Exploring the evaluation of antiepileptic drug change in people with intellectual disabilities and high-frequency epileptic seizures: seizure control and sustained responsiveness to the environment

PURPOSE

Optimum antiepilepsy medication should be successful in reducing seizures with minimal adverse effects on the patient's ability to concentrate or general level of awareness. The purpose was to investigate the potential of a method of measuring responsiveness to environmental events as a means of reflecting awareness levels among people with intellectual disabilities undergoing review of medication for high-frequency epileptic seizures.

METHODS

Observations of 22 participants referred to a specialist clinic were conducted three times a month over a 5-month period following the initial baseline measures and clinical intervention. Behavioral responsiveness was measured by calculating the likelihood of appropriate activity occurring given the occurrence of staff interaction. This likelihood was represented by the statistic Yule's Q. Seizure frequency was also evaluated.

RESULTS

Participant responsiveness after drug review was similar to baseline indicating an absence of long-term adverse effects. Participants experienced a significant decrease in seizure frequency.

CONCLUSION

It was concluded that drug review led to seizure reduction while behavioral measurement confirmed no loss of responsiveness.

Quality and Costs of Community-Based Residential Supports for People With Mental Retardation and Challenging Behavior

A longitudinal matched-groups design was used to examine the quality and costs of community-based residential supports to people with mental retardation and challenging behavior. Two forms of provision were investigated: noncongregate settings, where the minority of residents had challenging behavior, and congregate settings, where the majority of residents had challenging behavior. Data were collected for 25 people in each setting. We collected information through interviewing service personnel in each type of setting on the costs of service provision, the nature of support provided, and the quality of life of residents. We also conducted observations in each setting. Results suggest that noncongregate residential supports may be more cost effective than congregate residential supports.

Rational resourcing and productivity: relationships among staff input, resident characteristics, and group home quality

Relationships among staff input per resident, resident characteristics, setting characteristics, and service quality were investigated. Data were obtained from 51 group homes in Wales on (a) resident numbers, ages, gender, adaptive behavior, challenging behavior, and additional disabilities; (b) allocated staff hours and actual staff costs; (c) provider agency, date of provision, and internal operational arrangements; and (d) resident receipt of staff attention and resident activity. Variation in staff input was related to resident challenging behavior, smaller residence size, and provider agency or date of provision. Staffing input was associated with resident receipt of attention, as were operational arrangements. Resident activity was related to resident adaptive behavior and receipt of attention but not resource input. Cost-effectiveness implications are discussed.

Characterisation of the expression of a novel constitutive maize promoter in transgenic wheat and maize

A novel constitutive promoter from the maize histone H2Bgene was recently identified. In this study, we characterised H2B promoter activity in both wheat and maize tissues using the gusA reporter gene and two synthetic versions of the pat (phosphinothricin acetyl transferase) selectable marker gene, namely mopat and popat. Analyses of transgenic plants showed that the H2B promoter is able to drive the expression of gusA to strong, constitutive levels in wheat and maize tissues. Using an H2B:mopat construct and phosphinothricin selection, we recovered transgenic wheat plants at efficiencies ranging from 0.3% to 7.4% (mean 1.6%), and the efficiency of selection ranged from 40% to 100% (mean 77.7%). In another application, H2B was combined with the maize Ubi-1 or the maize Adh-1 intron to drive the expression of mopat and popat. Transformation efficiencies with the Ubi-1 intron were between 1.4- to 16-fold greater than with the Adh-1 intron. However, the use of either of the introns was necessary for the recovery of transgenic plants. Mopat gave higher transformation efficiencies and induced higher levels of PAT protein in maize tissues than popat.

Responsiveness to staff support: evaluating the impact of individual characteristics on the effectiveness of active support training using a conditional probability approach

BACKGROUND

Active support training was fully conducted in 38 community houses accommodating 106 adults with intellectual disabilities (ID; group 1), but not in a further 36 accommodating 82 adults with ID (group 2). The aims of the present study were to analyse whether staff became more effective in supporting resident activity after the implementation of active support, and whether there was evidence of differential responsiveness by people with differing status in relation to adaptive behaviour, psychiatric diagnosis, challenging behaviour or autism.

METHODS

Observations of staff:resident interaction and resident engagement in activity were taken before and after active support training. Changes in Yule's Q statistics, indicating the likelihood that resident engagement in activity followed staff giving residents verbal instruction or non-verbal assistance, were compared for the two groups. In addition, changes in similar statistics were compared for residents within group 1: (1) with Adaptive Behaviour Scale (ABS) scores above and below 180; and (2) with and without severe challenging behaviour, the triad of social impairments and mental illness.

RESULTS

Yule's Q for engagement given non-verbal assistance significantly increased post-training among group 1, but not among group 2. Similar significant increases were found among group 1 residents with ABS scores below 180 without challenging behaviour, with and without the triad of social impairments, and without mental illness, but not with an ABS score above 180, with challenging behaviour and with mental illness.

CONCLUSION

The present analysis reinforces previous studies on the effectiveness of active support training for adults with more severe ID (i.e. with ABS scores below 180). Active support was as effective for people with the triad of social impairments as for those without it. However, the effectiveness of support offered to people with challenging behaviour or mental illness did not significantly increase.

The adaptive behavior scale-residential and community (part I): towards the development of a short form

A potential 24-item short form (SABS) of the 73-item Adaptive Behavior Scale-Residential and Community (Part I) (ABS-RC2; Nihira et al., 1993a, b) was developed, based on data from two diverse UK samples of adults with intellectual disabilities living in residential services (n = 560 and 254). SABS factor and total scores showed good internal reliability in both samples (alpha 0.89-0.98), and were highly correlated with their full ABS-RC2 Part I equivalents (r = 0.97-0.99). Regression equations were calculated for SABS factor and total scores against their full ABS-RC2 Part I equivalents. Levels of agreement between predicted quartile scores (derived from the regression equations) and actual full ABS-RC2 Part I quartile scores were high (kappa 0.75-0.89; percentage agreement 82%-92%). It is concluded that the SABS is a potentially useful research tool, although further work is clearly needed to establish the reliability and cross-cultural validity of the instrument.

Evaluation of the dissemination of active support training in staffed community residences

Our aim was to replicate Active Support, a staff training intervention designed to increase the assistance given to adults with severe mental retardation living in community residences in order to increase their participation in activities. Training was conducted in 38 residences, involving 303 staff members and 106 persons with mental retardation. Active Support resulted in significant increases in assistance and engagement in activity. Significant correlations between participant abilities, receipt of assistance, and levels of engagement were found. Active Support was found to be of greater benefit to people with lower adaptive behavior and to have a diminishing value for people with higher adaptive behavior, implying that its implementation should be matched to the support needs of residents.

Characteristics of staffed community housing services for people with learning disabilities: a stratified random sample of statutory, voluntary and private agency provision

Within the staffed housing model relatively little is known about the characteristics of different types of provider agency. Data on size, homeliness and physical integration of settings, organisational culture, working methods, staffing levels and resident characteristics, were collected on a stratified random sample of provision in South-West England and Wales. Provider agencies did not differ significantly on three of the four variables relating to residents' characteristics. Nor did they differ in terms of the homeliness or physical integration of settings. However, there were significant differences between providers on the important variables of working methods and staffing levels. Resident ability correlated with staffing levels and organisational culture, but not with staff working methods. The results and their implications are discussed in the context of other research which has used the same measures.

The effectiveness of staff support: evaluating active support training using a conditional probability approach

Active Support, a package of procedures which includes activity planning, support planning, and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe mental retardation following a multiple baseline design. Real-time observational data were collected on the level of assistance residents received from staff and their engagement in activity. Active Support was shown in a companion paper (Jones et al., 1999) to increase the levels of assistance residents received and their engagement in activity. Increased assistance was particularly experienced by the behaviorally less able and the disparity in activity between the more and less able was reduced. In the analysis presented here, the effectiveness of assistance was evaluated before and after Active Support training by calculating the likelihood of engagement occurring given the occurrence of assistance. This likelihood was represented by the statistic, Yule's Q. Yule's Q significantly increased following Active Support training, an increase that was maintained at follow-up. The increased effectiveness of assistance was related to other research findings on the relationship between staff: resident interaction patterns and resident behavior.

Attitudinal effects of degrading themes and sexual explicitness in video materials

This study examined the independent and interactive effects of sexual explicitness and degrading themes toward women on mens' attitudes following exposure to video presentations of male-female interactions. Subjects were 83 male college students who viewed video vignettes under one of four stimulus conditions: (a) sexually explicit/degrading, (b) sexually explicit/nondegrading, (c) nonexplicit/degrading, and (d) nonexplicit/nondegrading. Results revealed that men exposed to degrading material, regardless of explicitness, were significantly more likely to express attitudes supportive of rape, while explicitness had no significant main or interactive effect on these attitudes. Further, the interaction of explicitness with degradation was found to impact scores on a measure of sexual callousness. Theoretical and clinical implications of these findings are discussed.

Opportunity and the promotion of activity among adults with severe intellectual disability living in community residences: the impact of training staff in active support

Active support, a package of procedures which includes activity planning, support planning and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe intellectual disability following a multiple baseline design. The residents were directly observed to ascertain the level of assistance they received from staff and their engagement in activity. The introduction of active support increased the levels of assistance residents received, their engagement in domestic activities and their total engagement in activity. The intervention did not affect the level of social engagement. Across individuals, increases in assistance and engagement in activity were significantly and positively correlated. Both were significantly inversely related to resident adaptive behaviour. At baseline, staff gave more attention and assistance to people who were behaviourally more able. After the introduction of active support, receipt of attention was unrelated to adaptive behaviour and the behaviourally less able received more assistance. The disparity in activity between the more and less able was reduced. Gains were maintained in the majority of houses.

Effect of fly control on trachoma and diarrhoea

BACKGROUND

Domestic flies are accepted vectors of diarrhoea, but their role in trachoma transmission has never been quantified and no study has shown that fly control decreases the prevalence of trachoma. We assessed the effect of fly control on public health in a pilot study in Gambian villages.

METHODS

We studied two pairs of villages--one pair in the 1997 wet season, and one pair in the 1998 dry season. For each pair, deltamethrin was sprayed for 3 months to control flies in one village whilst the other was used as a control. Fly populations were monitored with traps. We surveyed trachoma at baseline and at 3 months, and collected daily data on diarrhoea in children aged between 3 months and 5 years.

FINDINGS

Fly control decreased numbers of muscid flies by around 75% in the intervention villages compared with controls. Trachoma prevalence was similar at baseline (wet season, prevalence in intervention village 8.8% vs control 12.2%; dry season, 18.0% vs 16.0%), but after 3 months of fly control there were 75% fewer new cases of trachoma in the intervention villages (wet season 3.7% vs 13.7%; dry season 10.0% vs 18.9%; rate ratio and relative risk of pooled data 0.25 [adjusted 95% CI 0.09-0.64], p=0.003). There was 22% less childhood diarrhoea in the wet season (14% vs 19%, period prevalence ratio 0.78 [0.64-0.95], p=0.01), and 26% less diarrhoea in the dry season (6% vs 8%; 0.74 [0.34-1.59], p=0.60) compared with controls.

INTERPRETATION

Muscid flies are important vectors of trachoma and childhood diarrhoea in The Gambia. Deltamethrin spray is effective for fly control and may be useful for reducing trachoma and diarrhoea in some situations, but further research on sustainable fly-control methods is needed.

Service support to people in Wales with severe intellectual disability and the most severe challenging behaviours: processes, outcomes and costs

A survey of people with severe intellectual disability and the most severe challenging behaviour in Wales identified five adults living in family homes, 17 in new specialist community housing and 19 in traditional services. With the omission of two people from the latter group and with a restricted collection of data for people living in the family home, the present study explored service input, outcome and costs across the three setting types. Process and outcome indicators for the family home group, who received little service input, were better than those for the traditional service group, although less good than those for the community house group. The specialist community home model produced significant gains over the traditional services in virtually all areas. Across the residential data set as a whole, there was no association between staff:resident ratios and severity of disability or between costs and severity of disability. This was largely true of the service types separately. There was a relationship between costs and service quality. However, this association was underpinned by gross differences between community houses and traditional settings. Costs, processes and outcomes ceased to be related when the two residential types were considered separately. Although higher costs of new community services compared to traditional services may be set against improved outcomes, high costs within the former could not be related to benefit. Outcome indicators were generally related to each other, suggesting that high quality in one sense was matched by high quality in other senses. Outcome was significantly associated with the ability of residents. Outcome indicators also tended to be related to observed staff performance, which was independent of resident ability. Therefore, outcome may be considered as dually determined by differences in resident ability and in what staff did.

The characteristics and residential situations of people with severe intellectual disability and the most severe challenging behaviour in Wales

A total population study of people in Wales with severe intellectual disability and the most severe challenging behaviour was undertaken to identify their characteristics, and the nature of their residential arrangements and service support. Forty-one participants were identified: five living in family homes, 17 in community housing, 17 in hospitals and two in hostels. The family home group had slightly higher adaptive behaviour scores than residents in community housing. Both groups had significantly higher scores than the hospital and hostel residents combined. Assessments of challenging behaviour showed the groups to be similar and to have a considerable range and extent of severely problematic behaviour. Co-occurrence of several forms of frequent severe problem behaviour was the norm and there was a marked association with social impairment. The five people living in their family homes had nominated service keyworkers, but reported professional input was low. The residential situations comprised two main service types: (1) traditional services, which were characterized by large living unit and facility size, atypical architectural design, relative isolation from the community, a greater level of buildings adaptations, low staff:resident ratios, a relatively high percentage of qualified staff, and a relative absence of systematic approaches to goal planning and structured activity; and (2) new community houses, which were characterized by small size, domestic design, location within the community, a lower level of buildings adaptations, much higher staff:resident ratios, and less emphasis on qualified staff but a greater emphasis on systematic working methods. Community settings were similar in having 'specialist' resident groupings based on challenging behaviour or conditions like autism in which challenging behaviours are common. A policy to provide for people with these characteristics being resettled from traditional settings in this way seems to have been established.

EMLA cream effectively reduces the pain of spinal needle insertion

BACKGROUND AND OBJECTIVE

EMLA cream is an effective topical anesthetic, which is commonly used for analgesia during venous cannulation in the pediatric population. This study was designed to compare the efficacy of EMLA cream with that of infiltration with lidocaine in relieving the pain associated with administration of spinal anesthesia.

METHODS

The patient population consisted of 41 ASA status I and II women scheduled for postpartum tubal ligation. Spinal anesthesia was administered with a 25-gauge spinal needle via a 20-gauge introducer. The patients were randomly allocated to receive either EMLA cream for a minimum of 30 minutes or infiltration with 3 mL of 1% lidocaine prior to spinal needle insertion. Pain during spinal needle insertion was assessed immediately after each procedure by a 10-cm visual analog scale.

RESULTS

Pain scores were significantly lower in the EMLA group (mean, 1.5) than in the lidocaine group (mean, 3.52) (P < .001). The number of patients satisfied with the method of analgesia was significantly higher in the EMLA than in the lidocaine group (90% vs 55%, P < .05).

CONCLUSION

EMLA cream is an effective alternative to lidocaine infiltration for analgesia during the administration of spinal anesthesia when using a 25-gauge spinal needle via a 20-gauge introducer. Application of EMLA cream for at least 30 minutes prior to spinal needle insertion is adequate to provide good analgesia during needle insertion.

Challenging behaviour: the effectiveness of specialist support teams

Two specialist community services for people with learning disabilities and challenging behaviour were evaluated over approximately 3 years. Intervention effectiveness was assessed with respect to changes in subjects' skills, challenging behaviours, mental health and quality of life, and to changes in staff morale. Subjects assessed as having challenging behaviour but not referred for specialist input were also studied. Comparison of changes in referred and non-referred samples over time showed minor differences only, indicating little intervention effect and demonstrating stability in the comparison sample. Analysis of the two services separately yielded different results. Positive client change was evident with respect to one service, whilst little change was noted with respect to the other. There was little evidence to suggest that either service had any effect on staff morale. Differences between the two services in terms of structure, staffing characteristics and operational policies are discussed as possible factors in the differential results obtained. A major issue raised by the study concerns the quality of settings from which the subjects were referred for specialist support. This is discussed as a factor which may limit the effectiveness of specialist input.

A one-year follow-up study of depression in dementia sufferers

BACKGROUND

Little data are available about the course or incidence of depression in dementia sufferers.

METHOD

Monthly follow-up data over one year is reported regarding depression in a cohort of 124 dementia sufferers. Dementia was diagnosed according to DSM-III-R criteria. Depression was assessed with the Cornell Depression Scale and diagnosed according to RDC criteria. Cognitive functioning was assessed with the CAMCOG:

RESULTS

Eighty-nine of the 124 patients completed the follow-up. The annual incidence rates of RDC major depression and RDC minor depression were 10.6% and 29.8%, respectively. Twenty per cent of patients with depression experienced these symptoms for six months or longer. Patients with vascular dementia were significantly more likely to experience three or more months of depression than patients with other dementias. RDC minor depression was highly persistent among 23.8% of sufferers.

CONCLUSION

Depression is persistent in patients with vascular dementia. Some patients with minor depression have a dysthymia-like disorder.

Molecular biology in nutrition research: modeling of folate metabolism

Model CHO cells obtained by transfecting CHO mutants with the E. coli and human folylpolyglutamate synthetase genes have proven useful for assessing the role of folylpolyglutamates in one carbon metabolism and for delineating how folate intracellular stores are regulated. Cells expressing enzymes in specific subcellular compartments, expressing enzymes with different substrate specificity's, and expressing enzyme activity at different levels, all in a common background, in this case the CHO cell, has allowed the development of kinetic models for assessing the role of folypolyglutamate synthetase in folate retention and in the cytotoxicity of antifolates.

Volunteer bias in sexuality research

Biases associated with volunteering for studies in human sexuality were studied. Beginning with a sample of over 1000 introductory psychology students, subjects participated in a two-phase study in which those willing and unwilling to volunteer for a variety of sexuality studies were compared. In both phases of this study, volunteers were significantly different from nonvolunteers on some, but not all, dimensions assessed. Specifically, compared to nonvolunteers, volunteers reported a more positive attitude towards sexuality, less sexual guilt, and more sexual experience. These differences were independent of subject gender. Sobering implications of these findings for the generalizability of sexuality research results are discussed.