Health advocacy: a vital step in attaining human rights for adults with intellectual disability

BACKGROUND

People with intellectual disability (ID) experience health inequity compared with the general population, a key contributing factor being disparities in social determinants of health. The enactment of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) provides a platform for the progression and promotion of health and other interconnected rights to address barriers to the highest attainable standard of health for this populace. Rights can be brought to life through advocacy efforts. This paper explores the meaning, perceptions and experiences of advocacy by family members and paid support workers of adults with ID and locates the findings within a health and human rights discourse.

METHODS

As part of a larger randomised controlled trial, 113 parents and 84 support workers of adults with ID completed a telephone interview that included open-ended questions about their understanding and experiences of advocacy. Thematic analysis was used to identify relevant themes.

RESULTS

Five key themes were identified. The first underscored how advocacy to 'speak up' for the person with ID is integral to both parent and support worker roles. The second and third themes considered the contexts for advocacy efforts. Access to quality health care was a core concern, along with advocacy across other areas and sectors to address the person's wider psychosocial needs. The remaining themes highlighted the many dimensions to advocacy, including differences between parent and support worker views, with parental advocacy being an expression of 'caring' and support workers motivated by a 'duty of care' to protect the individual's 'rights'.

CONCLUSION

Parent and support worker advocacy provides one means to address the social determinants of health and fulfilment of health rights of and for people with ID. Policy and practice in the context of governmental obligation under the CRPD should support advocacy and make health rights the reality not rhetoric for this group of men and women.

Physical activity, family history of diabetes and risk of developing hyperglycaemia and diabetes among adults in Mainland China

AIMS

To investigate the joint influence of physical activity and family history of diabetes on the subsequent risk of developing hyperglycaemia and Type 2 diabetes among Chinese adults.

METHODS

A prospective community-based cohort study was conducted among adults aged 35 years and older during 2004-2007 in Nanjing, China. Four communities (three urban and one rural) were randomly selected from 11 urban districts and two rural counties. Hyperglycaemia and Type 2 diabetes were defined using World Health Organization criteria based on fasting blood glucose concentration and physicians' diagnosis, respectively. Physical activity, parental diabetes history, and other important covariates were assessed at baseline and in the third-year follow-up survey.

RESULTS

At study conclusion data were collected from 3031 participants (follow-up rate 81.3%). The 3-year cumulative incidence of hyperglycaemia and Type 2 diabetes was 6.2% and 2.4%, respectively. After adjustment for potential confounding variables, compared with those with positive family history and insufficient physical activity, the adjusted relative risk ratio (95% CI) of developing hyperglycaemia was 0.19 (0.02, 1.51) for participants with sufficient physical activity and a positive family history; 0.55 (0.31, 0.97) for participants with insufficient physical activity and a negative family history; and 0.36 (0.19, 0.70) for participants with sufficient physical activity but a negative family history. Participants who had a negative family history and insufficient physical activity were also less likely to develop Type 2 diabetes (RRR = 0.28; 0.14, 0.54), and participants with a negative family history and sufficient physical activity were the least likely to develop Type 2 diabetes (0.23; 0.10, 0.56).

CONCLUSIONS

Sufficient physical activity and negative family history of diabetes may jointly reduce the risk of developing hyperglycaemia and Type 2 diabetes in Chinese adults.

Item Validity of the Myers-Briggs Type Indicator

The present study presents a brief summary of four extensive psychometric analyses of the Myers-Briggs Type Indicator (MBTI) items. Positive empirical evidence supports the MBTI item validity. However, several measurement issues on item construction were raised to caution the future users.

Family average income and diagnosed Type 2 diabetes in urban and rural residents in regional mainland China

AIMS

To explore the relationship between family average income (FAI; an index of socio-economic status) and Type 2 diabetes in a region of mainland China.

METHODS

Population-based cross-sectional study, conducted between October 2000 and March 2001 in administrative villages (n = 45) randomly selected from three urban districts and two rural counties of NanJing municipality, mainland China, with a regional population of 5.6 million. Participants were all local residents aged > or = 35 years old (n = 29 340); 67.7% from urban areas, 32.3% from rural areas, 49.8% male and 50.2% female.

RESULTS

The response rate of eligible participants was 90.1%. The overall prevalence of self-reported Type 2 diabetes was 1.9%. After adjustment for possible confounding variables (age, gender, area of residence, body mass index, educational level, smoking status, occupational and leisure-time physical activity), participants in the higher and middle FAI categories were more than twice as likely to have Type 2 diabetes as those in the lower FAI category.

CONCLUSIONS

The prevalence of Type 2 diabetes is positively related to socio-economic status (indexed by FAI) in Chinese at the population level. After controlling for potential confounding factors, people in higher socio-economic status groups are more likely to have Type 2 diabetes. These associations are consistent with other effects of epidemiological transition and identify a need for preventive initiatives.

A new method for objective identification and measurement of airway lumen in paediatric flexible videobronchoscopy

BACKGROUND

Accurate measurements of airway and lesion dimensions are important to the developmental progress of paediatric bronchoscopy. The malacia disorders are an important cause of respiratory morbidity in children, but no methods are currently available to measure these lesions or the airway lumen accurately. A new measurement technique is described here.

METHODS

The magnification power of a paediatric videobronchoscope was defined and a simple and user friendly computer based program (Image J) was used to develop an objective technique (colour histogram mode technique, CHMT) for measurement of the airway lumen.

RESULTS

In vivo intra-observer and inter-observer repeatability coefficients for repeated area measurements from 28 images using the Bland-Altman method were 0.9 mm2 and 1.6 mm2, respectively. The average intraclass correlation coefficient for repeated measurements of area was 0.93. In vitro validation measurements using a 2 mm diameter tube resolved radii measurements to within 0.1 mm (coefficient of variability 8%). An "acceptable result" was defined in 92% of 734 images completed with the CHMT alone and 8% with its modification. The success rate for two of three images being within 10% of each other's area was 100%. Measurements of cricoid cross sectional areas from 116 patients compared with expected airway areas for age derived from endotracheal tube sizes were comparable.

CONCLUSIONS

The CHMT method of identifying and measuring airway dimensions is objective, accurate, and versatile and, as such, is important to the future development of flexible videobronchoscopy.

Quantification of the magnification and distortion effects of a pediatric flexible video-bronchoscope

BACKGROUND

Flexible video bronchoscopes, in particular the Olympus BF Type 3C160, are commonly used in pediatric respiratory medicine. There is no data on the magnification and distortion effects of these bronchoscopes yet important clinical decisions are made from the images. The aim of this study was to systematically describe the magnification and distortion of flexible bronchoscope images taken at various distances from the object.

METHODS

Using images of known objects and processing these by digital video and computer programs both magnification and distortion scales were derived.

RESULTS

Magnification changes as a linear function between 100 mm (x1) and 10 mm (x9.55) and then as an exponential function between 10 mm and 3 mm (x40) from the object. Magnification depends on the axis of orientation of the object to the optic axis or geometrical axis of the bronchoscope. Magnification also varies across the field of view with the central magnification being 39% greater than at the periphery of the field of view at 15 mm from the object. However, in the paediatric situation the diameter of the orifices is usually less than 10 mm and thus this limits the exposure to these peripheral limits of magnification reduction. Intraclass correlations for measurements and repeatability studies between instruments are very high, r = 0.96. Distortion occurs as both barrel and geometric types but both types are heterogeneous across the field of view. Distortion of geometric type ranges up to 30% at 3 mm from the object but may be as low as 5% depending on the position of the object in relation to the optic axis.

CONCLUSION

We conclude that the optimal working distance range is between 40 and 10 mm from the object. However the clinician should be cognisant of both variations in magnification and distortion in clinical judgements.

Single patient (n-of-1) trials with binary treatment preference

The use of a fully parametric Bayesian method for analysing single patient trials based on the notion of treatment 'preference' is described. This Bayesian hierarchical modelling approach allows for full parameter uncertainty, use of prior information and the modelling of individual and patient sub-group structures. It provides updated probabilistic results for individual patients, and groups of patients with the same medical condition, as they are sequentially enrolled into individualized trials using the same medication alternatives. Two clinically interpretable criteria for determining a patient's response are detailed and illustrated using data from a previously published paper under two different prior information scenarios.

Imaging with F-18 FDG PET is superior to Tl-201 SPECT in the staging of non-small cell lung cancer for radical radiation therapy

Thallium-201 (Tl-201) single photon emission computed tomography (SPECT) is funded for evaluation of malignancy in Australia and may have utility for staging of non-small cell lung cancer (NSCLC) if CT results are equivocal. Fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography (PET) is superior to CT for staging NSCLC but is more expensive and less widely available than Tl-201 SPECT. Therefore, these techniques were prospectively compared in 27 radical radiation therapy candidates. Patients were allocated a conventional, PET and Tl-201 stage. Tumour to background ratios (TBR) were recorded for the primary on both techniques. Metastatic disease was confirmed by surgical pathology, serial imaging or clinical follow up. Tumour to background ratios were consistently higher for FDG PET than Tl-201 SPECT (P < 0.0001). Positron emission tomography detected all known primary tumours but Tl-201 failed to image four primary tumours (15%). In 10 of 18 cases of discordance between PET and Tl-201 SPECT regarding stage, corroboration was available from pathology or disease progression. Positron emission tomography was shown to have a 100% positive predictive value, including all three patients with PET-detected distant metastases (P=0.002). Results indicate that PET is superior to Tl-201 SPECT scanning in the staging of NSCLC for radical radiation therapy, and that the low sensitivity for detection of local and metastatic disease is likely to limit the clinical impact and cost-effectiveness of this technique despite its lower cost.

The utility of a 3-dimensional, large-field-of-view, sodium iodide crystal--based PET scanner in the presurgical evaluation of partial epilepsy

(18)F-FDG PET is an accurate and reliable technique for localizing medically refractory temporal lobe epilepsy, but widespread use has been hindered by limited reimbursement in many countries because of the high cost of traditional PET equipment and radioisotopes. Additionally, the place of FDG PET as a cost-effective tool for presurgical evaluation of epilepsy has been questioned because of limited data showing that FDG PET provides localization information incremental to that provided by more established techniques, particularly MRI and ictal electroencephalography (EEG). Three-dimensional (3D), large-field-of-view, sodium iodide crystal-based scanners have lower equipment and running costs and better multiplanar resolution than traditional 2-dimensional bismuth germinate (BGO) systems but have not yet been validated for evaluation of epilepsy. Our purpose was to investigate the localization rate, accuracy, and prognostic value of FDG PET images acquired on a 3D, large-field-of-view, sodium iodide crystal-based PET scanner in the presurgical evaluation of intractable partial epilepsy. We also wanted to establish the incremental value of FDG PET over established MRI and ictal EEG techniques.

METHODS

Fifty-five patients who were surgical candidates because of medically refractory partial epilepsy were examined. For most of these patients, the lesions had not been clearly localized on conventional assessment. The FDG PET scans were reviewed independently by 2 reviewers who were unaware of the patients' clinical details, ictal EEG findings, and volumetric MRI results, and the FDG PET results were correlated with those of MRI and EEG and with postsurgical outcome.

RESULTS

Forty-two patients (76%) had localizing FDG PET images (37 temporal, 5 extratemporal). The ictal EEG recordings were localizing in 66%, and the MRI findings were localizing in 27% (which increased to 35% after the MRI findings were reviewed again after PET). Concordance between the site of the PET localizations and the site of the MRI or EEG localizations was 100%. The PET images were localizing in 63% and 69% of patients with nonlocalizing ictal EEG and MRI findings, respectively. Twenty-one of 24 patients who subsequently underwent epilepsy surgery had localizing FDG PET images; of these 21 patients, 18 (86%) had a class I outcome. Multiple regression analysis showed the FDG PET results to be predictive of postsurgical outcome independently of the MRI findings.

CONCLUSION

For intractable partial epilepsy, FDG PET using a 3D, large-field-of-view, sodium iodide crystal-based scanner provided clinically useful localizing information that was at least as accurate as the results reported for traditional BGO-based scanners. The PET images provided prognostically significant localization information incremental to that provided by volumetric MRI and ictal EEG, particularly if 1 of these studies was nonlocalizing.

29. F-18 FDG PET for Suspected or Confirmed Regional Recurrence of Colon Cancer. A Prospective Study of Impact and Outcome

Purpose: Survival of patients (pts) undergoing "curative" treatment for colorectal carcinoma remains poor. Retrospective studies suggest that F-18 FDG PET is more accurate than CT for restaging suspected recurrent disease and favourably impacts management. The aim of this study was to confirm this by prospective analysis.Patient Population and Methods: 102 consecutive patients for whom the referring clinicians had prospectively committed to a treatment plan based on conventional staging investigations and who then underwent F-18 FDG PET scanning were evaluated for management change and outcome. The accuracy of PET results was assessed by surgical findings or clinical follow-up.Results: Overall PET changed management in 66/102 (65%) pts including14 pts changed from observation to active treatment after PET localized disease and 6 pts planned for local therapy to observation after negative PET. Planned surgery was cancelled in 28 pts whereas surgery was initiated in 11 pts. Radiotherapy was prevented in 5 pts, initiated in 11 and the radiation field altered in 5 others. The accuracy of the PET results could be assessed in 63/66 (95%) pts in whom management was changed. Relapse was confirmed in 50/51 pts with a positive PET but disease extent was underestimated in 4 cases. False negative PET results were confirmed in 5 cases.Conclusion: FDG PET has a high and appropriate impact on patient management in patients with suspected recurrent disease. PET can miss small volume disease but the major benefit of PET is to prevent futile attempts at local salvage therapies.

Preoperative sestamibi scanning and surgical findings at bilateral, unilateral, or minimal reoperation for recurrent hyperparathyroidism after subtotal parathyroidectomy in patients with multiple endocrine neoplasia type 1

HYPOTHESES

Preoperative parathyroid radioisotope scanning is of little or no value in patients with multiple endocrine neoplasia type 1 when 4 or more hypertrophied glands are present. Scanning using technetium Tc 99m sestamibi and single photon emission computed tomography will achieve a high level of sensitivity and specificity after 3 or more glands have previously been removed, justifying limited surgical reexploration.

DESIGN

In a prospective study, the preoperative documented report of the predicted site of residual parathyroid was compared with the surgical findings in 13 patients having 19 scans and 17 reoperations.

SETTING

All patients belonged to one family, previously described as Tasman family 1, and were confirmed by genetic testing as having multiple endocrine neoplasia type 1. In 10 of 13 patients, reexploration was being undertaken more than 10 years after the first operation.

MAIN OUTCOME MEASURES

Scanning was regarded as successful when the documented preoperative report correctly predicted the side and quadrant in which a gland was found at surgery. Surgery was regarded as successful when calcium levels decreased to or below normal levels and were maintained.

RESULTS

All 13 scans before first reexploration were successful in identifying the location of a residual parathyroid. From a statistical viewpoint, this equates to 100% sensitivity and 92% specificity. However, despite accurate localization of 1 residual gland in every patient, 7 supernumerary glands in 4 patients and 1 parathyroid remnant in a fifth patient were not localized so that sensitivity in locating all glands in every patient was only 61%. Scans performed for persistent hypercalcemia 48 to 72 hours after reexploration in 2 patients were unsuccessful in demonstrating any residual parathyroid. Scans performed 3 months after surgery in the same 2 patients and a third patient were successful, with sensitivity and specificity of 100%. Apart from patient 11, who awaits reexploration, normocalcemia was eventually achieved in every patient, with 11 of 12 having an initial period of hypocalcemia.

CONCLUSIONS

Three months after reexploration and trimming or resection with transplant of half a gland left at first operation, sestamibi scanning achieved sensitivity and specificity of 100% in locating supernumerary parathyroids in patients with multiple endocrine neoplasia type 1 and persistent hypercalcemia. Before first reexploration, however, scans rarely provided new information, predominantly showing only the hypertrophied half-gland remnant.

A novel 26 kilodalton antigen expressed on the surface membrane of activated T cells

We have identified and characterized the tissue distribution of the antigen recognized by a novel monoclonal antibody (mAb) 1B10, raised against an activated gammadelta T cell clone. Immunohistochemistry of tissue sections, and analysis of single cell suspensions by flow cytometry revealed that mAb 1B10 weakly reacted with <6% of normal human peripheral blood mononuclear cells (PBMC). After 5-6 days of in vitro culture of PBMC activated with phytohemagglutinin (PHA), 55% of the CD4+ and 25% of the CD8+ T cells became 1B10+. 1B10 expression was maintained on long term cultured interleukin 2 (IL-2)-dependent T cell receptor (TCR) alphabeta+ and gammadelta+ clones, and importantly, in contrast to resting T cells, the majority of in vivo activated synovial T lymphocytes from a patient with rheumatoid arthritis were 1B10+. In addition, myelo-monocytic U927 cells, tissue macrophages and some epithelia and fibroblasts were found to react with mAb 1B10. Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) of molecules immuno-precipitated by mAb 1B10 from radio-iodinated cell surface membrane lysates of T lymphocyte and U937 cells revealed 26 and 29 kiloDalton (kDa) glycoproteins respectively. In conclusion, mAb 1B10 recognizes a novel <<late>> appearing 26 kDa T cell activation antigen that may be useful for further studies of activated T cells in health and disease.