Synthesising existing research on complicated grief in intellectual disability: findings from a systematic review

BACKGROUND

Complicated grief has been identified as a phenomenon in the general population, and there is an increasing body of research investigating complicated grief in people with intellectual disability. The aim of this study is to synthesise this existing knowledge from research published between 1999 and 2022.

METHODS

A structured systematic review using PRISMA guidelines was conducted, which searched three commonly used databases (Medline, PsycINFO and CINAHL) for research on the topic of bereavement and intellectual disability. The articles identified in this search were screened to identify those that addressed the issue of 'complicated grief', with all abstracts and subsequent full texts reviewed by two researchers.

RESULTS

In total, 179 abstracts were initially identified, with 34 articles eligible for full text screening and 18 papers reaching criteria for inclusion. Data relating to the studies' objectives were extracted under the headings of definition, defining principles, signs and symptoms, risk factors and treatments for complicated grief in intellectual disability. Thematic analysis of the extracted data was performed to identify key themes.

CONCLUSIONS

This review highlights that people with intellectual disability are likely to experience complicated grief reactions and that complicated grief is both underestimated and a clinically significant condition for people with intellectual disability. Future research should work to clarify diagnostic criteria and identify appropriate interventions.

76 HOW BLOGS SUPPORT THE TRANSFER OF KNOWLEDGE INTO PRACTICE IN THE FIELD OF DEMENTIA PALLIATIVE CARE: FACILITATORS AND BARRIERS

Background

Blogging can help to maximise the impact of one’s work in academia and beyond by making research findings accessible for multiple knowledge users. As part of the knowledge exchange and dissemination activities of the Model for Dementia Palliative Care Project, this study explored stakeholders’ views of blogs as a means to translate research findings in the field of Dementia Palliative care.

Methods

A web-based survey was developed, piloted, and revised. It was distributed electronically via key dementia and palliative care organisations. Complete responses (N=128) were received from healthcare researchers (n=53), healthcare providers (n=46) and others with an interest in healthcare research (n=29). Data were analysed using descriptive statistics and content analysis

Results

The preferred methods of reviewing research findings were scientific papers, websites and news articles. Respondents read healthcare blogs “sometimes” (39.1%), with <19% reading them “often” or “very often”. Receiving an email notification might increase the likelihood of reading a new blog post for 83% of respondents. Barriers to engaging with blogs included lack of time, preference for other media, lack of awareness regarding available blogs, and concerns about the credibility and source of information. An appropriate length and the author of the blog were key features that encouraged engagement with a blog. Most respondents (37.7 % ‘Yes’ and 23.0% ‘Maybe’) would read Dementia Palliative care blogs by the research team.

Conclusion

Despite respondents choosing a scientific paper as their preferred method to consume research findings, many indicated an openness to reading blogs on their area of interest. Creating concise, relevant, and credible blogs, and suitably promoting them, could increase the impact and reach of healthcare research, such as in the emerging field of dementia palliative care, and thus promote translation of research findings into practice.

75 EVALUATING DEMENTIA PALLIATIVE CARE SERVICES ACROSS IRELAND AND THE UK USING THE RE-AIM FRAMEWORK

Background

Dementia is a life-limiting illness, requiring a Palliative Care (PC) approach from diagnosis. In Ireland, People with Dementia (PwD) and their families rarely receive PC in a timely manner. This study aimed to evaluate five exemplar community-based dementia PC services across Ireland and the UK (as identified by key stakeholders), to inform a new service delivery model.

Methods

Data from semi-structured interviews and focus groups with 29 service providers, and service activity data (n=5), was evaluated using the RE-AIM framework.

Results

‘Reach’ - Caseloads varied significantly between 3-154 active cases. Most services accepted self-referrals; all wanted earlier referrals. Factors influencing reach included co-location, dyadic participation, service flexibility, and others’ awareness of PC appropriateness and the service’s existence.

‘Effectiveness’ - All service users received holistic assessments, person-centred care, advanced care planning, continuity of care, improved service access and ‘care-for-the-carer’. Some services offered complimentary therapies, 24/7 phone support, and bereavement support; these were perceived to improve quality-of-life, comfort, and independence.

‘Adoption’ - Staff were highly invested; some provided their personal numbers to families. Outside staff were more willing to engage (refer/support) if shared governance, training was provided, or already familiar with dementia or the tools. Incentive programmes increased adoption rates.

‘Implementation ’ - All services evolved on an ad-hoc basis, with funding provided by local organisations, and a single ‘driving force’, typically a consultant/nurse. Services heavily relied on volunteers. Perceived “essential” elements included a dyadic approach, MDT involvement, open communication, forming relationships, reflective practices, dedicated staff with problem solving skills, and staff support/training.

‘Maintenance’ - All services continued after initial project funding; three increased their activities/reach over time.

Conclusion

Important features and facilitators of community-based dementia palliative care services have been identified. These results are informing the development of the novel Dementia Palliative Care model for use in Ireland (https://pallcare4dementia.com/).

Smoking cessation for cancer patients through the lens of cancer specialists: challenges & solutions

Background

The benefits of smoking cessation (SC) for cancer patients are widely recognised. However, there has been a limited emphasis on SC in this context and it continues to be a challenge for cancer patients. As part of a larger feasibility study aiming to develop a structured SC pathway for cancer patients in Ireland, this qualitative study explored the SC practices, experiences and opinions of oncology healthcare professionals (HCPs).

Methods

Semi-structured interviews were conducted with 18 HCPs from lung, breast, cervical, head and neck and general oncology, across 4 specialist adult cancer hospitals in Ireland. Interview transcripts were analysed using thematic analysis.

Results

Four key themes emerged:

(1) Frequently ask and advise but infrequently assist: most HCPs ask about smoking and many advise about available supports, but few refer patients to SC services. Where offered, referrals were to hospital SC services and/or nicotine replacement therapy was prescribed; no HCP prescribed varenicline or bupropion. Barriers included lack of time, ill-defined referral pathways and lack of knowledge.

(2) Increased willingness but differing ability to quit: most patients were interested in quitting post diagnosis and had varying support needs, linked to cancer stage, social circumstances and stress levels.

(3) Need for an integrated or parallel service: all HCPs suggested that a structured and defined referral pathway will facilitate SC.

(4) Motivational counselling and pharmacotherapy combination: many HCPs suggested face to face as the best mode of intervention initially, with regular follow ups and ongoing support virtually, started pre-treatment, with an empathetic and empowering approach with provision of both motivational counselling and SC pharmacotherapy.

Conclusions

Smoking post cancer diagnosis has serious implications for cancer treatment and prognosis but is frequently overlooked. These findings will inform the design of a SC pathway for cancer patients.

Key messages

• Despite increased willingness to quit, there is inadequate and inconsistent SC support provision for cancer patients.

• Tailored SC support should be an integral part of comprehensive cancer care.

Healthcare utilisation and unmet health needs in children with intellectual disability: a propensity score matching approach using longitudinal cohort data

BACKGROUND

Health disparities for children with intellectual disabilities can be challenging to measure due to many other factors that can impact health and healthcare use. The aim of the current study was to use longitudinal cohort data to compare children with intellectual disability (ID) in Ireland between 2006 and 2014 on healthcare utilisation and unmet need, at ages 9 and 13, using a propensity score matching (PSM) approach.

METHODS

Using data from the Growing up in Ireland study, PSM was used to identify an appropriate control sample to compare with a sample of children with ID (n = 124). Participants were matched on variables that are known to influence healthcare utilisation to reduce the impact of confounding variables between groups so that differences between the groups can be estimated. Logistic regression was used to estimate effects at ages 9 and 13.

RESULTS

Children with ID were no more likely to have visited a general practitioner or emergency department in the past 12 months than children without ID. They did have a greater likelihood of visiting a doctor in a hospital in the past 12 months and of having an overnight stay in hospital by age 9. Primary caregivers of children with ID were more likely to report unmet health needs at ages 9 and 13.

CONCLUSIONS

This approach is a novel means of comparing healthcare use in this population by balancing the impact of other factors that may result in inequities, to which children with ID may be more vulnerable.

Long term NIV in an infant with Hallermann-Streiff syndrome: A case report and overview of respiratory morbidity

Hallermann-Streiff syndrome (HSS) is a rare congenital syndrome with different anomalies including midface hypoplasia, beak nose and micrognathia. The upper airways narrowness can lead to severe respiratory complications such as obstructive sleep apnoea syndrome (OSAS), particularly in infancy. The management of these severe OSAS is difficult and poorly documented in literature. We report the case of an infant with HSS complicated by severe and early OSAS successfully managed with non-invasive ventilation (NIV), provide an overview of respiratory morbidities and discuss treatment options for HSS-related OSAS.

Giant Cell Tumor of the Femoral Head: A Case Report and Review of the Literature

Introduction

Giant cell tumors (GCTs) of the bone are uncommon primary bone neoplasms that occur mainly in the epiphysis of long bones. GCT of the femoral head is rarely encountered.

Case Report

We report a rare case of GCT of the femoral head in a 20-year-old female. The patient presented with pathological fracture. The patient underwent total hip arthroplasty (THA). The aim of this paper is to present a case study with pathological fracture of the femoral head and to report the results of a literature review.

Conclusion

The treatment of choice for GCT of the proximal femur is a hip arthroplasty with either a standard THA for small confined tumors or endoprosthesis insertion for more extensive tumors. Joint preserving procedures have a high revision rate (47.06%). Denosumab has been tried as a neoadjuvant treatment with some success in certain cases.

Respiratory morbidity in children with congenital heart disease

OBJECTIVE

To evaluate the respiratory outcome in children with congenital heart disease (CHD), considering recent management procedures and the CHD pathophysiology.

DESIGN AND SETTING

Clinical and functional respiratory outcome were evaluated in 8-year-old children with isolated CHD followed up from birth in the prospective population-based EPICARD cohort.

PATIENTS

Children were assigned to two groups, based on the pathophysiology of the CHD: CHDs with left-to-right shunt (n = 212) and CHDs with right outflow tract obstruction (n = 113).

RESULTS

Current wheezing episodes were observed in 15% of the children with isolated CHD and left-to-right shunt, and 11% of the children with isolated CHD and right outflow tract obstruction (not significant). Total lung capacity (TLC) was the only respiratory function parameter that significantly differed between the two groups. It was lower in children with left-to-right shunt (88.72 ± 0.65% predicted) than in those with right outflow tract obstruction (91.84 ± 0.96, p = 0.006). In multivariate analysis, CHD with left-to-right shunt (coeff. [95% CI]: -3.17 [-5.45; -0.89]) and surgery before the age of 2 months (-6.52 [-10.90; -2.15]) were identified as independent factors associated with significantly lower TLC values.

CONCLUSION

Lower TLC remains a long-term complication in CHD, particularly in cases with left-to-right shunt and in patients requiring early repair. These findings suggest that an increase in pulmonary blood flow may directly impair lung development.

An exploratory study of self-reported complicated grief symptoms in parentally bereaved adults with intellectual disability

BACKGROUND

Complicated grief involves the experience of grief-related symptoms at a time, and severity, beyond which could be considered adaptive, while persistent complex bereavement disorder (PCBD) has been identified as a condition that requires further study in the typical population. The aims of this study are to (1) explore the symptoms of complicated grief associated with parental bereavement as self-reported by adults with intellectual disabilities (IDs) who have experienced a parental bereavement and (2) conduct an initial examination of how the existing criteria for PCBD apply to this group.

METHODS

This study uses a comparative group design, assessing self and staff (proxy) reports for a group of parentally bereaved individuals and a matched group of non-bereaved individuals using the Complicated Grief Questionnaire - ID Self-Report. Participants were 46 individuals with ID, 30 (65%) of whom who had experienced a parental bereavement within the previous 2 years. The age range was 23-67 years (mean = 43.8; SD = 10.3).

RESULTS

The results highlight the presence of a range of symptoms of complicated grief in individuals' self-reports, although there was some evidence that separation distress-related symptoms were more apparent. An analysis of individual symptoms showed patterns of higher reports among the bereaved group as would be expected. Comparing staff and self-reports, key criteria showed higher levels in self-reports among the bereaved group.

CONCLUSIONS

This study has demonstrated the capacity of people with ID to self-report personal experience of symptoms of complicated grief, when appropriate and accessible assessment tools are used. Some symptoms were more evident among bereaved individuals (compared with non-bereaved participants), and they tended to be from separation distress criteria. This may indicate the relevance of these symptoms for people with ID and question the existing criteria for PCBD in this population, which may have clinical implications for supporting people with ID experiencing a more complicated bereavement response.

Transradial approach for pediatric interventions: A review and analysis of the literature

BACKGROUND

Transradial access for interventions has been well studied in the adult population, but there is a paucity of literature of its use in the pediatric population.

METHODS

We conducted a systematic literature review and gathered and synthesized all of the available data into a cohesive resource for review and analysis of the topic.

RESULTS

Pooled analysis of the available data shows that transradial access in pediatric patients has a success rate of 91%, a vasospasm rate of 11.4%, and loss of pulse rate of 3.0% for a total complication rate of 14%. No permanent complications, or complications requiring surgery, were observed in any study. After stratifying for indication of intervention, neurological indications were associated with a lower complication rate compared to cardiac indications (0.1 vs 0.43, respectively, p = 0.004). In addition, studies published after 2013 were associated with a lower complication rate compared to those published during or before 2013 (0.11 vs 0.33, respectively, p = 0.01).

CONCLUSION

Compared to prior studies on pediatric transfemoral access, transradial access has a higher complication rate. But there may be a lower rate of complications that require surgical intervention. Further studies are needed to clarify any advantages that transradial access may have over transfemoral access for pediatric patients.

Mothers' perspectives of the experience and impact of caring for their child with a life-limiting neurodevelopmental disability

BACKGROUND

This study explored mothers' perspectives of the experiences and impact on themselves and their family when their child has a life-limiting neurodevelopmental disability.

METHODS

Twelve mothers were interviewed and topics included mothers' experiences of caring, the impact on themselves and their family of care provision, and the management of day-to-day life. Data were analysed using thematic analysis.

RESULTS

Four themes were identified. "Starting Out" relates to mothers' experiences of the birth of their child and the aftermath. "Keeping the Show on the Road" describes the strategies families employ to manage life day to day and the resources they use. "Shouldering the Burden" describes the range of physical, psychological, and social consequences of the situation for mothers and the family. "The Bigger Picture" relates to the world outside the family and how this is navigated.

CONCLUSIONS

Findings suggest mothers' overall experiences are characterized by a constant struggle, with evidence of negative impacts on family life, though there is also evidence of resilience and coping. Implications regarding the provision of services are discussed.

Achilles Tenorrhaphy in Five Dogs: A Modified Surgical Technique and Evaluation of a Cranial Half Cast

Achilles mechanism rupture in four of five dogs was treated with tenorrhaphy using a modified surgical technique designed to optimise accurate apposition of tendon to bone. Two bone tunnels were drilled in the calcaneal tuber from a plantomedial - dorsolateral, and plantolateral – dorsomedial direction respectively. The distal ends of the tendons were sutured to the calcaneal tuber using a Krachow suture pattern. The remaining dog had a mid-tendon Achilles mechanism rupture. A resinous half cast was placed on the cranial aspect of the tarsocrural joint of all five dogs, for a minimum of six weeks, in order to provide limited post operative support. Du e to insufficient cast material two of the support splints failed and one of these cases also required a second surgical procedure. A varying amount of soft tissue irritation was noted in each case. All of the five Achilles mechanisms healed, and all of the dogs returned to normal function.

Five dogs with surgical reconstruction of the Achilles mechanism were stabilised postoperatively with a resinous half cast placed on the cranial aspect of the tarsocrural joint for a minimum of six weeks. Two of these casts failed at the tarsocrural joint when six folds of casting material were used; all subsequent cases had eight folds applied. Variable soft tissue irration was observed under the cast in each case. A modified surgical technique using a Krachow suture pattern allowed good tendon-bone apposition. All five Achilles mechanisms healed, and all dogs returned to normal function. Bilateral lesions were identified in 3 of the 4 dogs examined.

Stifle joint luxation in the dog and cat: The use of temporary intraoperative transarticular pinning to facilitate joint reconstruction

Multiple ligament injuries of the canine and feline stifle joint which result in luxation are uncommon. Two cats and one dog, that had sustained such a joint injury were surgically treated. A rupture of the cranial and caudal cruciate ligaments, and at least one collateral ligament was observed in all of the three animals. Prosthetic reconstruction was used, as previously described, in combination with a novel technique of intraoperative placement of a temporary trans-articular pin (TTP) to maintain intra-operative anatomical reduction. TTP placement facilitated maintenance of joint alignment during surgical reconstruction and aided appropriate tensioning of the prosthetic sutures, preventing collapse of femorotibial joint compartments. The TTP was removed prior to closure of the joint allowing immediate post-operative joint mobilisation. Based on assessment by their owners, all the animals made a complete recovery. TTP was considered a relatively simple and effective adjunctive aid for surgical treatment of traumatic luxation of the stifle joint.

Neither Basic Life Support knowledge nor self-efficacy are predictive of skills among dental students

AIM

Basic life support (BLS) is considered a core competence for the graduating dentist. This study aimed to measure BLS knowledge, self-efficacy and skills of undergraduate dental students in Dublin.

METHODS

This study consisted of a cross-sectional survey measuring BLS knowledge and self-efficacy, accompanied by a directly observed BLS skills assessment in a subsample of respondents. Data were collected in January 2014. Bivariate correlations between descriptive and outcome variables (knowledge, self-efficacy and skills) were tested using Pearson's chi-square. We included knowledge and self-efficacy as predictor variables, along with other variables showing association, into a binary logistic regression model with BLS skills as the outcome measure.

RESULTS

One hundred and thirty-five students participated. Almost all (n = 133, 98.5%) participants had BLS training within the last 2 years. One hundred and four (77%) felt that they were capable of providing effective BLS (self-efficacy), whilst only 46 (34.1%) scored >80% of knowledge items correct. Amongst the skills (n = 85) subsample, 38.8% (n = 33) were found to pass the BLS skills assessment. Controlling for gender, age and skills assessor, the regression model did not identify a predictive relationship between knowledge or self-efficacy and BLS skills.

CONCLUSIONS

Neither knowledge nor self-efficacy was predictive of BLS skills. Dental students had low levels of knowledge and skills in BLS. Despite this, their confidence in their ability to perform BLS was high and did not predict actual competence. There is a need for additional hands-on training, focusing on self-efficacy and BLS skills, particularly the use of AED.

Fate of emerging and priority micropollutants during the sewage sludge treatment: Case study of Paris conurbation. Part 1: Contamination of the different types of sewage sludge

This article provides data on the contamination of different kinds of sludge (raw, centrifuged, digested, thermally dried sludge and sludge cake) from Paris conurbation by 71 various pollutants including pharmaceutical products (PHPs), hormones, perfluorinated acids (PFAs), linear alkylbenzene sulfonate (LAS), alkylphenols (APs), phthalates (PAEs), polycyclic aromatic hydrocarbons (PAHs) and polychlorobiphenyls (PCBs). Very high contents of LAS (0.1-10g/kg dry matter - DM) compared to other compounds were found in all types of sludge followed by DEHP (10-100mg/kg DM) and fluoroquinolones (1-100mg/kg DM). APs were measured at intermediary contents in Parisian sludge, lying in the 2-20mg/kg DM range. Finally, hormones, PAHs, PCBs, PAEs, PFAs and the remaining PHPs were all found at contents lower than 1mg/kg DM. For most compounds (PHPs, PFOS, DEHP, PAHs), no significant differences in the micropollutant contents were found for similar types of sludge from different WWTP in Paris, highlighting the homogeneity of sludge contamination in downstream Paris catchment. The variability of concentration is rather high (coefficient of variation >100%) for several PHPs, PFAs or PCBs while it is moderate (<100%) or low (<50%) for fluoroquinolones, hormones, PAHs, APs or LAS. In addition, digestion seems to have a buffer effect as variabilities are lower in digested sludge for PHPs, PFAs, APs and PCBs. During sludge treatment (centrifugation, digestion, thermal drying, sludge conditioning+press filtration), the hormones, LAS, APs, PAHs, DEHP and PCBs concentrations increased, while those of PHPs and PFAs decreased. In the case of digestion, the increase of content can be explained by no pollutant removal or a lower removal than DM removal (concentration phenomenon) whereas the decrease underlines that the compound is more removed than the DM. In any case, these concentration variations presuppose the mechanisms of dissipation that could be attributed to volatilization, biotic or abiotic transformation (complete or with metabolites production), bound residues formation. In addition, data on sludge liquors - centrifuged (CW) and condensed (TDW) waters - from respectively centrifugation and thermal drying were collected. Several hormones, PHPs, PFAs, LAS, PAEs, APs, PCBs and PAHs were quantified in CW and TDW, displaying a transfer through the water removal. The concentrations observed are rather comparable to those found in wastewater.

Concentrating on Beauty: Sexual Selection and Sociospatial Memory

In three experiments, location memory for faces was examined using a computer version of the matching game Concentration. Findings suggested that physical attractiveness led to more efficient matching for female faces but not for male faces. Study 3 revealed this interaction despite allowing participants to initially see, attend to, and match the attractive male faces in the first few turns. Analysis of matching errors suggested that, compared to other targets, attractive women were less confusable with one another. Results are discussed in terms of the different functions that attractiveness serves for men and women.

Using encapsulated freeze-dried lipids to trigger a gastrointestinal vagal reflex: validation in a pig model

BACKGROUND

Nutrient-sensing studies in humans frequently use intragastric intubation. A non-invasive alternative would be the use of freeze-dried lipids (FDL) capsules. We proposed to validate this method in pigs by (i) demonstrating that low-dose FDL can increase vagal activity, gastric compliance (GC), and delay gastric emptying time (GET); (ii) evaluating the release kinetics of encapsulated FDL.

METHODS

Nine conscious pigs fitted with duodenal catheter and gastric cannula were administered FDL (3-mL freeze-dried Intralipid(®) ). Vagal tone was estimated via heart rate variability (HRV) measurements, GC was measured via the barostatic method, and GET after a test meal was evaluated via scintigraphy. FDL vs placebo (methylcellulose [MC]) capsules release kinetics were also evaluated via scintigraphy.

KEY RESULTS

Duodenal FDL infusion increased GC in 2/8 trials only, but systematically delayed GET compared to saline (96 vs 70 min; p = 0.018). The presence of FDL in the duodenum decreased heart rate, increased vagal tone, and HRV. FDL capsules released their content in the duodenum before MC capsules (41 vs 67 min; p = 0.013), and MC induced ECG data quite similar to FDL except for HRV (p = 0.011).

CONCLUSIONS & INFERENCES

Low-dose FDL was a potent signal to induce vagal reflex and increase GET. FDL capsules released their content in the duodenum and activated the vagal pathway after approximately 40 min, which is an important data for designing future paradigms in humans. MC was not a good placebo because of its stickiness and ability to activate the vagal pathway too.

Expanding the test of counterfeit deviance: are sexual knowledge, experience and needs a factor in the sexualised challenging behaviour of adults with intellectual disability?

It is posited within the literature that the sexualised challenging behaviour of adults with intellectual disability may be influenced by low levels of sexual knowledge, lack of sexual experience and unmet sexual needs. In this study, individuals with sexualised challenging behaviour were identified and matched for gender, age and ability level with individuals recruited to the non-sexualised and no challenging behaviour groups. All (n=24) were interviewed using the Socio-Sexual Knowledge and Attitudes Tool - Revised (SSKAAT-R) and the Sexual Knowledge, Experience and Needs Scale for Intellectual Disability (Sex-Ken-ID) to assess their sexual knowledge, experience and needs. Adaptive behaviour was measured as a covariate. In the current study, contrary to expectations in the wider literature, the sexualised challenging behaviour group showed significantly higher levels of sexual knowledge in several areas when adaptive behaviour was controlled. Their needs in relation to Dating and Intimacy were also significantly higher but no differences were found between groups in relation to sexual experience. The implications of these findings for service provision are outlined along with the considerations of directions for future research.

Validation of the confusion assessment method in the palliative care setting

The Confusion Assessment Method (CAM) is widely used in the palliative care setting despite the fact that its performance in this population has not been validated. The aim of the study was to determine the sensitivity and specificity of the CAM when used by Non-Consultant Hospital Doctors (NCHDs) working in a specialist palliative care unit. A pilot phase was performed in which NCHDs received a 1-hour training session based on the original CAM training manual. 32 patients underwent 33 assessments in the pilot phase but the sensitivity of the CAM was only 0.5 (0.22-0.78) and specificity was 1.0 (0.81-1.0). An 'enhanced' training programme was devised that took place over two 1-hour sessions and involved case-based learning focused on the areas where the NCHDs were experiencing difficulty. 52 patients underwent 54 assessments in the main phase of the study and the performance of the CAM improved significantly. Sensitivity was 0.88 (0.62-0.98) and specificity was 1.0 (0.88-1.0). The results suggest that the CAM is a valid screening tool for delirium in the palliative care setting but its performance is dependent on the skill of the operator. NCHDs require a certain standard of training before becoming proficient in its use.

A study of complicated grief symptoms in people with intellectual disabilities

INTRODUCTION

Previous studies have shown a significant association between familial bereavement and the onset of challenging behaviours and psychopathology in people with intellectual disabilities (ID). However, little work has been done to accurately describe the specific symptoms of grief, in particular symptoms of complicated grief in this population. Consensus criteria for the diagnosis of complicated grief have been drawn up and tested for validity in the general population.

AIMS

To examine the occurrence of symptoms of complicated grief, and to explore the relationships between complicated grief and bereavement experience.

METHOD

A bereavement history questionnaire and a newly developed measure examining for symptoms of complicated grief were administered to a group of carers of people with mild or moderate ID, who had experienced a parental bereavement within the previous 2 years. The questionnaires were also administered to a matched comparison group, who had not been bereaved.

RESULTS/CONCLUSIONS

This carer-based comparison study has revealed that bereaved individuals with ID experience complicated grief symptoms following the death of a parent, with one-third of the bereaved group experiencing 10 or more clinically apparent symptoms. In addition, complicated grief symptoms were more likely to occur with higher rates of bereavement ritual involvement. These findings have both clinical and research implications.

Peripheral blood lymphocytes from patients with rheumatoid arthritis are differentially sensitive to apoptosis induced by anti-tumour necrosis factor-alpha therapy

OBJECTIVE

The efficacy of anti-tumour necrosis factor-alpha (TNF-alpha) therapies in rheumatoid arthritis (RA) has been mainly attributed to TNF-alpha neutralisation. Other mechanism as immune cell apoptosis, which is impaired in RA, may also be induced by anti-TNF-alpha therapies. The aim of our study was to investigate whether TNF-alpha inhibitors could induce apoptosis in vitro of the peripheral blood lymphocytes of RA patients.

METHODS

Peripheral blood mononuclear cells (PBMC) isolated from 24 patients with RA and 18 healthy donors were incubated with anti-TNF-alpha agents, infliximab or etanercept, in comparison with no agent and including an isotypic control, for 48 hours. Apoptosis was detected and quantified by annexin V labelling of phosphatidylserine externalization using cytofluorometric analysis and compared with PBMC production TNF-alpha in vitro.

RESULTS

In healthy donors, induced apoptosis was observed in 0.3% to 3.8% of lymphocytes with both therapies. In RA patients the treatment induced lymphocyte apoptosis in 17 of 24 patients with a percentage of annexin V-positive lymphocytes ranging from 0.1% to 25%. Among these 17 RA patients, a significant in vitro lymphocyte apoptosis (> 4%) was observed in 11 patients (46%) compared with healthy donors (p < 0.01). The variability of the response to anti-TNF-alpha within the RA population was not dependent on TNF-alpha synthesis or disease activity.

CONCLUSION

In vitro induction of lymphocyte apoptosis by anti-TNF-alpha was observed in a subgroup of RA patients. Based on these data, it would be of interest to further study the interindividual variations of sensitivity to apoptosis induced by TNF alpha inhibitors in relation to treatment efficacy or resistance observed in RA patients.

The prevalence of features of attention deficit hyperactivity disorder in a special school in Ireland

BACKGROUND

The prevalence of features of attention deficit hyperactivity disorder (ADHD) in children with intellectual disabilities (ID) in Irish schools is unknown. The aim of this study was to examine the prevalence of features of ADHD in a special school, in order to ascertain the number of children who may need further assessment for ADHD. The study also explores the reliability of the Conners Teachers Rating Scale in this population.

METHOD

All teachers in a special school for children with ID were asked to complete the Conners Teachers Rating Scale and the Attention-Distractibility, Inhibition-Excitation Classroom Assessment Rating Scale, for those children whose parents had consented for them to take part in this study. Consent was obtained for 84 children a response rate of 71%, between the ages of 5 and 18 (mean = 10.5 years; SD = 3.7).

RESULTS

The Conners Teachers Rating Scale was found to be internally reliable and had a normal distribution with our results. Overall, 55.9% of participants (47/84) had markedly elevated scores (T > 69) for at least one of the target subscales, which were the 'Hyperactivity', 'Inattention' and the 'ADHD Index' subscales of the Conners Teachers Rating Scales. In addition, the findings would suggest that the Conners Teachers Rating Scale can be a useful screening tool in the population of school children with ID.

CONCLUSIONS

The study suggests that ADHD may be under diagnosed in children with ID. This has practical implications for the mental health needs of these children. It is recommended that further studies are carried out to determine the prevalence of ADHD in this population.

Blood transfusion requirement prediction in patients undergoing primary total hip and knee arthroplasty

The aim of this study was to identify the clinical factors associated with the need for peri-operative blood transfusion in non-anaemic patients undergoing hip or knee arthroplasty. We prospectively evaluated 162 consecutive patients who underwent total hip or knee arthroplasty. Analysis was performed to establish the relationship between all independent variables and the need for postoperative transfusion. Univariate analysis revealed a significant relationship between the need for postoperative blood transfusion and the pre-operative haemoglobin levels (P= 0.001), weight (P= 0.019) and age (P= 0.018). Multivariate analysis identified a significant relationship only between the need for transfusion and the pre-operative haemoglobin level (P= 0.0001). The pre-operative haemoglobin level of the patient was the only variable to independently predict the need for blood transfusion after primary hip or knee arthroplasty.

Survey of prick test, total and specific age during food allergy in children

AIM

To analyze the results of a systematic survey of biological tests in a symptomatic pediatric population consulting for the exploration of a possible food allergy.

PATIENTS AND METHODS

406 children included in this study, mean age 3.3+3.2 years (2 months-16 years), 159 girls and 247 boys, had cutaneous tests (Stallergènes, Paris, France), assaying of total and specific IgE, and RAST Fx5 (Pharmacia & Upjohn Diagnostics AB, Uppsala, Sweden). Those children suffering from eczema (34.9%), digestive disorders (26.1%), ORL and pulmonary (8.3%), anaphylactic choc (3.4%) or mixed symptoms (27.3%).

RESULTS

The overall positivity of cutaneous tests, all confused age periods, was 34.1% with the following order: egg white (52%, p < 0.05 vs. other food), peanut (46%), egg yolk (42%), fish (34%), wheat (33%), soy (32%), cow's milk (24%) and rice (17%). It decreased significantly with age only for the egg white, 61% (0-1 year) and 68% (1-2 years) vs 31% (> 6 years), p < 0.05. The positivity of cutaneous tests for egg and peanut was more frequent with eczema than with digestive manifestations (64% vs. 44%, 57.6% vs. 34% and 56% vs. 38.7%, p < 0.05). The title of total IgE increased with age, r 0.5 p 0.001. The positivity of specific food IgE was more frequent at 4-6 years (68%) than at 0-1 year (36%), p < 0.05. It revealed, all confused age periods, the following order: egg white (74%) and peanut (64%), p < 0.05 vs. other food, cow's milk (59%), wheat (55%), soy (45%) and fish (24%). The number of high specific food IgE titers was significantly higher than the number of positive cutaneous tests by order of frequency; egg white, peanut, cow's milk, wheat and soy, p < 0.05; the reverse was observed for fish, p < 0.05. Percentage of subjects combining a high title of specific food IgE and a positive cutaneous test for egg white (39.4%) was significantly higher than the percentage of those combining a high RAST Fx5 title and a positive cutaneous test for at least one of 6 corresponding foods (25.2%), p < 0.05.

CONCLUSION

The positivity of different food cutaneous tests, the rate of total and specific IgE titers and the agreement of the results varied according to age, food and symptoms.

Hydrogen peroxide as an irrigation solution in arthroplasty – A potential contributing factor to the development of aseptic loosening

The reason for revision of primary total hip arthroplasty is quoted as aseptic loosening in 60.6% of cases between 1979 and 2003 in the Swedish National Hip Arthroplasty Registry. Much research effort has been directed toward enhancing the bone-cement interface of total joint arthroplasties, in an attempt to reduce this complication. Haemostatic agents have been popularized as effective means of retarding the development of potentially harmful debris interposition adjacent to, and blood lamination patterns within, the methylmethacrylate. Such agents include hydrogen peroxide (H(2)O(2)), local freezing saline, saline at room temperature and adrenaline solution. One main concern with the use of hydrogen peroxide is whether it affects the material properties of bone cement such that in the long term it contributes to aseptic loosening. This would have enormous clinical consequences. Preliminary studies indicate that porosity increases and that the tensile strength and yield stresses are reduced by up to a factor of 10 by contaminating samples with increasing concentrations of hydrogen peroxide. We postulate that the current use of hydrogen peroxide as an irrigation solution in arthroplasty contributes to the development of aseptic loosening.

Emergence of constraint in self-organizing systems

Practitioners of agent-based modeling are often tasked to model or design self-organizing systems while the theoretical foundation of self-organization in science remains to be set. This paper explores self-organization in the context of an agent-based model of ant colony food foraging. We gather specific measures of order-creation and constraint construction particular to leading theories of nonequilibrium thermodynamics that purport to govern self-organizing dynamics. These measures are used to explore three claims: (a) Constraints are constructed from entropy-producing processes in the bootstrapping phase of self-organizing systems; (b) positive feedback loops are critical in the structure formation phase; and (c) constraints tend to decay. The continued presence of far-from-equilibrium boundary conditions are required to reinforce constraints in the maintenance phase.

The relationship of APOE genotype to neuropsychological performance in long-term cancer survivors treated with standard dose chemotherapy

PURPOSE

The primary purpose of this study was to compare the neuropsychological performance of long-term survivors of breast cancer and lymphoma treated with standard dose chemotherapy who carried the epsilon 4 allele of the Apolipoprotein E (APOE) gene to those who carry other APOE alleles.

PATIENTS AND METHODS

Long-term survivors (mean=8.8+/-4.3 years post-treatment) of breast cancer (N=51, age=55.9+/-8.8) or lymphoma (N=29, age=55.8+/-11.6) who had been treated with standard-dose chemotherapy completed a standardized battery of neuropsychological and psychological tests. Survivors were also classified into two groups based on the presence (N=17) or absence (N=63) of at least one epsilon 4 allele of APOE.

RESULTS

Analysis of covariance, controlling for age, gender, education, diagnosis, and WRAT-3 reading subtest (a proxy measure of baseline IQ), indicated that survivors with at least one epsilon 4 allele scored significantly lower in the visual memory (p<0.03) and the spatial ability (p<0.05) domains and tended to score lower in the psychomotor functioning (p<0.08) domain as compared to survivors who did not carry an epsilon 4 allele. No group differences were found on depression, anxiety, or fatigue.

CONCLUSIONS

The results of this study provide preliminary support for the hypothesis that the epsilon 4 allele of APOE may be a potential genetic marker for increased vulnerability to chemotherapy-induced cognitive decline.

Changes in intragastric meal distribution are better predictors of gastric emptying rate in conscious pigs than are meal viscosity or dietary fibre concentration

The effect of dietary fibre on the gastric emptying rate of solids is controversial. Similarly, the mechanisms by which it modulates food intake are partially unknown. Gastric emptying and proximal v. distal stomach filling were evaluated in triplicate on four conscious pigs using scintigraphic imaging. Each animal received in an isoenergetic manner a concentrate low-fibre diet enriched in starch (S) and two high-fibre diets based on sugar beet pulp (BP) or wheat bran (WB). All meals had the same viscosity before ingestion (100.0-100.5 Pa.s). Viscosity of the gastric contents was measured in four additional animals fitted with a gastric cannula. The gastric emptying rate of BP diet was significantly slower than S and WB diets (t1/2 78.4 (sem 5.68), 62.8 (sem 10.01) and 111.6 (sem 10.82) min for S, WB and BP diets respectively, P<0.05). For BP diet only, rate of distal stomach filling was steady during the first 120 min after the meal whereas that of S and WB diets decreased in an exponential manner. Numerous backflow episodes from the distal into the proximal stomach were observed for BP diet that generated the larger intragastric viscosity (0.26 (sem 0.03), 0.3 (sem 0.02) and 0.52 (sem 0.002) Pa.s for S, WB and BP respectively). In conclusion, viscosity of the meal or the percentage total fibre, unlike viscosity of the gastric contents, are poor predictors for emptying. The reduced emptying rate observed with BP is associated with major changes in intragastric distribution of the meal absent with WB and S diets.

Cleavage and relocation of the tyrosine kinase P59FYN during Fas-mediated apoptosis in T lymphocytes

Ligation of Fas with its natural ligand or with anti-Fas antibodies induces an apoptotic program in Fas sensitive cells. We report here the identification of the tyrosine kinase p59Fyn as a substrate for CPP32-like proteinases and more particularly caspase 3 during Fas-mediated apoptosis in Jurkat T cells. Inhibition of CPP32-like proteinases by Ac-Asp-Glu-Val-Asp-aldehyde but not by Ac-Tyr-Val-Ala-Asp-aldehyde prevents CPP32, PARP and p59Fyn cleavage indicating that CPP32 or CPP32-like proteinases are responsible for the cleavage of p59Fyn. Cleavage occurs in the N-terminal domain of p59Fyn between Asp19 and Gly20 and is accompanied by relocation of an active p57Fyn kinase to cytoplasm of Fas-stimulated Jurkat cells as judged by both biochemical and confocal microscopy experiments. Thus, p59Fyn relocation and activity may play an important role during Fas-mediated cell death in human T lymphocytes.

Floquet perturbative analysis for STIRAP beyond the rotating wave approximation

We present a perturbative analysis of Floquet eigenstates in the context of two delayed laser processes (STIRAP) in three level systems. We show the efficiency of a systematic perturbative development which can be applied as long as no non-linear resonances occur.

Synergistic effects of colony-stimulating factor 1 and leukemia inhibitory factor in inducing early myeloid cell differentiation

Cells of the M1D+ murine myeloid leukemic cell line differentiate into macrophages in response to either leukemia inhibitory factor (LIF) or interleukin 6. Previously, it was shown that LIF treatment of M1D+ cells leads to an increased expression of colony-stimulating factor (CSF) receptor mRNA encoded by c-fms. CSF-1, a macrophage growth factor, induces the survival, growth, and differentiation of mononuclear phagocytes but has not been implicated in the regulation of early myeloid cell differentiation. Here we show that low-dose LIF treatment of M1D+ cells results in CSF-1 secretion and CSF-1 receptor up-regulation. CSF-1, when applied alone, induces some M1D+ adherence and the up-regulation of lysozyme M, a macrophage-specific marker. Finally, we show that when applied together, LIF and CSF-1 act synergistically to induce macrophage morphology, phagocytosis, and the expression of the macrophage-specific markers CD11b/Mac-1 alpha chain, lysozyme M, FcgammaRII, and JE/MCP.1. These results indicate that instead of being part of exclusive pathways, as thought until this work, LIF and CSF-1 can function synergistically to further stimulate the early stages of myeloid differentiation.

Diabetes during pregnancy does not alter whole body bone mineral content in infants

A previous study using single photon absorptiometry has reported low bone mineral density of the radius in infants of diabetic mothers. The aim of this study was to assess by dual x-ray absorptiometry the whole body bone mineral content (WbBMC) and the body composition of 40 infants of diabetic mothers at birth (mean gestational age +/- SD, 37.5 +/- 1.3 weeks; mean birth weight +/- SD, 3815 +/- 641 g). WbBMC was not correlated with gestational age, but was well correlated with birth weight (r = 0.73; P = 0.0001) and also with fat mass (r = 0.87; P = 0.0001) and lean mass (r = 0.42; P = 0.008). The z-scores +/- SD adjusted for weight for WbBMC and fat mass were significantly increased (1.3 +/- 0.9 and 2.6 +/- 1.3, respectively (P < 0.0001), but were not significantly influenced either by in utero growth or by the type of the diabetes mellitus of the mother. Bone mineralization and fat mass studied by whole body dual x-ray absorptiometry are increased at birth in these infants compared with reference curves.

Endopeptidase 24.11 (CD10/NEP) is required for phorbol ester-induced growth arrest in Jurkat T cells

Jurkat T cells express a functional endopeptidase 24.11 that is involved in the regulation of T cell activation. We have analyzed the effect of ectopic CD10 expression in mutant Jurkat cell clones that fail to express CD10 and, unlike wild-type cells, are resistant to the growth-inhibitory effects of the protein kinase C activator, PMA. No differences in the expression of the mRNA encoding the alpha, beta, gamma, delta, epsilon, and zeta isoforms of PKC were found in parental vs. PMA-resistant Jurkat cells, ruling out the possibility that the defect could be accounted for by an altered expression of one of these isoforms. Phorbol ester-induced growth arrest was not due to apoptosis since PMA failed to trigger DNA fragmentation in parental and mutant Jurkat T cells. CD10 mRNA expression and activity were abrogated in four independent PMA-resistant Jurkat T cell clones compared to parental cells, whereas the activities of several other peptidases were unaffected. Transfection of one mutant clone with a functional endopeptidase 24.11 restored in a significant manner PMA-induced growth arrest in all the clones selected and tested, whereas transfection of an inactive form of endopeptidase 24.11 had no effect, demonstrating that the enzymatic activity of CD10 is critical in the mediation of the PMA growth arrest. The data presented here demonstrate that a functional CD10 is required for PMA-induced growth arrest in Jurkat cells and provide further evidence for a role of endopeptidase 24.11 in the regulation of tumor cell proliferation.

CD10 (endopeptidase 24.11) is a thymic peptide-degrading enzyme possibly involved in the regulation of thymocyte functions

Human immature thymocytes express significant levels of the CD10 (endopeptidase 24.11) cell surface antigen. We report here that IOB5, an anti-CD10 mAb, as well as the phorbol ester PMA down-regulate CD10 activity at the surface of human thymocytes. The kinetics of CD10 modulation were drastically different for both effectors, indicating different regulatory mechanisms. We also demonstrated that intact human thymocytes hydrolyze thymopentin and that CD10 significantly participates in this process. Finally, we found that thymopentin and to a lesser extent phosphoramidon, a specific endopeptidase 24.11 inhibitor, induced up-regulation of CD4 and CD8 molecules at the thymocyte cell surface. In view of these results, we suggest that down-regulation of endopeptidase 24.11 at the thymocyte cell surface might reduce its activity toward thymic factors possibly involved in the regulation of thymocyte functions.

Thrombin and trypsin-induced Ca(2+) mobilization in human T cell lines through interaction with different protease-activated receptors

This study was conducted to determine whether serine proteinases may induce [Ca(2+)]i mobilization in different hematopoietic cell lines and to analyze their mechanisms of action. We show that in addition to thrombin and thrombin receptor agonist peptide (TRP, SFLLRN), trypsin induced [Ca(2+)]i mobilization in a highly thrombin-sensitive Jurkat T cell clone. Thrombin, TRP, and trypsin were found to induce [Ca(2+)]i release in three different Jurkat T cell clones differing in the level of T cell receptor expression. Similar results were obtained with a prothymocytic leukemic cell line, HPB.ALL, although these cells were much more responsive to trypsin than to thrombin and TRP. Other cell types such as THP1, a myelomonocytic cell line, or CEM, a CD4(+) positive leukemic cell line, were unresponsive to thrombin, TRP, and trypsin. The effect of trypsin was mimicked by SLIGRL, a peptide corresponding to the cleaved amino-terminal sequence of the recently characterized murine trypsin-activated receptor (PAR2). At suboptimal concentrations, the effects of SFLLRN and SLIGRL were additive, whereas saturating doses of peptides did not further increase [Ca(2+)]i mobilization in Jurkat T cells, indicating that both peptides were able to mobilize the same pool of calcium. Northern blot analysis of mRNAs from different leukemic cell lines indicated a remarkable correlation between PAR2 expression in different cell lines and SLIGRL or trypsin responses in the same cells. The expression of the "trypsin receptor" was also confirmed by polymerase chain reaction analysis. Moreover, a 24 h treatment of Jurkat cells by an anti-CD3 monoclonal antibody, a condition known to down-regulate thrombin receptor expression, induced loss of thrombin and TRP responses but only partially affected trypsin stimulation of [Ca(2+)]i release. Finally, after a first stimulation with either thrombin or trypsin, Jurkat cells were still able to respond to trypsin or thrombin, respectively, demonstrating that thrombin and trypsin essentially activated their own receptors. Our data provided evidence that 1) the human T leukemic cell line Jurkat and other T cell lines express at least two different functional protease-activated receptors, the thrombin receptor and a highly sensitive trypsin receptor, likely the human counterpart of the murine PAR2, and 2) at variance with the commonly accepted model, trypsin exerts most of its effect in T leukemic cell lines by thrombin receptor-independent mechanisms.

High levels of functional endopeptidase 24.11 (CD10) activity on human thymocytes: preferential expression on immature subsets

Although it is now well established that cells of the immune system express most of the exopeptidases described so far, little information is available concerning the identification and the characterization of the peptidases associated with the surface of human thymocytes. In the present study we have focused on CD10 expression on thymocytes using both FACS and enzymatic analysis. Unfractionated intact human thymocytes were shown to express significant levels of CD10-specific enzymatic activity, as assessed by the hydrolysis of the neutral endopeptidase (NEP) substrate Suc-Ala-Ala-Phe-pNA and of D-Ala2-Leu-enkephalin, a typical NEP substrate. CD10 activity was abolished by specific NEP inhibitors, including thiorphan, retrothiorphan and phosphoramidon. Moreover, high performance liquid chromatography (HPLC) analysis showed that intact thymocytes and purified NEP hydrolysed thymopentin, a thymic factor known to induce the maturation of prothymocytes into thymocytes. Finally, CD 10/NEP was preferentially associated with CD3- CD3low and immature CD4- CD8- thymocytes. The data demonstrate for the first time that human thymocytes express functional NEP and suggest a role for this enzyme in the maturation of human thymocytes.

Secondary trisomy or mosaic "tetrasomy" 8p

We report on two patients with mosaic tetrasomy of 8p[46,XY/47,XY,+i(8p)], a previously unreported cytogenetic anomaly. The first patient had a low percentage of tetrasomic (secondary trisomic) cells in lymphocytes and fibroblasts, an only mildly abnormal phenotype, and a rather benign clinical course. The second patient had a considerably larger percentage of tetrasomic cells in lymphocytes and fibroblasts, and had more severe congenital anomalies that led to his death at 8 months. A characteristic phenotype +i(8p) is suggested but not yet established. The manifestations of these two patients resemble those of mosaic trisomy 8 and mosaic trisomy 8p, with rib and vertebral abnormalities, absent corpus callosum, and enlarged cerebral ventricles.

Heterogeneity in ampR-ampC gene interaction in Enterobacter cloacae

The ampR gene and its regulation of AmpC beta-lactamase synthesis were investigated for Enterobacter cloacae 1194E, a wild-type strain producing a group A (pI 8.7) enzyme. Expression of the cloned E. cloacae 1194E ampR-ampC region was examined initially in Escherichia coli HB101. However, transformants showed only constitutive beta-lactamase expression. For study of enzyme expression in a more closely related host, the cloned E. cloacae 1194E ampR-ampC region was transformed into E. cloacae 55, a wild-type strain producing a group B (pI 7.8) enzyme. Results indicated a functional E. cloacae 1194E ampR gene that could not be transcomplemented by E. cloacae 55. A comparative analysis of ampR nucleotide and amino acid-sequence data from E. cloacae 1194E and E. cloacae MHN1 revealed related but divergent genes. Thermal induction studies of AmpC beta-lactamase also indicated a difference between E. cloacae 1194E and E. cloacae 55 in ampR-ampC interaction. Thus, it appears that, in at least some strains of Enterobacter, significant intraspecies divergence of ampR has occurred. This heterogeneity in ampR would not have been detected with beta-lactamase expression studies conducted exclusively in E. coli.