Developmental Associations between Cognition and Adaptive Behavior in Intellectual and Developmental Disability

Background

Intellectual and developmental disabilities (IDDs) are associated with both cognitive challenges and difficulties in conceptual, social, and practical areas of living (DSM-5). Individuals with IDD often present with an intellectual disability in addition to a developmental disability such as autism or Down syndrome. Those with IDD may present with deficits in intellectual functioning as well as adaptive functioning that interfere with independence and living skills. The present study sought to examine associations of longitudinal developmental change in domains of cognition (NIH Toolbox Cognition Battery, NIHTB-CB) and adaptive behavior domains (Vineland Adaptive Behavior Scales-3; VABS-3) including Socialization, Communication, and Daily Living Skills (DLS) over a two-year period.

Methods

Eligible participants for this multisite longitudinal study included those who were between 6 and 26 years at Visit 1, and who had a diagnosis of, or suspected intellectual disability (ID), including borderline ID. Three groups were recruited, including those with fragile X syndrome, Down syndrome, and other/idiopathic intellectual disability. In order to examine the association of developmental change between cognitive and adaptive behavior domains, bivariate latent change score (BLCS) models were fit to compare change in the three cognitive domains measured by the NIHTB-CB (Fluid, Crystallized, Composite) and the three adaptive behavior domains measured by the VABS-3 (Communication, DLS, and Socialization).

Results

Over a two-year period, change in cognition (both Crystalized and Composite) was significantly and positively associated with change in daily living skills. Also, baseline cognition level predicted growth in adaptive behavior, however baseline adaptive behavior did not predict growth in cognition in any model.

Conclusions

The present study demonstrated that developmental improvements in cognition and adaptive behavior are associated in children and young adults with IDD, indicating the potential for cross-domain effects of intervention. Notably, improvements in Daily Living Skills on the VABS-3 emerged as a primary area of adaptive behavior that positively related to improvements in cognition. This work provides evidence for the clinical, "real life" meaningfulness of the NIHTB-CB in IDD, and important empirical support for the NIHTB-CB as a fit-for-purpose performance-based outcome measure for this population.

Deviation scores: An innovative approach to interpreting cognitive test results for individuals with intellectual disabilities

BACKGROUND

Students with Intellectual Disability undergo frequent cognitive testing. Testing with this population is limited by insensitivity to relative strengths and weaknesses due to floor effects.

AIM

The study explored the utility of deviation scores via four case studies as a supplement to educational decision-making.

METHODS

Four students with Intellectual Disability completed cognitive testing. Deviation scores were calculated using age dependent raw z-score transformations to determine deviation from the standardization sample norms.

RESULTS

The application of deviation scores highlighted true relative strengths and weaknesses for students with Intellectual Disability rather than documenting previously known deficits. The four cases studies illustrated where deviation scores could, or could not, add value above and beyond traditional scoring.

DISCUSSION

Deviation scores can supplement placement and service decisions for students. Practical and psychometric considerations are reviewed.

CONCLUSION

The findings highlight the usefulness of deviation scores in providing meaningful information to school- and clinic-based practitioners.

Assessment of Local and Regional Control in Atypical (WHO Grade 2) Meningiomas Receiving Fractioned Stereotactic Radiotherapy

PURPOSE/OBJECTIVE(S)

The optimal delivery of postoperative radiotherapy to WHO grade 2 or atypical meningiomas (AM) is controversial. The historical standard of care has been high dose fractionated radiation to the resection bed and a 2 cm CTV as in RTOG 0539. Single fraction radiosurgery offers a more conformal alternative with demonstrated local control for smaller AM in less sensitive areas. Though less studied, fractionated stereotactic radiosurgery (FSRT) promises safer treatment of larger AM in more sensitive locations while minimizing the treated volume. This single institution retrospective review examines the hypothesis that local and marginal failure patterns in AM treated with five fraction FSRT remain unacceptably high.

MATERIALS/METHODS

Thirty-nine patients received 27.5 - 30 Gy in 5 fractions to their AM from 2009 to 2022 with grading based on the WHO criteria active at the time of treatment. All treatments were frameless VMAT deliveries with no PTV margin. Histological diagnosis of AM, gross disease at time of FSRT, five fraction FSRT, and lack of prior local radiation were required for inclusion. Single fraction treatments were excluded. Local recurrence was defined similar to RECIST criteria as an increase of 20% in the greatest cross-sectional diameter on MRI (or CT if MRI contraindicated) with at least one voxel touching the prescription volume. To examine the role of CTV margin, marginal recurrence was defined as any new lesion outside of the prescription volume but within 2 cm of the resection cavity. High grade toxicity per CTCAE v5 was an irreversible grade 3 or any grade 4 toxicity. Resection for radionecrosis was considered a local failure if any viable tumor was seen on pathology.

RESULTS

Median follow up was 32.5 months (range 3.2-147.5 months). The number of AM treated post STR, post GTR recurrence, and definitively were 26, 16, and 5 respectively. 3-year local tumor control was estimated to be 84%. As expected, larger tumors were more likely to fail locally (p >.001). Two (5%) patients experienced high grade toxicity - both symptomatic radionecrosis requiring resection. Three-year marginal control was estimated to be 92.3%. Of the 5 tumors treated to the entire resection cavity, none experienced a marginal failure. Interestingly, recurrent tumors s/p GTR were more likely to recur marginally than tumors treated after STR (p = .009). Only 1 (4%) tumor treated after STR failed marginally while 4 (33%) tumors treated after GTR recurrence failed.

CONCLUSION

The rate of high-grade toxicity in AM receiving FSRT was low. Local control appeared comparable to historical rates which may suggest the need for dose escalation with longer term follow-up. Recurrent tumors appear more prone to marginal failures, however more work is needed to determine which patients may benefit from additional CTV margin and more prolonged fractionated dose schedules. Improved targeting with newer imaging studies (e.g., DOTATATE PET) should be examined to determine if more accurate targeting will improve outcomes.

The comparison of expressed emotion of parents of individuals with fragile X syndrome to other intellectual disabilities

BACKGROUND

Parenting children and young adults with intellectual disabilities, including individuals with fragile X syndrome and Down syndrome, is challenging, joyful, and complicated. Exploring how parents talk about their children, and the quality of the parent/child relationship can provide insight into the home environment and interactional patterns of the family.

METHOD

Expressed emotion (EE) is a measurement of a family's emotional climate based on a parent or caregiver's report of warmth, emotional overinvolvement, hostility, and criticism. The purpose of this study was to describe EE for a sample of parents of individuals with intellectual disabilities and to determine any differences in EE amongst individuals within subgroups. Based on previous research about fragile X syndrome and family systems, we hypothesized that there would be significant differences between the disability groups (higher EE in families with children/young adults with fragile X syndrome).

RESULTS

Results showed relatively high proportions of EE across groups of individuals with intellectual disabilities, however, there were no significant differences between the subgroups. Null findings suggest that differences in EE may not relate directly to a child's specific genetic condition. Rather, increased EE in caregiver populations may simply reflect well-documented stressors related to stigma, caregiver burden, and limited community supports. Critical statements were infrequent, however, over half of the participants reported dissatisfaction with their situation, and many were categorized as having emotional overinvolvement, as measured by frequent statements of intense worry and self-sacrifice.

CONCLUSION

Findings point to potential utility in family-level interventions focused on providing structured caregiver therapy to manage excessive worry and grief related to a diagnosis of intellectual disability, and respite care to encourage caregiver independence and pursuit of personal care.

Sensitivity of the NIH Toolbox to Detect Cognitive Change in Individuals With Intellectual and Developmental Disability

BACKGROUND AND OBJECTIVE

Individuals with intellectual disability (ID) experience protracted cognitive development compared with typical youth. Sensitive measurement of cognitive change in this population is a critical need for clinical trials and other intervention studies, but well-validated outcome measures are scarce. This study's aim was to evaluate the sensitivity of the NIH Toolbox Cognition Battery (NIHTB-CB) to detect developmental changes in groups with ID-fragile X syndrome (FXS), Down syndrome (DS), and other ID (OID)-and to provide further support for its use as an outcome measure for treatment trials.

METHODS

We administered the NIHTB-CB and a reference standard cross-validation measure (Stanford-Binet Intelligence Scales, Fifth Edition [SB5]) to 256 individuals with FXS, DS, and OID (ages 6-27 years). After 2 years of development, we retested 197 individuals. Group developmental changes in each cognitive domain of the NIHTB-CB and SB5 were assessed using latent change score models, and 2-year growth was evaluated at 3 age points (10, 16, and 22 years).

RESULTS

Overall, effect sizes of growth measured by the NIHTB-CB tests were comparable with or exceeded those of the SB5. The NIHTB-CB showed significant gains in almost all domains in OID at younger ages (10 years), with continued gains at 16 years and stability in early adulthood (22 years). The FXS group showed delayed gains in attention and inhibitory control compared with OID. The DS group had delayed gains in receptive vocabulary compared with OID. Unlike the other groups, DS had significant growth in early adulthood in 2 domains (working memory and attention/inhibitory control). Notably, each group's pattern of NIHTB-CB growth across development corresponded to their respective pattern of SB5 growth.

DISCUSSION

The NIHTB-CB is sensitive to developmental changes in individuals with ID. Comparison with levels and timing of growth on the cross-validation measure shows that the NIHTB-CB has potential to identify meaningful trajectories across cognitive domains and ID etiologies. Sensitivity to change within the context of treatment studies and delineation of clinically meaningful changes in NIHTB-CB scores, linked to daily functioning, must be established in future research to evaluate the battery more completely as a key outcome measure.

Evaluation of the use and attitudes of pregnant and postpartum women towards medicine utilisation during pregnancy in the United Arab Emirates: A national cross-sectional study

INTRODUCTION

Pregnancy period is of high concern to every woman. Knowledge about medication use needs to be highlighted at such a critical stage.

OBJECTIVE

This study aimed to assess pregnant and postpartum women's use and attitude regarding the utilisation of medications during pregnancy in the United Arab Emirates (UAE).

METHODS

A self-administrated survey was distributed among 500 pregnant and postpartum women randomly selected from the general population of five different cities within the UAE: Abu Dhabi, Dubai, Sharjah, AL Fujairah and Ajman over a period of 3 months. All analyses were two-sided, and a P-value of ≤.05 was taken as the cut-off for statistical significance.

RESULTS

Overall, 434 participants took part in the survey. Forty-one percent of respondents reported that they use drugs during pregnancy, and the most frequently used medications during pregnancy were multivitamins, analgesics and folic acid. Moreover, 77.9% of female participants acquired their knowledge from their gynaecologists. Only 21.7% of respondents reported that the pharmacist provided enough information during dispensing. Most ladies had an uplifting mentality towards medicines, but they believed pregnant ladies should be more wary with respect to medication use during pregnancy. A significant association was found between participants' nationality and occupation, and attitudes about medications (P < .001), where women with Arab nationality and those with health-related careers agreed that they have a higher threshold for using medicines during pregnancy.

CONCLUSION

During pregnancy, ladies were more moderate and doubter towards the drug, healthcare providers should know about such mentalities while encouraging pregnant ladies to take prescription.

Adapting Medication for Type 2 Diabetes to a Low Carbohydrate Diet

Healthcare professionals in the primary care setting need to be competent to safely adapt diabetes medications when patients with Type 2 Diabetes (T2D) alter their diet. Safe prescribing practice is supported through an understanding of the clinical evidence, basic science, and pharmacology of medications. This review article supports clinicians in the practical application of this knowledge to achieve safe practice. Traditional medical training and clinical practice for chronic disease has long revolved around the teaching of intensifying therapy and evidenced based prescribing, a crucial skill when chronic disease progresses. Now that we are witnessing remission of Type 2 Diabetes through nutritional interventions specifically low carbohydrate diets (LCD) we must apply the same effort and thought to de-prescribing as the underlying metabolic condition improves. There is minimal guidance in the literature on how to actively de-prescribe. The American Diabetes Association in their Standards of Medical Care in Diabetes–2021 acknowledges low carbohydrate nutritional therapy (LCD) as a viable option in the management of Type 2 Diabetes (T2D). Thus, the goal of our paper is to help close the gap between the clinical evidence, basic science, and pharmacology of T2D medications to the practical application and teamwork needed to facilitate safe medication reduction in the primary care setting when applied to a LCD. The LCD is an increasingly popular and effective option for managing T2D and can lead to an improvement in the condition, reduced medication burden, and contribute to significant weight loss. Safe initiation of a LCD in patients on medications requires significant monitoring and medication adjustments to decrease and eliminate the risk of hypoglycemia and hypotension. The health care team including clinicians in primary care, nursing, pharmacy and nutrition need to be competent in adjusting diabetes and antihypertensive medications to achieve safe and effective care. The most immediate and important adjustments are to insulin, sulfonylureas, SGLT2 inhibitors, blood pressure medications and diuretics. Interdisciplinary care teams can individualize therapy while following the guidance, which includes monitoring blood glucose and blood pressure closely, decreasing medications that can cause hypoglycaemia and hypotension, evaluating blood glucose and blood pressure data responses regularly, and open access communication with the team. The article is an international consensus document on de-prescribing that was put together by a multidisciplinary team of clinicians.

Challenges associated with mental health management: Barriers and consequences

Introduction

Mental illness has become a global public health issue and according to WHO report in 2015, United Arab Emirates (UAE) recorded the highest level of depression among all countries at Eastern Mediterranean Region. Many people frequently suffer from mental health diseases but tend not to obtain help. Treatment delay can become life-threatening.

Objectives

This study aimed to identify the barriers to seeking professional help for mental illness and the consequences of untreated mental health disorders. The study also aimed to examine outcomes in patients when help was provided by health care providers.

Methods

A self-administrated survey was distributed among 377 people randomly selected from general population of three different cities at United Arab Emirates (UAE): Abu Dhabi, Dubai and Sharjah. Their perception of the barriers, consequences and outcomes was analyzed to achieve the objectives of the study.

Results

Overall, 341 participants completed the survey. Wrong thought regarding mental disorders (60.1%) and being ashamed (58.9%) were identified to be the most common and significant barriers (P < 0.001) that prevent people from obtaining healthcare providers’ assistance. The majority of responders reported building confidence (78.9%) and improvement in relationships (73.0%) as outcomes for taking professional help in mental illness. Moreover, many individuals believed that untreated mental illness could lead to problems with family and friends (69.2%) as well as to suicidal thoughts (56.3%).

Conclusion

This research gives some insights regarding the challenges associated with mental diseases management in the UAE. Majority of responders had a negative perception of mental health service due to a lack of awareness regarding treatment effectiveness for mental disorders.

Validation of the NIH Toolbox Cognitive Battery in intellectual disability

OBJECTIVE

To advance the science of cognitive outcome measurement for individuals with intellectual disability (ID), we established administration guidelines and evaluated the psychometric properties of the NIH-Toolbox Cognitive Battery (NIHTB-CB) for use in clinical research.

METHODS

We assessed feasibility, test-retest reliability, and convergent validity of the NIHTB-CB (measuring executive function, processing speed, memory, and language) by assessing 242 individuals with fragile X syndrome (FXS), Down syndrome (DS), and other ID, ages 6 through 25 years, with retesting completed after 1 month. To facilitate accessibility and measurement accuracy, we developed accommodations and standard assessment guidelines, documented in an e-manual. Finally, we assessed the sensitivity of the battery to expected syndrome-specific cognitive phenotypes.

RESULTS

Above a mental age of 5.0 years, all tests had excellent feasibility. More varied feasibility across tests was seen between mental ages of 3 and 4 years. Reliability and convergent validity ranged from moderate to strong. Each test and the Crystallized and Fluid Composite scores correlated moderately to strongly with IQ, and the Crystallized Composite had modest correlations with adaptive behavior. The NIHTB-CB showed known-groups validity by detecting expected executive function deficits in FXS and a receptive language deficit in DS.

CONCLUSION

The NIHTB-CB is a reliable and valid test battery for children and young adults with ID with a mental age of ≈5 years and above. Adaptations for very low-functioning or younger children with ID are needed for some subtests to expand the developmental range of the battery. Studies examining sensitivity to developmental and treatment changes are now warranted.

An Evaluation of US Food and Drug Administration's Program to Register HIV Drugs for Use in Resource-Constrained Settings

IMPORTANCE

The US Food and Drug Administration (FDA) program to review antiretroviral drugs for use in low-resource settings via the US President's Emergency Plan for AIDS Relief (PEPFAR) now supports treatment of more than 14 million patients with HIV. However, an in-depth evaluation of the program has not been undertaken.

OBJECTIVE

To conduct a quantitative analysis of the FDA-reviewed antiretroviral drug applications in order to assess the contributions of PEPFAR and to identify areas for improvement.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study was conducted of all PEPFAR applications submitted to the FDA from December 1, 2004, to May 31, 2018. The analyses were conducted between October 2018 and February 2019.

MAIN OUTCOMES AND MEASURES

Numbers and types of applications reviewed, how long it took for applications to obtain approval or tentative approval (time to registration), how often the FDA issued a complete response letter (CRL) identifying deficiencies precluding application approval or tentative approval and their reasons, and the association between CRLs and time to registration.

RESULTS

Overall, 260 PEPFAR applications for 327 antiretroviral therapies were reviewed by FDA, of which 216 applications (83%) for 272 drugs were authorized for use. Of the 216 authorized applications, 184 applications for 231 drugs remain in active status and, thus, are available for use. Twenty-six percent (56 of 216) of the applications were for pediatric-specific formulations or strengths; the remainder were for adults. For all 216 applications, the median (interquartile range) time to registration was 10.0 (7.0-17.5) months. Thirty-seven percent (95 of 260) of the applications received 1 or more CRLs, resulting in a total of 172 CRLs; most applications received 1 CRL, whereas some were issued up to 6 CRLs. Among all CRLs, 264 deficiency reasons were identified; the most common deficiencies were associated with manufacturing processes (155 [44%]), followed by product labeling (62 [23%]), and failing facility inspections (54 [20%]). Complete response letters were associated with an increased time to registration. Applications without CRLs had a median (interquartile range) time to registration of 9.0 (5.5-12.0) months, whereas those with at least 1 CRL took a median (interquartile range) of 22.0 (14.0-38.0) months (P < .001).

CONCLUSIONS AND RELEVANCE

The FDA's PEPFAR program has made many antiretroviral drugs available for global use. However, FDA and the pharmaceutical companies could take steps to improve the quality of applications submitted to prevent avoidable deficiencies in manufacturing processes and labeling. Further efforts to develop better, easier to use pediatric-specific therapies are needed.

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.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Reading in Children With Fragile X Syndrome: Phonological Awareness and Feasibility of Intervention

Individuals with fragile X syndrome (FXS) present with significant deficits in reading skills, but scant research exists to understand the characteristics of the reading delays or best practices for reading instruction with this population. Study 1 examined the relationship between phonological awareness and reading skills in individuals with FXS. Study 2 evaluated the feasibility of a web-based reading intervention, which incorporated phonological awareness and phonics instruction but was originally developed for mainstream students, for children with FXS. Results suggest that phonological awareness and reading skills are correlated in this population, and that instruction targeting phonological awareness and phonics should not be ruled out for individuals with FXS. Further studies are needed to examine their potential effects.

Adaptive behaviour, executive function and employment in adults with Down syndrome

BACKGROUND

Individuals with Down syndrome (DS) demonstrate difficulties with aspects of executive function (EF) and adaptive behaviour across the lifespan. There is a current lack of information regarding how these difficulties relate to employment outcomes in adulthood. This study evaluated the adaptive behaviour and EF profiles of individuals with DS during early adulthood and the association between these areas of functioning and employment status.

METHODS

Parents or caregivers of primarily young adults with DS (n = 31; mean chronological age = 25.9 years; SD = 5.92) completed the Vineland Adaptive Behavior Scales - Second Edition the Behavior Rating Inventory of Executive Function - Adult version and a demographic questionnaire that requested information regarding adult employment status.

RESULTS

Findings indicated a distinct pattern of relative strengths and challenges in adaptive behaviour and EF. In addition, the EF sub-domain of working memory was a significant predictor of employment status.

CONCLUSIONS

Specific aspects of the DS cognitive profile may have an important influence on employment status in primarily young adults with DS. Implications for interventions are discussed.

The NIH Toolbox Cognitive Battery for intellectual disabilities: three preliminary studies and future directions

BACKGROUND

Recent advances in understanding molecular and synaptic mechanisms of intellectual disabilities (ID) in fragile X syndrome (FXS) and Down syndrome (DS) through animal models have led to targeted controlled trials with pharmacological agents designed to normalize these underlying mechanisms and improve clinical outcomes. However, several human clinical trials have failed to demonstrate efficacy of these targeted treatments to improve surrogate behavioral endpoints. Because the ultimate index of disease modification in these disorders is amelioration of ID, the validation of cognitive measures for tracking treatment response is essential. Here, we present preliminary research to validate the National Institutes of Health Toolbox Cognitive Battery (NIH-TCB) for ID.

METHODS

We completed three pilot studies of patients with FXS (total n = 63; mean age 19.3 ± 8.3 years, mean mental age 5.3 ± 1.6 years), DS (n = 47; mean age 16.1 ± 6.2, mean mental age 5.4 ± 2.0), and idiopathic ID (IID; n = 16; mean age 16.1 ± 5.0, mean mental age 6.6 ± 2.3) measuring processing speed, executive function, episodic memory, word/letter reading, receptive vocabulary, and working memory using the web-based NIH-TB-CB, addressing feasibility, test-retest reliability, construct validity, ecological validity, and syndrome differences and profiles.

RESULTS

Feasibility was good to excellent (≥80 % of participants with valid scores) for above mental age 4 years for all tests except list sorting (working memory). Test-retest stability was good to excellent, and convergent validity was similar to or better than results obtained from typically developing children in the normal sample for executive function and language measures. Examination of ecological validity revealed moderate to very strong correlations between the NIH-TCB composite and adaptive behavior and full-scale IQ measures. Syndrome/group comparisons demonstrated significant deficits for the FXS and DS groups relative to IID on attention and inhibitory control, a significant reading weakness for FXS, and a receptive vocabulary weakness for DS.

CONCLUSIONS

The NIH-TCB has potential for assessing important dimensions of cognition in persons with ID, and several tests may be useful for tracking response to intervention. However, more extensive psychometric studies, evaluation of the NIH-TCB's sensitivity to change, both developmentally and in the context of treatment, and perhaps establishing links to brain function in these populations, are required to determine the true utility of the battery as a set of outcome measures.

Mortality among veterans with type 2 diabetes initiating metformin, sulfonylurea or rosiglitazone monotherapy

AIMS/HYPOTHESES

Despite oral hypoglycaemic medications being the most commonly used pharmacological treatments for type 2 diabetes, research is limited on their comparative safety, particularly their effects on overall mortality. We compared mortality risk with monotherapy initiation of four oral hypoglycaemic medications in a nationwide cohort of US veterans with type 2 diabetes.

METHODS

We identified new users of oral hypoglycaemic medication monotherapy between 2004 and 2009 who received care for at least 1 year from the Veterans Health Administration.Patients were followed until initial monotherapy discontinuation,addition of another diabetes pharmacotherapy, death or end of follow-up. Mortality HRs were estimated using Cox regression adjusted for potential confounding factors.

RESULTS

Among new users of metformin, sulfonylureas and rosiglitazone (185,360 men, 7,812 women), 4,256 (2.2%) died during follow-up. Average duration of medication use ranged from 1.4 to 1.7 years. Significantly higher mortality risk was seen for glibenclamide (known as glyburide in the USA and Canada) (HR 1.38, 95% CI 1.27, 1.50) or glipizide (HR 1.55,95% CI 1.43, 1.67) compared with metformin monotherapy,and for glipizide compared with rosiglitazone (HR 1.27, 95%CI 1.01, 1.59) or glibenclamide monotherapy (HR 1.12, 95%CI 1.02, 1.23). A significant sex–rosiglitazone interaction was seen (p=0.034) compared with metformin monotherapy, with women having a higher HR (HR 4.36, 95% CI 1.34, 14.20)than men (HR 1.19, 95% CI 0.95, 1.49).

CONCLUSIONS/INTERPRETATIONS

Significantly higher mortality was associated with glibenclamide, glipizide and rosiglitazone use compared with metformin, and with glipizide use compared with rosiglitazone or glibenclamide. The potential for residual confounding by indication should be considered in interpreting these results.

Enhanced medication management services in the community: A win-win proposal from an economic, clinical and humanistic perspective

BACKGROUND

Pharmacists are now receiving reimbursement by the Ontario government to do medication reviews for patients on 3 or more medications. However, they are often too busy in the community setting to thoroughly review medications with patients. Having a designated pharmacist to provide medication reviews could increase the number of reviews performed.

METHODS

Step 1 involved developing a business plan to determine the number of medication reviews that needed to be done to pay a pharmacist a full-time salary. Step 2 involved establishing the core elements of medication therapy management that included medication review, a medication-related action plan, documentation and follow-up. In step 3, eligible patients were called and invited to attend an appointment to review their medications with the pharmacist. Upon completion of the medication reviews, a random group of patients were requested to complete a satisfaction survey after the medication review.

RESULTS

Three hundred thirty-six patients received billable medication reviews from April 4 to July 27, 2012. Twenty-seven additional visits were performed as follow-up visits. Eighty pharmaceutical opinions met the eligibility criteria for billing. Fifteen patients received counselling for smoking cessation. Medication reviews were completed for 19 patients from 8 other pharmacies. Extra revenue was generated through the sales of replacements of expired products. An average of 2.08 drug-related problems per patients was identified. One hundred percent of the patients were very satisfied with the service.

CONCLUSION

A full-time pharmacist position providing enhanced medication management services generated enough income to pay for a full-time pharmacist's salary. The benefits to the patients were an increase in identification and resolution of drug-related problems, as well as an opportunity to receive disease state education and experience an improvement in disease states. Patients were extremely satisfied with the medication review process and the service provided to them. Can Pharm J 2013;146:162-168.

SU-E-T-158: Neutron Damage of Power Electronics Used during Image Guidance in Proton Therapy

PURPOSE

A series of measurements were performed in a clinical proton therapy beam to assess the sensitivity of silicon-based electronics in commercial x-ray generators to single event burnout from the secondary neutron background in proton therapy treatments.

METHODS

Failure rates were nondestructively measured in various metal oxide semiconductor field-effect transistors (MOSFETs) as a function of applied voltage using a dedicated test circuit board. Neutrons were produced by 230 MeV protons stopping in a brass beam target and high beam current was used to accelerate testing. Neutron fluences were measured by activation analysis of carbon and aluminum in both the test setup and in situ at the generator. Failure rates were determined by scaling results based on beam monitor output to the relevant neutron fluence rate.

RESULTS

Current pulses from the test board clearly indicated the onset of single event burnout without destroying the MOSFET. The neutron fluence measured on the test board was 4.3 ± 0.8×106 n cm-2 MU-1 and this is consistent with previous measurements. The MOSFET failure rate decreased rapidly with a reduction in the applied voltage and is 20-30 times lower in higher-rated components at the same voltage. Under nominal operating conditions the estimated failure rate is tens of failures per year for a generator 6m from the treatment position.

CONCLUSION

The sensitivity of x-ray generator power electronics to neutron-induced single-event burnout is significant and can affect the implementation of image-guided techniques for proton therapy. Strategies and system designs to mitigate this phenomenon are being investigated to help enable x-ray generators withstand the proton therapy environment. This research was supported by the NIH/NCI under grant number 6-PO1 CA 21239.

IRT-Sofia BNCT beam tube optimization study

An optimization study of IRT-Sofia BNCT beam tube is presented. In the study we used the MIT/FCB experience. The enlarging of filter/moderator cross section dimensions and the decreasing of collimator length within the limits of the IRT-Sofia reactor design were analyzed. The influence of beam and reactor core axes non-coincidence on the beam properties was also evaluated. The irradiation resistance of polytetrafluoroethylene (Teflon(®)) was also evaluated. The results provide information for making decisions on the IRT-Sofia BNCT beam construction.