprofen Dental Pain Study

Ketoprofen is a nonsteroidal antiinflammatory drug, recently approved as an over-the-counter (OTC) analgesic at a 12.5 mg dosage strength. This is the first published study which explores the analgesic efficacy and safety of ketoprofen 12.5 mg in patients experiencing pain following the removal of impacted third molars. This study was single-dose, double-blind and randomized utilizing a 6-hour in-patient evaluation period. Patients ingested a single dose of ketoprofen 12.5 mg (n = 30), ketoprofen 37.5 mg (n = 32) or placebo (n = 15) when their post-surgical pain reached at least a moderate intensity on a 5-point categorical (CAT) scale and greater than 50 mm on a 100 mm visual analog scale (VAS). Measures of pain intensity and relief were gathered every 20 minutes for the first 2 hours, and then hourly from hours 3 through 6. Adverse drug reactions were also recorded as they occurred. Both dosages of ketoprofen were significantly more efficacious than placebo (two way ANOVAs, p < 0.05). For pain intensity difference (PID) and pain relief, the 12.5 mg dose exhibited statistical superiority from hours 1 through 3, while the 37.5 mg dose exhibited statistical superiority from 40 minutes through 4 hours. Ketoprofen 37.5 mg was significantly more efficacious than the 12.5 mg dose only at 40 minutes for PID(VAS) and relief, and at 60 minutes for PID(VAS). Both ketoprofen dosages displayed significantly greater 3-hr, 4-hr and 6-hr summary analgesic measures (SPID(VAS), SPID(CAT), TOTPAR) than placebo, with the exception of the 6-hr SPID(CAT) measure for ketoprofen 12.5 mg. No serious side effects were observed in this study. We conclude that ketoprofen in a dose range of 12.5 mg to 37.5 mg is a safe and effective analgesic for the relief of post-operative dental pain.

Analgesic efficacy and safety of an intraoral lidocaine patch

The effectiveness of intraoral II-docaine patches was tested by asking participants to rate the pain experienced after insertions of a 25-gauge needle. Needlesticks were performed at baseline and at various time points after patch placement. Each needlestick included contact with the periosteum. Lidocaine patches achieved significantly better analgesia than the placebo within 2.5 to five minutes after placement. Drug-related side effects were minimal and venous blood levels of lidocaine were low, averaging 10 to 14 times less than those achieved with a typical injection of lidocaine plus epinephrine. The authors conclude that the lidocaine patches used in this study are effective and safe in reducing needle insertion pain in adults.

Prevalence and cluster typology of maladaptive behaviors in a geographically defined population of adults with learning disabilities

BACKGROUND

Maladaptive behaviours are frequently present in individuals with learning disabilities; however, their prevalence varies between studies and the aetiology, classification and most appropriate management of such behaviors remain unclear. The aims of the study were twofold: firstly to determine the prevalence of maladaptive behaviours, and secondly to develop a classification typology.

METHOD

A population of 2202 adults with learning disabilities was surveyed to determine the prevalence of maladaptive behaviours. These were subjected on the basis of 13 behavioural characteristics to cluster analysis. The clusters were further examined in respect of secondary variables.

RESULTS

Over 60% of individuals demonstrated the presence of at least one maladaptive behaviour and in 40% this problem was of either severe degree or frequent occurrence. Men were more likely to demonstrate physical aggression, property destruction, tantrums and verbal abuse than women. Although some severe maladaptive behaviours diminished with age, many persisted through all age groups. Six behavioural clusters were devised which demonstrated face validity and which differed in respect of demographic and developmental variables, and the prevalence of maladaptive habits and autistic symptoms.

CONCLUSIONS

These findings demonstrate a high prevalence of maladaptive behaviours and 'objectionable habits' among people with learning disabilities. A classification of behavioural symptoms may be possible on the basis of symptom clusters.

Analgesic efficacy of the kappa-receptor agonist, enadoline, in dental surgery pain

To study the analgesic efficacy of enadoline, a selective agonist of the kappa-opioid receptor, a double-blind, randomized comparison was made of enadoline versus placebo and a combination of acetaminophen-codeine in patients with pain after surgical extraction of impacted molar teeth. An initial study involving a comparison of enadoline, a combination, and placebo failed to show any analgesic effect of enadoline. Therefore, a second study with the same design but using higher doses of enadoline was conducted. Despite continued safety and tolerability even at the higher doses, enadoline could not be shown to be superior to placebo. The acetaminophen-codeine combination was significantly more effective than enadoline or placebo. Enadoline did not show analgesic efficacy in this study. Possible reasons for this lack of efficacy are discussed.

Histrionic personality disorder as pseudo-learning disability

The case of a 20-year-old woman with a histrionic personality disorder is described. She claims to have a mild learning disability, and indeed, is receiving special college education for people with learning disabilities and has a specialist learning disability social worker, despite being of above average intelligence. Aetiologically, her persona is viewed as a psychological defence, rather than a deliberate attempt at deception. A process of 'institutionalization' appears to have occurred and compounded the problems with further regression. Psychiatrists and professionals in allied disciplines should not accept that a person has a learning disability purely because that person tells you that he or she has one.