Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.

Child drowning mortality in the Sundarbans, India: Applying the Community Knowledge Approach

Background

The Sundarbans in India is a rural, forested region where children are exposed to a high risk of drowning due to its waterlogged geography. Current data collection systems capture few drowning deaths in this region due to its remoteness and poor coverage of health and police systems. Household methodology was found to be resource and time intensive, and so a Community Knowledge Approach was used and applied to calculate injury mortality for the first time.

Methods

A community-based survey was conducted in the Sundarbans to determine the drowning mortality rate for 1-4 and 5-9 year old children. A Community Knowledge Approach was applied. Meetings were held with law community residents and key informants to identify drowning deaths in the population. Identified deaths were verified by the child's household through a structured survey, inquiring on the circumstances around the drowning death.

Results

The drowning mortality rate for children aged 1-4 years old was 243.8 per 100,000 children and 38.8 per 100,000 children for 5-9-year olds. 58.0% of deaths were of 1-2-year-old children. Most children drowned in ponds within 50 metres of their homes. Children were usually unaccompanied with their primary caretaker engaged in household work. Only one third of deaths were reported to hospitals or civil registration systems. Of deaths listed by community members, 63.0% were identified by both residents and by at least one key informant, 25.6% by key informants only, and 11.4% (n = 79) by community residents only.

Conclusions

Drowning is a major cause of death among children in the Sundarbans, particularly those aged 1-4 years old. The results illustrate how routine data collection systems grossly underestimate drowning deaths, emphasising the importance of community-based in rural low-and middle-income country contexts.

Key messages

Drowning is likely the largest killer of 1-9 year old children in the Sundarbans region, emphasising the need to better understanding drowning epidemiology in similar rural LMICs contexts. The Community Knowledge Approach provides a low-resource, valid method for capturing injury mortality data.

Diabetes in adults with intellectual disability: prevalence and associated demographic, lifestyle, independence and health factors

BACKGROUND

As people with intellectual disabilities (ID) are now living longer, they are more at risk of developing non-communicable diseases, including type 2 diabetes mellitus. However, understanding of factors associated with diabetes for targeted management and prevention strategies is limited. This study aimed to investigate prevalence of diabetes in adults (aged ≥18 years) with ID and its relationship with demographic, lifestyle, independence and health factors.

METHOD

This was a cross-sectional analysis of interview data from 1091 adults with ID from the Leicestershire Learning Disability Register from 1 January 2010 to 31 December 2016. Logistic regression models were used to identify factors associated with diabetes in the study population.

RESULTS

The study population did not have healthy lifestyles: just under half reported having lower physical activity levels than people without ID of a similar age; one-quarter consumed fizzy drinks daily; and 20% consumed five or more fruit and/or vegetables per day. Prevalence of carer/self-reported diabetes was 7.3% (95% confidence interval 5.9-9.0). After adjustment, diabetes was positively associated with South Asian ethnicity (P = 0.03) and older age groups (P < 0.001). Diabetes was less common in people living with family members (P = 0.02). We did not find a relationship between any of the lifestyle, independence and health factors investigated.

CONCLUSIONS

A significant proportion of people with ID are living with diabetes. Diabetes management and prevention strategies should be tailored to individuals' complex needs and include consideration of lifestyle choices. Such strategies may want to focus on adults of South Asian ethnicity and people living in residential homes where prevalence appears to be higher.

Multimorbidity and lifestyle factors among adults with intellectual disabilities: a cross-sectional analysis of a UK cohort

BACKGROUND

Multimorbidity [two or more conditions in addition to intellectual disability (ID)] is known to be more common among people with ID. However, the relationship between multimorbidity and lifestyle factors is currently unknown. The aim of this study was to determine the prevalence of multimorbidity in a population of adults with ID. We also aimed to identify risk factors, including lifestyle factors, for multimorbidity in this population.

METHODS

This was a cross-sectional analysis using data from a diabetes screening study of 920 adults aged 18-74 years with ID living in Leicestershire, UK. We described comorbidities and the prevalence of multimorbidity in this population. We explored the relationship between multimorbidity and age, gender, ethnicity, severity of ID, socio-economic status, physical activity, sedentary behaviour, fruit and vegetable consumption and smoking status using multiple logistic regression.

RESULTS

The prevalence of multimorbidity was 61.2% (95% CI 57.7-64.7). Multimorbidity was independently associated with being female (P < 0.001) and severe/profound ID (P = 0.004). Increasing age was of borderline significance (P = 0.06). Individuals who were physically inactive or sedentary were more likely to be multimorbid, independent of ability to walk, age, gender, severity of ID, ethnicity and socio-economic status (adjusted OR = 1.91; 95% CI 1.23-2.97; P = 0.004 and OR = 1.98; 95% CI 1.42-2.77; P < 0.001). After excluding probable life-long conditions (autism spectrum conditions, attention deficit hyperactivity disorders, epilepsy, cerebral palsy and other paralytic syndromes) as contributing comorbidities, the effect of sedentary behaviour, but not physical activity, remained (P = 0.004). We did not observe a relationship between multimorbidity, fruit and vegetable consumption and smoking status.

CONCLUSIONS

Multimorbidity presents a significant burden to people with ID. Individuals who were physically inactive or sedentary were more likely to be multimorbid, but further work is recommended to explore the relationship between multimorbidity and lifestyle factors using standardised objective measures.

The characteristics of 76 atypical neurofibromas as precursors to neurofibromatosis 1 associated malignant peripheral nerve sheath tumors

Background

Neurofibromatosis 1 (NF1) leads to the development of benign and malignant peripheral nerve sheath tumors (MPNST). MPNST have been described to develop in preexisting benign plexiform neurofibromas (PN) and have a poor prognosis. Atypical neurofibromas (ANF) were recently described as precursor lesions for MPNST, making early detection and management of ANF a possible strategy to prevent MPNST. We aimed to clinically characterize ANF and identify management approaches.

Methods

We analyzed clinical, imaging, and pathology findings of all patients with NF1 and ANF at 3 institutions.

Results

Sixty-three patients had 76 ANF (32M/31F; median age 27.1 y). On MRI, most ANF appeared as distinct nodular lesions and were 18F-fluorodeoxyglucose (FDG) avid. Forty-six ANF were associated with pain, 19 with motor weakness, 45 were palpable or visible, and 13 had no clinical signs. Completely resected ANF (N = 57) have not recurred (median follow-up, 4.1 y; range, 0-14 y). Four ANF transformed into MPNST and 17 patients had a history of MPNST in a different location than was their ANF.

Conclusions

Growth of distinct nodular lesions, pain, and FDG-PET avidity should raise concern for ANF in NF1. Patients with ANF are at greater risk for development of MPNST. Complete resection of ANF may prevent development of MPNST.

Psychiatry of learning disability – a future with mental health?

Aims and Method

A postal survey was sent to all consultants in the psychiatry of learning disability from four English regions. Their views on job satisfaction, their core roles and the management re-structuring of services were elicited.

Results

The proportion agreeing or strongly agreeing with each management option was 79% for integrated mental health–learning disability trusts, 61% for specialist learning disability trusts, 47% for care trusts, 10% for primary care trusts and 5% for social services. Only 34% felt consulted or able to influence the process of change and only 33% were satisfied with the current management changes within their trust but 67% were satisfied overall with their jobs.

Clinical Implications

Management from integrated mental health–learning disability trusts is the most preferred option for psychiatrists in learning disability. A large number of consultants, though otherwise satisfied with their jobs, feel excluded or unable to influence the current changes in management structures. A model of integrated service provision in line with the government's learning disability strategy is presented.

Type 2 diabetes and glucose intolerance in a population with intellectual disabilities: the STOP diabetes cross-sectional screening study

BACKGROUND

Adults with intellectual disabilities (ID) may be at increased risk of developing type 2 diabetes and cardiovascular disease, due to lifestyle factors, medications and other diagnosed conditions. Currently, there is lack of evidence on prevalence and prevention in this population. The aim of this study was to conduct a diabetes screening programme to determine prevalence of previously undiagnosed type 2 diabetes and impaired glucose regulation in people with ID.

METHODS

Screening was conducted in a variety of community settings in Leicestershire, UK. Adults with ID were invited via: general practices; the Leicestershire Learning Disability Register; ID psychiatric services; and some people directly contacted the research team due to publicity about the study. Screening involved collection of anthropometric, biomedical and questionnaire data. Type 2 diabetes and impaired glucose regulation were defined according to (venous) fasting plasma glucose or HbA1c, following current World Health Organisation criteria.

RESULTS

Nine hundred thirty adults (29% of those approached) participated. Mean age was 43 years, 58% were male and 16% of South Asian ethnicity. Most participants were either overweight or obese (68%). Diabetes status was successfully assessed for 675 (73%) participants: Nine (1.3%, 95% confidence interval 0.6 to 2.5) were found to have undiagnosed type 2 diabetes, and 35 (5.2%, 95% confidence interval 3.6 to 7.1) had impaired glucose regulation. Key factors associated with abnormal glucose regulation included the following: non-white ethnicity and a first degree family history of diabetes.

CONCLUSIONS

Results from this large multi-ethnic cohort suggest a low prevalence of screen-detected (previously undiagnosed) type 2 diabetes and impaired glucose regulation in adults with ID. However, the high levels of overweight and obesity we found emphasise the need for targeted lifestyle prevention strategies, which are specifically tailored for the needs of people with ID.

Inhibition of B Cell Receptor Signaling by Ibrutinib in Primary CNS Lymphoma

Primary CNS lymphoma (PCNSL) harbors mutations that reinforce B cell receptor (BCR) signaling. Ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor, targets BCR signaling and is particularly active in lymphomas with mutations altering the BCR subunit CD79B and MYD88. We performed a proof-of-concept phase Ib study of ibrutinib monotherapy followed by ibrutinib plus chemotherapy (DA-TEDDi-R). In 18 PCNSL patients, 94% showed tumor reductions with ibrutinib alone, including patients having PCNSL with CD79B and/or MYD88 mutations, and 86% of evaluable patients achieved complete remission with DA-TEDDi-R. Increased aspergillosis was observed with ibrutinib monotherapy and DA-TEDDi-R. Aspergillosis was linked to BTK-dependent fungal immunity in a murine model. PCNSL is highly dependent on BCR signaling, and ibrutinib appears to enhance the efficacy of chemotherapy.

Plasma and cerebrospinal fluid pharmacokinetics of doxil after intravenous administration in adults with primary CNS lymphoma

e14067

Background: Doxil, a pegylated liposomal doxorubicin (PLD) has excellent CNS penetration in rodent brain tumor models and is active in patients with lymphoma. The CNS penetration of doxil in humans is unknown. We evaluated the plasma and cerebrospinal fluid (CSF) pharmacokinetics (PK) of doxil in adults primary CNS lymphoma (PCNSL) as a surrogate for CNS penetration. Methods: Adults with PCNSL enrolled on a NCI phase I study of ibrutinib and multi-agent immune-chemotherapy (NCT02203526) received doxil 50 mg/m2 IV over 1 hour on day 2 of 21-day cycles of chemotherapy. In 4 patients with indwelling Ommaya reservoirs serial blood and CSF samples were obtained prior to infusion and until a median of 345 hours, (range 72-477 hours) after doxil administration. Total doxorubicin concentration (liposome bound + protein bound + free) was quantified with a validated liquid chromatography/tandem mass spectrometry assay (lower limit of quantification plasma=0.29 ng/mL, and CSF=0.06 ng/mL). PK parameters were estimated using non-compartmental methods. CSF penetration was calculated from the AUCCSF:AUCplasma. Results:Total doxorubicin plasma concentration time curves were characterized by sustained drug exposure and a median terminal half-life of 64.5 hours. (range, 61.9-65.1 hours). Doxorubicin was measurable in CSF in all patients, but CSF penetration was low. The terminal half-life of doxorubicin in CSF could not be calculated due to persistently measurable concentrations throughout the sampling times. Conclusions: In patients with PCNSL doxorubicin was measurable in CSF for prolonged time periods after doxil administration, but CSF penetration is low. Clinical trial information: NCT02203526. [Table: see text]

Dip pen nanolithography-deposited zinc oxide nanorods on a CMOS MEMS platform for ethanol sensing

Zinc oxide nanorods integration with CMOS MEMS substrate using dip pen nanolithography for low cost, low power ethanol sensor development.

Mortality from sudden unexpected death in epilepsy (SUDEP) in a cohort of adults with intellectual disability

BACKGROUND

People with intellectual disability (ID) and epilepsy are more likely to die prematurely than the general population. A significant number of deaths in people with epilepsy may be potentially preventable through better seizure control, regular monitoring and raising awareness among patients and carers. The aim of this project was to study mortality from sudden unexpected death in epilepsy (SUDEP) in adults with ID.

METHODS

All adults (≥20 years old) living in Leicester city, Leicestershire and Rutland, UK, with ID between 1993 and 2010 were identified using the Leicestershire Intellectual Disability Register database. People with and without ID who died during the same period were identified using death certificate data from the Office for National Statistics (ONS). Deaths from probable and definite SUDEP were identified. Additional information on adults with ID who had died from probable or definite SUDEP was obtained from case notes and post-mortem reports, where available. Cases of probable and definite SUDEP in adults with ID were compared with the general population using standardised mortality ratios (SMRs).

RESULTS

A total of 898 adults with ID had died over the 18-year study period. Of these, 244 deaths (27%) occurred in people with ID who had a diagnosis of epilepsy. Twenty-six people with ID died from probable or definite SUDEP, which was the second most common cause of death among adults with ID and epilepsy. All-cause specific SMRs were 2.2 [95% confidence interval (CI): 2.0-2.4] and 2.8 (95% CI: 2.5-3.1) for men and women with ID respectively. SMRs were 3.2 (95% CI: 2.7-3.8) and 5.6 (95% CI: 4.6-6.7) for men and women with epilepsy and ID respectively. During the same study period, 83 adults without ID had died of probable or definite SUDEP. The SMRs for SUDEP in patients with ID were 37.6 for men (95% CI: 21.9-60.2) and 52.0 for women (95% CI: 23.8-98.8). We found that in the majority of ID cases there was little detailed documentation on the circumstances surrounding deaths, no communication with patients/carers about risk of SUDEP and an absence of post-mortem reports or carers' referral for bereavement counselling.

CONCLUSION

The authors believe that a comprehensive risk management under a multiagency/multidisciplinary framework should be undertaken for all adults with ID and epilepsy in day-to-day clinical practice to reduce mortality in people with ID.

Precursor of transition to turbulence: spatiotemporal wave front

To understand transition to turbulence via 3D disturbance growth, we report here results obtained from the solution of Navier-Stokes equation (NSE) to reproduce experimental results obtained by minimizing background disturbances and imposing deterministic excitation inside the shear layer. A similar approach was adopted in Sengupta and Bhaumik [Phys. Rev. Lett. 107, 154501 (2011)], where a route of transition from receptivity to fully developed turbulent stage was explained for 2D flow in terms of the spatio-temporal wave-front (STWF). The STWF was identified as the unit process of 2D turbulence creation for low amplitude wall excitation. Theoretical prediction of STWF for boundary layer was established earlier in Sengupta, Rao, and Venkatasubbaiah [Phys. Rev. Lett. 96, 224504 (2006)] from the Orr-Sommerfeld equation as due to spatiotemporal instability. Here, the same unit process of the STWF during transition is shown to be present for 3D disturbance field from the solution of governing NSE.

Urban-rural differences in the nature and prevalence of mental ill-health in adults with intellectual disabilities

BACKGROUND

In the general population there are statistically significant urban-rural differences in the rate of common mental disorders. In people with intellectual disability (ID) no study has attempted to address this issue.

AIMS

To compare the prevalence of mental illness, autism spectrum disorder (ASD) and behaviour disorder in people with ID living in urban areas with those living in rural areas.

METHODS

Cross-sectional study of 2713 individuals registered with an ID service. Participants were assigned to urban or rural groups using the Department for Environment Food and Rural Affairs rural/urban local authority classification for their district. The main outcome variable was a clinical diagnosis of mental illness, ASD and behaviour disorder. Differences between diagnoses of mental illness in urban and rural areas were evaluated using the chi-squared test for the difference in two independent proportions.

RESULTS

No differences were observed between gender, age and level of ID of service users based on their place of residence. But more people from an ethnic minority background were living in urban areas than rural areas. No differences were observed in the overall prevalence of mental illness by place of residence. However, the results showed that ASD was more common in people living in rural areas.

CONCLUSIONS

We found these results surprising and at odds with the majority of studies carried out in the general population and propose several reasons for the differences found. We believe that the results and further studies in this area will help inform health service provision for those with ID who live in different geographical areas.

Direct numerical simulation of two-dimensional wall-bounded turbulent flows from receptivity stage

Deterministic route to turbulence creation in 2D wall boundary layer is shown here by solving full Navier-Stokes equation by dispersion relation preserving (DRP) numerical methods for flow over a flat plate excited by wall and free stream excitations. Present results show the transition caused by wall excitation is predominantly due to nonlinear growth of the spatiotemporal wave front, even in the presence of Tollmien-Schlichting (TS) waves. The existence and linear mechanism of creating the spatiotemporal wave front was established in Sengupta, Rao and Venkatasubbaiah [Phys. Rev. Lett. 96, 224504 (2006)] via the solution of Orr-Sommerfeld equation. Effects of spatiotemporal front(s) in the nonlinear phase of disturbance evolution have been documented by Sengupta and Bhaumik [Phys. Rev. Lett. 107, 154501 (2011)], where a flow is taken from the receptivity stage to the fully developed 2D turbulent state exhibiting a k(-3) energy spectrum by solving the Navier-Stokes equation without any artifice. The details of this mechanism are presented here for the first time, along with another problem of forced excitation of the boundary layer by convecting free stream vortices. Thus, the excitations considered here are for a zero pressure gradient (ZPG) boundary layer by (i) monochromatic time-harmonic wall excitation and (ii) free stream excitation by convecting train of vortices at a constant height. The latter case demonstrates neither monochromatic TS wave, nor the spatiotemporal wave front, yet both the cases eventually show the presence of k(-3) energy spectrum, which has been shown experimentally for atmospheric dynamics in Nastrom, Gage and Jasperson [Nature 310, 36 (1984)]. Transition by a nonlinear mechanism of the Navier-Stokes equation leading to k(-3) energy spectrum in the inertial subrange is the typical characteristic feature of all 2D turbulent flows. Reproduction of the spectrum noted in atmospheric data (showing dominance of the k(-3) spectrum over the k(-5/3) spectrum in Nastrom et al.) in laboratory scale indicates universality of this spectrum for all 2D turbulent flows. Creation of universal features of 2D turbulence by a deterministic route has been established here for the first time by solving the Navier-Stokes equation without any modeling, as has been reported earlier in the literature by other researchers.

Onset of turbulence from the receptivity stage of fluid flows

The traditional viewpoint of fluid flow considers the transition to turbulence to occur by the secondary and nonlinear instability of wave packets, which have been created experimentally by localized harmonic excitation. The boundary layer has been shown theoretically to support spatiotemporal growing wave fronts by Sengupta, Rao, and Venkatasubbaiah [Phys. Rev. Lett. 96, 224504 (2006)] by a linear mechanism, which is shown here to grow continuously, causing the transition to turbulence. Here, we track spatiotemporal wave fronts to a nonlinear turbulent state by solving the full 2D Navier-Stokes equation, without any limiting assumptions. Thus, this is the only demonstration of deterministic disturbances evolving from a receptivity stage to the full turbulent flow. This is despite the prevalent competing conjectures of the event being three-dimensional and/or stochastic in nature.

Nature and quality of antipsychotic prescribing practice in UK psychiatry of intellectual disability services

BACKGROUND

Antipsychotics are perceived to be over-used in the management of behavioural problems in people with an intellectual disability (ID). Published guidelines have set good practice standards for the use of these drugs for behavioural indications. We sought to identify the range of indications for which antipsychotic drugs are prescribed in people with ID and to audit clinical practice against the standards.

METHOD

Data were collected from the clinical records of individuals with ID who were under the care of mental health services in the UK, and prescribed an antipsychotic drug.

RESULTS

The sample comprised 2319 patients from 39 clinical services. Twenty-seven per cent of the patients had a diagnosis of a psychotic illness (ICD-10 F20-29) and 27% an affective illness (ICD-10 F30-39). The proportion who did not have a psychiatric diagnosis ranged from 6% of those with borderline/mild ID to 21% of those with severe/profound ID. Overall, the most common indications for prescribing an antipsychotic drug were comorbid psychotic illness, anxiety and agitation, and a range of behavioural disturbances. The prevalence of use of antipsychotic drugs to manage challenging behaviour in the absence of concomitant mental illness increased with the severity of ID and accounted for almost half of prescriptions in those with severe/profound ID. Adherence to the audit standards related to documentation of clinical indications and review of efficacy was high. Side effect monitoring was less assiduous.

CONCLUSIONS

In clinical practice, most prescriptions for antipsychotic drugs in people with ID are consistent with the evidence base and the overall quality of prescribing practice, as measured against recognised standards, is good, although in some patients potentially remedial side effects may not be detected and treated.

Overcoming the barriers experienced in conducting a medication trial in adults with aggressive challenging behaviour and intellectual disabilities

BACKGROUND

Aggressive challenging behaviour in people with intellectual disability (ID) is frequently treated with antipsychotic drugs, despite a limited evidence base.

METHOD

A multi-centre randomised controlled trial was undertaken to investigate the efficacy, adverse effects and costs of two commonly prescribed antipsychotic drugs (risperidone and haloperidol) and placebo.

RESULTS

The trial faced significant problems in recruitment. The intent was to recruit 120 patients over 2 years in three centres and to use a validated aggression scale (Modified Overt Aggression Scale) score as the primary outcome. Despite doubling the period of recruitment, only 86 patients were ultimately recruited.

CONCLUSIONS

Variation in beliefs over the efficacy of drug treatment, difficulties within multidisciplinary teams and perceived ethical concerns over medication trials in this population all contributed to poor recruitment. Where appropriate to the research question cluster randomised trials represent an ethically and logistically feasible alternative to individually randomised trials.

Neuroleptics in the treatment of aggressive challenging behaviour for people with intellectual disabilities: a randomised controlled trial (NACHBID)

OBJECTIVE(S)

To assess the effects and cost-effectiveness of haloperidol, risperidone and placebo on aggressive challenging behaviour in adults with intellectual disability.

DESIGN

A double-blind randomised controlled trial of two drugs and placebo administered in flexible dosage, with full, independent assessments of aggressive and aberrant behaviour, global improvement, carer burden, quality of life and adverse drug effects at baseline, 4, 12 and 26 weeks, and comparison of total care costs in the 6 months before and after randomisation. At 12 weeks, patients were given the option of leaving the trial or continuing until 26 weeks. Assessments of observed aggression were also carried out with key workers at weekly intervals throughout the trial.

SETTING

Patients were recruited from all those being treated by intellectual disability services in eight sites in England, one in Wales and one in Queensland, Australia.

PARTICIPANTS

Patients from all severity levels of intellectual disability; recruitment was extended to include those who may have been treated with neuroleptic drugs in the past.

EXCLUSION CRITERIA

treatment with depot neuroleptics/another form of injected neuroleptic medication within the last 3 months; continuous oral neuroleptic medication within the last week; those under a section of the Mental Health Act 1983 or Queensland Mental Health Act 2000.

INTERVENTIONS

Randomisation to treatment with haloperidol (a typical neuroleptic drug), risperidone (an atypical neuroleptic drug) or placebo using a permuted blocks procedure. Dosages were: haloperidol 1.25-5.0 mg daily; risperidone 0.5-2.0 mg daily.

MAIN OUTCOME MEASURES

Primary: reduction in aggressive episodes between baseline and 4 weeks using Modified Overt Aggression Scale. Secondary: Aberrant Behaviour Checklist; Uplift/Burden Scale; 40-item Quality of Life Questionnaire; Udvalg for Kliniske Undersøgelser scale; Clinical Global Impressions scale. Economic costs recorded using a modified version of Client Service Receipt Inventory for 6 months before and after randomisation.

RESULTS

There were considerable difficulties in recruitment because of ethical and consent doubts. Twenty-two clinicians recruited a total of 86 patients. Mean daily dosages were 1.07 mg rising to 1.78 mg for risperidone and 2.54 mg rising to 2.94 mg for haloperidol. Aggression declined dramatically with all three treatments by 4 weeks, with placebo showing the greatest reduction (79%, versus 57% for combined drugs) (p = 0.06). Placebo-treated patients showed no evidence of inferior response in comparison to patients receiving neuroleptic drugs. An additional study found that clinicians who had not participated in clinical trials before were less likely to recruit. Mean total cost of accommodation, services, informal care and treatment over the 6 months of the trial was 16,336 pounds for placebo, 17,626 pounds for haloperidol and 18,954 pounds for risperidone.

CONCLUSIONS

There were no significant important benefits conferred by treatment with risperidone or haloperidol, and treatment with these drugs was not cost-effective. While neuroleptic drugs may be of value in the treatment of aggressive behaviour in some patients with intellectual disability, the underlying pathology needs to be evaluated before these are given. The specific diagnostic indications for such treatment require further investigation. Prescription of low doses of neuroleptic drugs in intellectual disability on the grounds of greater responsiveness and greater liability to adverse effects also needs to be re-examined.

Brief report: Aggressive challenging behaviour in adults with intellectual disability following community resettlement

BACKGROUND

Aggressive challenging behaviour is common in adults with intellectual disability (ID) in long-term care facilities. The government's commitment to the closure of all facilities in England has led to concerns over how to manage this behaviour in the community. The aim of this study was to assess changes in aggressive challenging behaviour and psychotropic drug use in adults with ID following resettlement using a person-centred approach.

METHOD

The Modified Overt Aggression Scale was administered to carers of 49 adults with ID prior to discharge from a long-stay hospital and 6 months and 1 year after community resettlement.

RESULTS

All areas of aggressive challenging behaviour reduced significantly between baseline and 6 months following resettlement (P < 0.001). This reduction remained (but did not decrease further) at 1-year follow-up.

CONCLUSIONS

Further work is needed to evaluate the role of environmental setting on aggressive challenging behaviour in adults with ID.

Psychiatric service use and psychiatric disorders in adults with intellectual disability

BACKGROUND

UK policies aim to facilitate access to general psychiatric services for adults with intellectual disability (ID). If this is to be achieved, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population.

METHODS

A cross-sectional study was carried out on all adults with ID using specialist services in Leicestershire and Rutland, UK, between 2001 and 2006. Characteristics of individuals seen by psychiatric services and the nature and prevalence of psychiatric disorders were investigated.

RESULTS

Of 2711 adults identified, 1244 (45.9%) accessed specialist psychiatric services at least once during the study period. Individuals attending psychiatric services were more likely to be older and to live in residential settings; they were less likely to be south Asian or to have mild/moderate ID. The prevalence of psychiatric disorders among the total study population was 33.8%; the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%). Epilepsy was highly prevalent (60.8%) among those attending psychiatric services without a mental health diagnosis. Behaviour disorders and autistic spectrum disorders were more common in men and in adults with severe/profound ID, whereas schizophrenia and organic disorders were more common in women and in adults with mild/moderate ID. Depression was also more common in women with ID.

CONCLUSIONS

Psychiatric disorders and specialist health problems are common among adults with ID and the profile of psychiatric disorders differs from that found in general psychiatry. Close collaboration between general and specialist service providers is needed if the current move towards use of general psychiatric services in this population is to be achieved. The measures should include a clear care pathway for people with ID and mental health problems to facilitate the smooth transfer of patients between specialist and generic mental health services and arrangements for joint working where input from both services is required. The commissioning framework for such processes should be in place with appropriate pooling of resources.

Body mass index in adults with intellectual disability: distribution, associations and service implications: a population-based prevalence study

BACKGROUND

Previous studies of weight problems in adults with intellectual disability (ID) have generally been small or selective and given conflicting results. The objectives of our large-scale study were to identify inequalities in weight problems between adults with ID and the general adult population, and to investigate factors associated with obesity and underweight within the ID population.

METHODS

We undertook a population-based prevalence study of 1119 adults with ID aged 20 and over on the Leicestershire Learning Disability Register who participated in a programme of universal health checks and home interviews with their carers. We performed a cross-sectional analysis of the register data and compared the observed and expected prevalences of body mass index categories in the ID and general populations using indirect standardisation for age. We used logistic regression to evaluate the association of a range of probable demographic, physical, mental and skills attributes with obesity and underweight.

RESULTS

In those aged 25 and over, the standardised morbidity ratio (SMR) for obesity was 0.80 (95% CI 0.64-1.00) in men and 1.48 (95% CI 1.23-1.77) in women. The SMR for underweight was 8.44 (95% CI 6.52-10.82) in men and 2.35 (95% CI 1.72-3.19) in women. Among those aged 20 and over, crude prevalences were 20.7% for obesity, 28.0% for overweight, 32.7% for normal weight and 18.6% for underweight. Obesity was associated with living independently/with family, ability to feed/drink unaided, being female, hypertension, Down syndrome and the absence of cerebral palsy. Underweight was associated with younger age, absence of Down syndrome and not taking medication.

CONCLUSION

Obesity in women and underweight in both men and women was more common in adults with ID than in the general population after controlling for differences in the age distributions between the two populations. The associated factors suggest opportunities for targeting high-risk groups within the ID population for lifestyle and behaviour modification.

Virulence attenuation of a UDP-galactose/N-acetylglucosamine beta1,4 galactosyltransferase expressing Leishmania donovani promastigote

Protozoan parasites of the genus Leishmania are the causative agent of leishmaniasis, a disease whose manifestations in humans range from mild cutaneous lesions to fatal visceral infections. Human visceral leishmaniasis is caused by Leishmania donovani. Long-term culture in vitro leads to the attenuation of the parasite. This loss of parasite virulence is associated with the expression of a developmentally regulated UDP-Galactose/N-acetylglucosamine beta 1-4 galactosyltransferase and galactose terminal glycoconjugates as determined by their agglutination with the pea nut agglutinin (PNA). Thus, all promastigotes passaged for more than 11 times were 100% agglutinated with PNA, and represent a homogeneous population of avirulent parasites. Identical concentrations of PNA failed to agglutinate promastigotes passaged for < or =5 times. These PNA(-) promastigotes were virulent. Promastigotes passaged from 5 to 10 times showed a mixed population. The identity of populations defined by virulence and PNA agglutination was confirmed by isolating PNA(+) avirulent and PNA(-) virulent clones from the 7th passage promastigotes. Only the PNA(+) clones triggered macrophage microbicidal activity. The PNA(+) clones lacked lipophosphoglycan. Intravenous administration of [(14)C] galactose-labeled parasite in BALB/c mice resulted in rapid clearance of the parasite from blood with a concomitant accumulation in the liver. By enzymatic assay and RT-PCR we have shown the association of a UDP-Galactose/N-acetylglucosamine beta1,4 galactosyltransferase with only the attenuated clones. By immunofluorescence we demonstrated that the enzyme is located in the Golgi apparatus. By western blot analysis and SDS-PAGE of the affinity-purified protein, we have been able to identify a 29 KDa galactose terminal protein from the avirulent clones.

Physical aggression towards others in adults with learning disabilities: prevalence and associated factors

BACKGROUND

Many people with learning disabilities (LD) show aggressive behaviour, but the extent of the problem and its associated factors and effects are unclear.

METHODS

A cross-sectional analysis was carried out using interview data from 3065 adults with LD on the Leicestershire LD Register. Physical aggression towards others was defined as carers reporting frequent (more than three times per week) and/or severe episodes. Individuals with and without aggression were compared using multiple logistic regression models for potential physical and psychological factors.

RESULTS

Carers reported that 443 (14%) of adults were physically aggressive towards others. Men (P = 0.001), younger individuals (P < 0.001), people with more severe LD (P < 0.001) and those in institutional settings (P < 0.001) had a significantly higher prevalence of physical aggression. People with Down syndrome had a lower prevalence of physical aggression (P < 0.001). After adjustment, we found no relationship between aggression and the presence of epilepsy or autism. Among psychological factors, symptoms of frustration (P < 0.001) and mood swings (P < 0.001) were associated with higher levels of aggression. Failure to cope among carers was reported by 14% overall: 42% of people caring for adults with aggression said they were unable to cope compared with 10% of those caring for adults without aggression.

CONCLUSIONS

Physical aggression towards other people presents a significant challenge to carers of adults with LD. Further research is needed to identify aetiological factors with a view to finding effective interventions to reduce, and improve management of, this behaviour.

Molecular imaging of gene expression in living subjects by spliceosome-mediated RNA trans-splicing

Spliceosome-mediated RNA trans-splicing (SMaRT) provides an effective means to reprogram mRNAs and the proteins they encode. SMaRT technology has a broad range of applications, including RNA repair and molecular imaging, each governed by the nature of the sequences delivered by the pre-trans-splicing molecule. Here, we show the ability of SMaRT to optically image the expression of an exogenous gene at the level of pre-mRNA splicing in cells and living animals. Because of the modular design of pre-trans-splicing molecules, there is great potential to employ SMaRT to image the expression of any arbitrary gene of interest in living subjects. In this report, we describe a model system that demonstrates the feasibility of imaging gene expression by transsplicing in small animals. This represents a previously undescribed approach to molecular imaging of mRNA levels in living subjects.

Infectivity and attenuation of Leishmania donovani promastigotes. II: Association of the loss of parasite infectivity with the terminal galactosylation of precursor acceptors present in virulent parasites by the developmentally regulated galactosyltransferase

The beta1-4 galactosyltransferase enzyme of the Leishmania donovani promastigotes, was found to be developmentally regulated and expressed only in the attenuated parasites. The enzymatic product of soluble determinants of virulent promastigotes and the galactosyltransferase enzyme was found to stimulate the macrophage burst activity but inhibit in vitro intracellular parasitism. In contrast, removal of terminal galactose moieties from soluble determinants of attenuated parasites resulted in the inhibition of macrophage respiratory burst activity but did not now inhibit intracellular parasitism. We propose that the terminal galactosylation of acceptor substrates present in virulent parasites by the developmentally regulated galactosyltransferase is associated with loss of parasite virulence.

Optical imaging of Renilla luciferase, synthetic Renilla luciferase, and firefly luciferase reporter gene expression in living mice

We have recently demonstrated that Renilla luciferase (Rluc) is a promising bioluminescence reporter gene that can be used for noninvasive optical imaging of reporter gene expression in living mice, with the aid of a cooled charged couple device (CCD) camera. In the current study, we explore the expression of a novel synthetic Renilla luciferase reporter gene (hRluc) in living mice, which has previously been reported to be a more sensitive reporter than native Rluc in mammalian cells. We explore the strategies of simultaneous imaging of both Renilla luciferase enzyme (RL) and synthetic Renilla luciferase enzyme (hRL):coelenterazine (substrate for RL/hRL) in the same living mouse. We also demonstrate that hRL:coelenterazine can yield a higher signal when compared to Firefly luciferase enzyme (FL): D-Luciferin, both in cell culture studies and when imaged from cells at the surface and from lungs of living mice. These studies demonstrate that hRluc should be a useful primary reporter gene with high sensitivity when used alone or in conjunction with other bioluminescence reporter genes for imaging in living rodents.

Cytokine-induced production of NO by macrophages induces apoptosis and immunological rejection of AK-5 histiocytic tumor

The immunological rejection of the AK-5 histiocytoma in syngeneic hosts involves the participation of NK cells and the upregulation of Th1 type cytokine response. The tumor cells are killed by necrosis and apoptosis. We have studied the role of host peritoneal macrophages in tumor regression. Activated macrophages from tumor- bearing animals produce cytokines like IL-1 beta, TNF-alpha, IL-12 and free radicals like nitric oxide during tumor regression. IL-12 and IFN-gamma played a crucial role in the induction of NO production by the host macrophages, since administration of anti IL-12 and anti IFN-gamma antibodies in AK-5 tumor-bearing animals suppressed NO production by the macrophages. Similarly the cytotoxic activity of the host macrophages which is dependent on NO production was also affected in antibody injected animals. These studies indicate an important role for cytokines in the activation of host macrophages which in turn produce nitric oxide that is involved in the induction of apoptosis in AK-5 cells, leading to the regression of the tumor.

Prevalence, morbidity and service need among South Asian and white adults with intellectual disability in Leicestershire, UK

BACKGROUND

Previous reports have suggested that South Asian and white UK populations have different prevalences of intellectual disability (ID), related psychological morbidity and service use. The aim of the present study was to compare these rates among South Asian and white adults in Leicestershire, UK.

METHOD

This cross-sectional study is comprised of two parts. The analysis of prevalence is based on data from all South Asian and white adults known to the Leicestershire Learning Disabilities Register in 1991, with population denominators being drawn from the 1991 census. The other analyses use data collected from the most recent semi-structured home interviews, carried out between 1987 and 1998, with 206 South Asian and 2334 white adults.

RESULTS

The prevalence of ID in adults in Leicestershire is 3.20 per 1000 in South Asians and 3.62 per 1000 in whites. Among adults with ID, South Asians have similar prevalences of disabilities to whites and significantly lower skill levels. South Asians show similar levels of psychological morbidity, but make significantly lower use than whites of psychiatric services, residential care and respite care. South Asians use community services as extensively as whites, but feel that they have a substantially greater unmet need, especially with regard to social services.

CONCLUSION

South Asian and white populations have similar prevalences of ID and related psychological morbidity. Culturally appropriate services for South Asian adults may need to focus on skill development and community care.

Optical imaging of Renilla luciferase reporter gene expression in living mice

Imaging reporter gene expression in living subjects is a rapidly evolving area of molecular imaging research. Studies have validated the use of reporter genes with positron emission tomography (PET), single photon emission computed tomography (SPECT), MRI, fluorescence with wild-type and mutants of green fluorescent protein, as well as bioluminescence using Firefly luciferase enzyme/protein (FL). In the current study, we validate for the first time the ability to image bioluminescence from Renilla luciferase enzyme/protein (RL) by injecting the substrate coelenterazine in living mice. A highly sensitive cooled charge-coupled device camera provides images within a few minutes of photon counting. Cells, transiently expressing the Rluc were imaged while located in the peritoneum, s.c. layer, as well as in the liver and lungs of living mice tail-vein injected with coelenterazine. Furthermore, d-luciferin (a substrate for FL) does not serve as a substrate for RL, and coelenterazine does not serve as a substrate for FL either in cell culture or in living mice. We also show that both Rluc and Fluc expression can be imaged in the same living mouse and that the kinetics of light production are distinct. The approaches validated will have direct applications to various studies where two molecular events need to be tracked, including cell trafficking of two cell populations, two gene therapy vectors, and indirect monitoring of two endogenous genes through the use of two reporter genes.

Nutrient recovery and biodegradation of inedible tomato plant residues by activated sludge cultures and Phanerochaete chrysosporium

The biodegradation of inedible biomass and the recovery of nutrients from hydroponically grown tomato plant material were investigated under various growth conditions of activated sludge and the fungus Phanerochaete chrysosporium. The experiments were carried out in shaker flasks at three incubation temperatures (25 degrees C, 40 degrees C, and 60 degrees C for the activated sludge and 25 degrees C, 40 degrees C, and 50 degrees C for the fungi) with heat-pretreated samples at 150 degrees C for 30 min, and without pretreatment of the inedible residues. Under the experimental conditions tested, both cultures exhibited similar performance in terms of solids reduction and nutrient recovery. Solids reduction as high as 70% was obtained in both systems. Most of the solids degradation occurred the first 16 days of incubation. Cellulose degradation reached about 90% but no significant reduction in the solids lignin content was observed. Recovery of nitrogen (as NO2-N and NO3-N) and other micronutrients was sufficiently high and was accompanied by an average 70% reduction in COD, indicating that the final effluent is suitable for hydroponic plant growth. Incubation temperature had a minimal effect on solids degradation but appeared to influence the leachability of certain nutrients.

Activated macrophages migrate to the subcutaneous tumor site via the peritoneum: a novel route of cell trafficking

Spontaneous regression of AK-5 tumor in syngeneic hosts reported earlier involves the interplay of Th1-type cytokines and cell-mediated immunity. Upon subcutaneous transplantation of AK-5 cells, there was accumulation of immune cells in the peritoneum, of which macrophages were the predominant type and were found to be in a hyperactive state. They released macrophage-derived tumoricidal mediators like NO, O2(-), and ONOO(-) which exhibited potent cytotoxic activity against AK-5 cells in vitro. Interestingly, there was a dramatic disappearance of these hyperactive cells from the peritoneal cavity which correlated well with the onset of tumor regression at the subcutaneous site. Direct labeling of these cells in the peritoneum by the tracking dye PKH26 showed their migration to the tumor site. Similarly, frozen tumor sections when scanned under confocal microscope clearly exhibited fluorescent macrophages embedded into the tumor. Immunohistochemical sections of these intratumoral macrophages showed nitrotyrosine residues, indicating their contribution in the free-radical-mediated AK-5 cell death, thereby leading to successful tumor remission. These observations suggest a directional migration of the hyperactivated peritoneal population to the tumor site. We have also confirmed the influx of macrophages and other immune cells into the peritoneum after sc transplantation of Meth A tumor cells in Balb/c mice. Our studies suggest a role for the peritoneal compartment in imparting appropriate stimulus to the immune cells prior to their participation in the antitumor immune response. These studies suggest a novel route of macrophage trafficking via the peritoneum.

Treatment-emergent behavioural side effects with selective serotonin re-uptake inhibitors in adults with learning disabilities

Selective serotonin re-uptake inhibitors are widely used for the treatment of depression suffered by adults with learning disabilities. However, the presentation, time of onset and prevalence of treatment emergent symptoms, have not been extensively studied in adults with learning disabilities. The aim of this study was to determine these aspects of treatment. The study design involved retrospective analysis of case notes of all adults with learning disabilities treated with either fluoxetine or paroxetine for depression. During 31% of treatment episodes, patients suffered treatment emergent symptoms during treatment with either selective serotonin re-uptake inhibitor (SSRI). These symptoms subsided on discontinuation of the SSRI. The common emergent symptoms in this group were elevated mood (39%), decreased sleep (35%), hyperactivity (30%), overtalkativeness (26%), agitation (24%) and aggression (37%). In 20% symptoms developed within 1 month and in 67% within 7 months of starting treatment with a SSRI. There were no significant differences noted in the frequency and nature of treatment emergent symptoms between fluoxetine and paroxetine. Few guidelines, if any, exist for initiating and continuing antidepressant treatment for therapeutic or prophylactic use in this patient population. Close monitoring of efficacy and tolerability, including treatment emergent psychiatric symptoms is warranted. Copyright 2001 John Wiley & Sons, Ltd.

Differential modulation of nitric oxide production by curcumin in host macrophages and NK cells

Curcumin, the yellow pigment from Curcuma longa, has been shown to possess tumoricidal activity. We have earlier reported the induction of apoptosis in AK-5, rat histiocytic cells by curcumin leading to the inhibition of tumor growth in vivo. In this study we have observed differential activation status in host macrophages and NK cells induced by curcumin during the spontaneous regression of subcutaneously transplanted AK-5 tumors. Closer scrutiny of the cytokine profile and nitric oxide (NO) production by immune cells showed an initial downregulation of Th1 cytokine response and NO production by macrophages, and their upregulation in NK cells, which picked-up upon prolonged treatment with curcumin, culminating in a stronger tumoricidal effect. These studies suggest that the host macrophages and NK cells play an important modulatory role in the remission of AK-5 tumor.