Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Nurses' perceptions of personal attributes required when working with people with a learning disability and an offending background: a qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Learning disability nursing in the area of people with a learning disability and an offending background has developed considerably over recent years, particularly since the publication of the Bradley (). There has been limited work into the competencies nurses require to work in this area, and even less about the personal attributes of learning disability nurses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Learning disability nursing's specific contribution to the care of this population lies in their knowledge of the interaction between the learning disability, an individual's, sometimes abusive, personal history and an understanding of the subsequent offending behaviour. The knowledge base of nurses working with people with learning disabilities and an offending background needs to reflect the changing service user group. This is particularly in relation to substance misuse, borderline personality disorder, and mental health and the way such factors inter-relate with the learning disability. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further research is required into the relationship among decision making, risk taking or reluctance to do this, and the personal attributes required by nurses to work in secure learning disability care. Learning disability secure services are likely to continue to undergo change as circumstances alter and the offending population demonstrate greater complexity; nursing competencies and personal attributes need similarly to adapt to such changes. Mental health nursing has a great deal to contribute to effective working with this population, specifically with regard to developing strong relationships when concerns around borderline personality disorder or substance misuse are particularly in evidence.

ABSTRACT

Aim To identify and discuss the personal attributes required by learning disability nurses to work effectively with people with an offending background in secure and community settings. Background This study was part of a larger research investigation into the nursing competencies required to work with people with an offending background. There are few existing studies examining the personal attributes necessary for working with this group. Design A qualitative study addressing the perceptions of nurses around the personal attributes required to work with people with learning disabilities and an offending background. Methods A semi-structured interview schedule was devised and constructed, and 39 individual interviews were subsequently undertaken with learning disability nurses working in high, medium, low secure and community settings. Data were collected over 1 year in 2010/11 and analysed using a structured thematic analysis supported by the software package MAXqda. Findings The thematic analysis produced three categories of personal attributes, named as looking deeper, achieving balance and connecting, each of which contained a further three sub-categories. Conclusion Nursing of those with a learning disability and an offending background continues to develop. The interplay among personal history, additional background factors, nurses' personal attributes and learning disability is critical for effective relationship building.

Anxiety and compulsion patterns in the maintenance of bingeing/purging behaviours by individuals with bulimia nervosa

Bulimia nervosa, if not treated or if treated unsuccessfully, can develop into a severe and enduring eating disorder. Analysis of self-management of Seed-BN indicates that individuals frequently experience significant negative mental health issues and a complex relationship with medication management. Two discrete patterns of coping strategies to prevent deterioration in distressing symptoms were in evidence, controlled vomiting, which was related to the management of anxiety, and uncontrolled vomiting due to more dominant self-management of compulsive acts. The implications for nursing revolve around accurate assessment of vomiting and subsequent engagement by the individual with their coping strategies in relation to perceived deterioration in distressing symptoms. This paper reports on the results of a study into the self-reported coping strategies employed by a small sample (n = 12) of individuals diagnosed with bulimia nervosa purging sub-type, severe and enduring eating disorder (Seed-BN), referred to an outpatient clinic for psychotherapy. Data collection focused on the vomiting activities of participants through analysis of their self-management from diary extracts, which recorded vomiting patterns. Participants all experienced significant mental health issues, had complex histories of BN over a prolonged period, difficulties maintaining relationships, and many had an additional history of substance misuse including dependence on prescription drugs. The study findings indicated two different self-management strategies, anxiety containment and compulsion maintenance. There was a clear association between anxiety and controlled weekly vomiting patterns compared with compulsion and daily vomiting patterns. The implications for nursing practice relate to the potential for assessment of differences in vomiting patterns to indicate self-management status and subsequent interventions focusing on either anxiety or compulsive patterns.

Participatory action research: moving beyond the mental health 'service user' identity

Contemporary models of involvement within statutory services pay little regard to the identity of individuals beyond the 'service user' label and in doing so unwittingly perpetuate and sustain the negative impact of mental illness. The aim of this paper is to discuss the process of a 3-year participatory action research study facilitated by a mental health nurse. It highlights the perspective of those involved as co-researchers, all having experience of accessing statutory mental health services. It identifies both the process and the impact of this type of involvement on them illustrating their move beyond an illness identity. The study involved them undertaking a series of interviews with other service users in relation to their life stories. They subsequently mapped and analysed the transcripts. In order that the people were enabled to undertake these roles the study included a process of interviewing and appointing service user researchers followed by a programme of training workshops, supervision and discussion group/peer support. The accounts provided reflect the six researchers' attempts to make sense of their experience and reveal the path of transformation through collaboration.

Managing risk: a qualitative study of community-based professionals working with learning-disabled sex offenders

This study reports on research conducted to examine how community practitioners manage the difficulties of risk assessment in relation to people with a learning disability and a history of sexually offensive or abusive behaviour. Semi-structured interviews were conducted with a number of key professionals from various disciplines, all currently involved in the assessment process with the aim of determining potential referral to community settings. Data analysis revolved around a thematic exposition of factors influencing the relationship between the objective science of psychiatric investigation and the subjective interpretation of real-world practicalities in working with this group. Findings surrounded three major themes, frame conflict, relating to the difficulties of decision making in this area, therapeutic performance, whereby professionals were expected to engage in some form of active intervention, and safety outcomes, involving consideration of the problematic nature of judging the likelihood of re-offending.

Cultural change in a learning disability secure service: the role of the 'toggle' group

This paper reports the findings of a study into the management of change within a learning disability service in transition from medium to low secure status. The relationship between the service culture and resistance to change was a key consideration. A focus group approach was utilized with eight professionals from a range of disciplines meeting on six separate occasions, and the data were subsequently subject to thematic analysis. The study findings revealed markedly different perceptions of the response of the staff team to the implementation of change, with three groups adopting very different identities and allegiances: a dynamic group, embracing change and showing initiative, a strategically resistant group and a third group, the 'toggle', vacillating between the other two groups according to changing circumstances. The paper concludes that the toggle group were extremely influential with regard to the implementation of change, and may be of significance in analysis of strategies of resistance.

Relative torque profiles of elite male youth footballers: effects of age and pubertal development

This study aimed to establish the effect of age and pubertal development on relative peak torque in youth footballers. One hundred and fifty-seven subjects were arranged into U12-U18 age groups; of these 133 also completed a self-reporting measure of pubertal development (PDS) and were grouped accordingly. Bilateral isokinetic testing included mean peak torque/body weight (PT/BW) and angle of peak torque (AoPT) for reps 2-4 of 5 in concentric quadriceps (CQ), concentric hamstrings (CH) and eccentric hamstrings (EH) at 60 degrees s(-1). Two minutes rest were provided between concentric and eccentric tests for both legs. A significant increase with age was noted for PT/BW in CQ, CH and EH (P<0.05), although POST HOC analyses revealed different patterns of significance dependent upon muscle and type of contraction. Specifically, the U18 s (CQ:2.20 nm/kg, CH:1.39 nm/kg, EH:2.16 nm/kg) were not significantly stronger than the U16 s and U15 s (CQ:2.42/2.29 nm/kg, CH:1.41/1.27 nm/kg, EH:2.22/2.15 nm/kg) even though they had entered full time training. The relationship between EH PT/BW and AoPT showed a weak but significant inverse correlation (P<0.001; R= -0.390 and -0.346 for dominant and non dominant legs). The findings of this study present unique football specific normative and age/PDS group data for PT/BW and AoPT, and the corresponding relationship between these variables.

Use of radionuclide bone scans in multicenter clinical trials: Opportunities for quality improvement

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Background: Radionuclide bone scans are widely utilized to screen for osseous metastases given their high sensitivity for detection of metastatic disease. However, the variance in image quality can significantly impact the diagnostic interpretation. Methods: Prospective assessment of image quality on 478 digital and hard copy planar bone scans received as part of several multi-center clinical trials was completed using a two reviewer paradigm. To improve image quality, the following steps were taken: an Internal Image Quality Task Committee was formed, a comprehensive training program for all internal quality control reviewers was completed, and a site qualification process was initiated prior to site selection and/or subject enrollment with direct feedback to the sites. Results: Significant image quality issues potentially limiting the diagnostic interpretation of the radionuclide scans were initially identified in 21% of the submitted radionuclide bone scans. Quality issues were based on: technical factors, poor imaging technique, and subject factors which could not be corrected. A discordance rate of 4.3% among the two reviewers was also measured. After institution of the above steps, the net result was a 58% decrease in the quality control issues that were previously identified. The most significant improvements occurred on the basis of the site qualification process where sites changed from sending hard copy to digital images and there was direct feedback from the Imaging Core Lab to the sites to correct identified issues. Conclusions: Image quality of bone scans in multicenter clinical trials can be improved with direct communication coupled with a site qualification process prior to subject enrollment. We suspect these quality improvements will impact event driven endpoints that rely on the accurate assessment of bone lesions. We further suspect this level of quality control will continue to increase in importance as technology evolves to include hybrid scanning techniques such as SPECT/CT. This parallels our experience in the level of quality control and site qualification required for deployment of FDG-PET imaging in multicenter clinical trials.

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Forensic psychiatric nursing: skills and competencies: II clinical aspects

This study reports on research undertaken to identify the skills and competencies of forensic psychiatric nurses working in secure psychiatric services in the UK. The rationale for this research is the lack of clarity in the role definition of nurses working in these environments and the specific content that may underscore the curriculum for training forensic nurses. Over 3300 questionnaires were distributed to forensic psychiatric nurses, non-forensic psychiatric nurses and other disciplines and information obtained on (1) the perceived clinical problems that give forensic nurses the most difficulty; (2) the skills best suited to overcome those problems; and (3) the priority aspects of clinical nursing care that needs to be developed. A 35% response rate was obtained with 1019 forensic psychiatric nurses, 110 non-forensic psychiatric nurses and 43 other disciplines. The results highlighted a 'top ten' list of main problems with possible solutions and main areas for development. The conclusions drawn include a focus on skills and competencies regarding the management of personality disorders and the management of violence and aggression.

Forensic psychiatric nursing: skills and competencies: I role dimensions

This paper reports on an investigation into the skills and competencies of forensic psychiatric nurses from the perspective of three groups: (A) forensic psychiatric nurses; (B) non-forensic psychiatric nurses; and (C) other disciplines. A national survey of forensic psychiatric services in the UK was conducted, and information gathered on the perceived skills and competencies in this growing field of psychiatric practice. From 3360 questionnaires, 1172 were returned, making a response rate of 35%. The results indicate a small discrepancy between forensic nurses' and non-forensic nurses' perceptions of the role constructs of forensic practice. However, a larger difference was noted between nurses' perceptions and other disciplines' perceptions of the constituent parts to forensic psychiatric nursing. Nurses tended to focus on personal qualities both in relation to themselves and the patients, while the other disciplines focused on organizational structures both in defining the role and in the resolution of perceived deficits. The findings have implications for multidisciplinary working, as well as policy formulation and curriculum development in terms of the skills and competencies of forensic nurse training.

Ethiopia: between Sub-Saharan Africa and western Eurasia

Ethiopia is central to population genetic studies investigating the out of Africa expansion of modern humans, as shown by Y chromosome and mtDNA studies. To address the level of genetic differentiation within Ethiopia, and its relationship to Sub-Saharan Africa and Eurasia, we studied an 8 kb segment of the X-chromosome from 72 chromosomes from the Amhara, Oromo and Ethiopian Jews, and compared these results with 804 chromosomes from Middle Eastern, African, Asian and European populations, and 22 newly typed Saharawi. Within Ethiopia the two largest ethnic groups, the Amhara and Oromo, were not found to be statistically distinct, based on an exact test of haplotype frequencies. The Ethiopian Jews appear as an admixed population, possibly of Jewish origin, though the data remain equivocal. There is evidence of a close relationship between Ethiopian and Yemenite Jews, likely a result of indirect gene flow. Within an African and Eurasian context, the distribution of alleles of a variable T(n) repeat, and the spread of haplotypes containing Africa-specific alleles, provide evidence of a genetic continuity from Sub-Saharan Africa to the Near East, and furthermore suggest that a bottleneck occurred in Ethiopia associated with an out of Africa expansion. Ethiopian genetic heterogeneity, as evidenced by principal component analysis of haplotype frequencies, most likely resulted from periods of subsequent admixture. While these results are from the analysis of one locus, we feel that in association with data from other marker systems they add a complementary perspective on the history of Ethiopia.

Joint acute toxicity of diazinon and ammonia to Ceriodaphnia dubia

Diazinon is an organophosphorous pesticide widely found in municipal effluents as well as in agricultural and urban storm-water discharges. Ammonia is frequently also present in such effluents as a consequence of bacterial degradation of organic material. Because these two contaminants may occur concurrently, their relationship with respect to joint toxicity is of interest, particularly in regard to interpreting the results of effluent tests and subsequent toxicity identification evaluations (TIEs). In this particular case, we obtained an effluent sample that exhibited toxicity to Ceriodaphnia dubia. Toxicity identification evaluations manipulations suggested that ammonia (40 mg\L as total NH3) and diazinon (0.75 microgram/L) both contributed to toxicity. As part of the Phase 3 confirmation studies, an independent investigation was conducted to evaluate the interactions between these two toxicants using static tests that incorporated a 48-h exposure period. Chemical concentrations were verified analytically. Mortalities were measured at 24-h intervals and joint toxicity calculated on the basis of toxic units (TUs) for each toxicant. The 48-h LC50 values (lethal concentrations for 50% of the population) for the individual chemicals averaged 0.36 microgram/L and 1.11 mg/L for diazinon and un-ionized ammonia, respectively. Under the assumption of strict additivity, the sum of TUs contributed by each toxicant at the LC50 of the mixture should total unity. The TUs associated with the mixtures in laboratory water averaged 1.37 and 1.47, respectively, for 24- and 48-h exposure intervals. These results were similar to those obtained with the actual effluent sample and suggest that diazinon and ammonia exhibit less than additive toxicity when present together.

"Diverticula" of anterior mitral valve leaflet as a cause of subvalvular aortic stenosis

A 77-year-old male patient presented with symptoms of shortness of breath, fatigue, chest pain on exertion and dizziness. Transthoracic echocardiography suggested the presence of a diaphragmatic type of obstruction in the subaortic area of the left ventricular outflow tract. The systolic peak gradient at rest was 34 mmHg with a mean of 23 mmHg. Cardiac catheterization demonstrated rounded radiolucencies in the left ventricular outflow tract in the form of two "pouches" that moved back and forth causing subaortic stenosis. There was also a 70% stenosis of the left anterior descending coronary artery. Left ventricular function was normal. At surgery, a transesophageal echocardiogram demonstrated two distinct pouches arising from the anterior leaflet of the mitral valve. The larger of the two originated near the free edge of the leaflet and was attached via a chord to the membranous septum traversing the subaortic area of the left ventricular outflow tract. The patient underwent a left internal mammary to left anterior descending bypass graft, excision of the larger pouch and over-sewing of the smaller pouch. The excision and repair were performed through the aortic root and aortic valve. The patient made an uncomplicated recovery and on follow up his symptoms disappeared. This case shows the excellent results that can be obtained by surgery of diverticula of the mitral valve causing intermittent subaortic stenosis, a rare pathologic entity, morphologically different from the classical diaphragmatic subaortic stenosis.

The St. Thomas's Hospital maternity case notes study: a randomised controlled trial to assess the effects of giving expectant mothers their own maternity case notes

At an antenatal clinic in St. Thomas's Hospital, London, 246 expectant mothers were randomly allocated to hold either their own maternity case notes or the standard co-operation card. Information was collected on three occasions during their care on attitudes and health behaviour. Clinical outcomes were recorded and the effects of the two systems on clinic administration were observed. More of the notes group expressed satisfaction with most aspects of their care and delivery and significantly more of the notes group felt well informed and satisfied with their companion during labour. There were no differences in clinical outcomes between the two groups except that, for no identifiable systematic reason, there were more assisted deliveries among the notes group. A number of administrative advantages resulted from mothers holding their own notes and although initial reservations were found amongst professional staff interviewed at the start of the study, the results proved persuasive and the practice of giving mothers their own notes is now to be extended throughout the department.

Some questions of identity: late miscarriage, stillbirth and perinatal loss

This paper examines some of the attitudes and procedures which de-construct the identities of a mother and baby when loss occurs through late miscarriage, stillbirth and perinatal loss. Various factors which play a part in a woman's acceptance of her loss are explored, such as contact with the dead baby, formal and 'informal' ritual and early hospital discharge. Ways in which hospitals deal with and define these losses are looked at. It is suggested that all-too-often there seems to be no physical or psychological space for a maternity case without a baby. Is she a mother or is she a patient? The findings suggest that both roles may be lost simultaneously. The dead baby is usually whisked away and the bereaved woman sent back to the community with what feels like indecent haste. Birth and death seem to cancel out. Definitional ambiguities and anomalies about the status of the baby are examined and common sense views about 'hierarchies of sadness' are discussed. This study challenges existing assumptions about the way in which some babies are seen by the professionals as 'lesser' losses, and looks at the implications of these perceptions. The findings are based upon interviews with health professionals in four London hospitals; and a series of in-depth interviews with bereaved parents.