The relationship between clinical presentation and the nature of care in adults with intellectual disability and epilepsy - national comparative cohort study

BACKGROUND

A quarter of People with Intellectual Disabilities (PwID) have epilepsy compared with 1% of the general population. Epilepsy in PwID is a bellwether for premature mortality, multimorbidity and polypharmacy. This group depends on their care provider to give relevant information for management, especially epilepsy. There is no research on care status relationship and clinical characteristics of PwID and epilepsy.

AIM

Explore and compare the clinical characteristics of PwID with epilepsy across different care settings.

METHOD

A retrospective multicentre cohort study across England and Wales collected information on seizure characteristics, intellectual disability severity, neurodevelopmental/biological/psychiatric comorbidities, medication including psychotropics/anti-seizure medication, and care status. Clinical characteristics were compared across different care settings, and those aged over and younger than 40 years.

RESULTS

Of 618 adult PwID across six centres (male:female = 61%:39%), 338 (55%) received professional care whereas 258 (42%) lived with family. Significant differences between the care groups existed in intellectual disability severity (P = 0.01), autism presence (P < 0.001), challenging behaviour (P < 0.001) and comorbid physical conditions (P = 0.008). The two groups did not vary in intellectual disability severity/genetic conditions/seizure type and frequency/psychiatric disorders. The professional care cohort experienced increased polypharmacy (P < 0.001) and antipsychotic/psychotropic use (P < 0.001/P = 0.008).The over-40s cohort had lower autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) comorbidity (P < 0.001/P = 0.007), increased psychiatric comorbidity and challenging behaviour (P < 0.05), physical multimorbidity (P < 0.001), polypharmacy (P < 0.001) and antipsychotic use (P < 0.001) but reduced numbers of seizures (P = 0.007).

CONCLUSION

PwID and epilepsy over 40 years in professional care have more complex clinical characteristics, increased polypharmacy and antipsychotic prescribing but fewer seizures.

Clinical characteristics of people with intellectual disability admitted to hospital with constipation: identifying possible specific high-risk factors

BACKGROUND

People with intellectual disabilities (ID) die on an average 20 years earlier to the general population. They have higher rates of multimorbidity and polypharmacy. Around 25% of people with ID report chronic constipation. The England Learning Disabilities Mortality Review found that nearly 25% of deaths identified constipation as a long-term health problem. However, the likely risk factors for constipation related harm are poorly enumerated. We sought to identify possible specific high-risk factors by examining the clinical characteristics of people with ID admitted to hospital with constipation.

METHODS

Data of people with ID admitted with constipation in two general hospitals covering a population of 1.3 million from 2017 to 2022 were reported using the STROBE guideline for cohort studies. Collected data included age, gender, intellectual disability severity, recorded medication, presenting complaint and co-morbidities. The medication anticholinergic burden was calculated using the anticholinergic burden scale. Continuous variables were summarised by mean and standard deviation if normally distributed, with categorical variables summarised by the number and percentage in each category.

RESULTS

Of 46 admissions (males 52%), 57% had moderate to profound ID, 37% had epilepsy, 41% prescribed antiseizure medication (ASM) and 45% were on laxatives. Average age was 46 years. The anticholinergic burden score mean was 2.3 and median, one.

CONCLUSIONS

We can hypothesise that people with more severe ID, suffering from epilepsy and on ASM may be more at risk of developing severe constipation. Some admissions may be avoided with earlier use of laxatives in the community.

Summary and Comparison of the 2022 ACC/AHA/HFSA and 2021 ESC Heart Failure Guidelines

The guidelines released by the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) in 2022 and those released in 2021 by the European Society of Cardiology (ESC) play a crucial role in offering evidence-based recommendations for the diagnosis and management of heart failure (HF). This comprehensive review aims to provide an overview of these guidelines, incorporating insights from relevant clinical trials. While there is considerable alignment between the two sets of guidelines, certain notable differences arise due to variations in publication timelines, which we will outline. By presenting this summary, our objective is to empower clinicians to make informed decisions regarding HF management in their own practice, and facilitate the development of more harmonized guidelines in the future.

Short term outcomes of children with abusive head trauma two years post injury: A retrospective study

PURPOSE

Abusive head trauma (AHT) can have debilitating sequelae for children who survive. A retrospective medical record review was used to describe short-term developmental outcomes of children with AHT and identify predictors of poorer outcomes.

METHOD

Children with AHT who received follow up by the hospital's rehabilitation department for 12 to 24 months post-injury were included in this review. Data for 85 children were collected on hearing, vision, gross motor, fine motor, speech and language, cognition, play, adaptive functioning, behaviour and personal-social skills.

RESULTS

Global assessment found 42% of children had a good recovery, 34% had a moderate disability and 24% had a severe disability. For whom there was data, more than half had abnormal cognition, behaviour and personal-social skills, whilst more than a third had abnormal speech and language, neurological signs on last assessment, vision, play skills, and gross and fine motor skills. Factors that predicted poorer prognosis across all developmental domains included paediatric intensive care unit admission, longer length of hospital stay, breathing difficulty and lower Glasgow Coma Scale on presentation.

CONCLUSION

This study highlights the substantial number of children who have abnormal development in the short-term post-AHT and assists in identifying those who require extensive long-term follow up.

Analytic Form of the Full Two-Loop Five-Gluon All-Plus Helicity Amplitude

We compute the full-color two-loop five-gluon amplitude for the all-plus helicity configuration. In order to achieve this, we calculate the required master integrals for all permutations of the external legs, in the physical scattering region. We verify the expected divergence structure of the amplitude and extract the finite hard function. We further validate our result by checking the factorization properties in the collinear limit. Our result is fully analytic and valid in the physical scattering region. We express it in a compact form containing logarithms, dilogarithms, and rational functions.

Ethical Issues in the Development of Readiness Cohorts in Alzheimer's Disease Research

There is growing interest in the development of novel approaches to secondary prevention trials in Alzheimer's disease to facilitate screening and recruitment of research participants and to reduce the time and costs associated with clinical trials. Several international research collaborations are setting up research infrastructures that link existing research cohorts, studies or patient registries to establish 'trial-ready' or 'readiness' cohorts. From these cohorts, individuals are recruited into clinical trial platforms. In setting up such research infrastructures, researchers must make ethically challenging design decisions in at least three areas: re-contacting participants in existing research studies, obtaining informed consent for participation in a readiness cohort, and disclosure of Alzheimer's disease-related biomarkers. These ethical considerations have been examined by a dedicated workgroup within the European Prevention of Alzheimer's Dementia (EPAD) project, a trans-European longitudinal cohort and adaptive proof-of-concept clinical trial platform. This paper offers recommendations for the ethical management of re-contact, informed consent and risk disclosure which may be of value to other research collaborations in the process of developing readiness cohorts for prevention trials in Alzheimer's disease and other disease areas.

Psychological, behavioral and social effects of disclosing Alzheimer's disease biomarkers to research participants: a systematic review

BACKGROUND

Current Alzheimer's disease (AD) research initiatives focus on cognitively healthy individuals with biomarkers that are associated with the development of AD. It is unclear whether biomarker results should be returned to research participants and what the psychological, behavioral and social effects of disclosure are. This systematic review therefore examines the psychological, behavioral and social effects of disclosing genetic and nongenetic AD-related biomarkers to cognitively healthy research participants.

METHODS

We performed a systematic literature search in eight scientific databases. Three independent reviewers screened the identified records and selected relevant articles. Results extracted from the included articles were aggregated and presented per effect group.

RESULTS

Fourteen studies met the inclusion criteria and were included in the data synthesis. None of the identified studies examined the effects of disclosing nongenetic biomarkers. All studies but one concerned the disclosure of APOE genotype and were conducted in the USA. Study populations consisted largely of cognitively healthy first-degree relatives of AD patients. In this group, disclosure of an increased risk was not associated with anxiety, depression or changes in perceived risk in relation to family history. Disclosure of an increased risk did lead to an increase in specific test-related distress levels, health-related behavior changes and long-term care insurance uptake and possibly diminished memory functioning.

CONCLUSION

In cognitively healthy research participants with a first-degree relative with AD, disclosure of APOE ε4-positivity does not lead to elevated anxiety and depression levels, but does increase test-related distress and results in behavior changes concerning insurance and health. We did not find studies reporting the effects of disclosing nongenetic biomarkers and only one study included people without a family history of AD. Empirical studies on the effects of disclosing nongenetic biomarkers and of disclosure to persons without a family history of AD are urgently needed.

TRIAL REGISTRATION

PROSPERO international prospective register for systematic reviews CRD42016035388 . Registered 19 February 2016.

So Close, Yet So Far Away

This article presents a marital horizon theory of emerging adulthood that posits that young people's perceptions of marriage are central factors in determining subgroup differences in the length of emerging adulthood as well as the specific behaviors that occur during this period in the family life cycle. The model was tested with a sample of 813 emerging adults who were recruited from six college sites across the country. Results demonstrated that there are significant differences between young people who have relatively close marital horizons (i.e., those who desire marriage in their early 20s) and those who have more distant marital horizons (i.e., those who desire marriage in their mid-20s or later) in the areas of substance use patterns, sexual permissiveness, and family formation values. Results suggest that changes in lifestyle patterns previously assumed to be associated with the transition to marriage may in fact be initiated when young people anticipate marriage in their near future.

Perceptions of the transition to adulthood among Chinese and American emerging adults

This study explored cultural differences in the criteria young people have for becoming an adult. Specifically, the study sought (a) to compare Chinese and American responses concerning whether they believe they have reached adulthood; (b) to examine whether adulthood criteria could fit a common statistical model for both cultures; and (c) after estimating this model, to compare the importance of adulthood criteria for Chinese and Americans. Results indicated that Chinese students considered themselves to be adults more than did American students. Also, Chinese students ascribed greater importance to criteria that reflect obligations toward others than did the Americans. The influence of culture in the transition to adulthood was discussed.

The influence of culture in emerging adulthood: Perspectives of Chinese college students

Emerging adulthood refers to a time period (18–25 years of age) between adolescence and adulthood. Recent research suggests that it may be a cultural construction. More traditional, non-Western cultures may have a shortened period of emerging adulthood, or no emerging adulthood at all, because these cultures tend to place greater emphasis on practices that lead to an earlier transition to adulthood. The purpose of this study was to examine emerging adulthood in the Chinese culture, including (1) the types of criteria Chinese young people deem necessary for becoming an adult, (2) the types of behaviours Chinese emerging adults are engaging in, (3) identity-related issues, and (4) other aspects of Chinese culture that might suggest that emerging adulthood in China may be different than in the United States. Participants in this study were 207 students at Beijing Normal University located in Beijing, China. Results provided evidence to support the notion that emerging adulthood is affected by culture. Findings revealed that the majority of Chinese college students (1) feel they have reached adult status in their early twenties, (2) have culturally specific criteria for adult status, and (3) tend to engage in behaviours and have beliefs and values that appear to differ from emerging adults in Western cultures.

Towards a Standard Psychometric Diagnostic Interview for Subjects at Ultra High Risk of Psychosis: CAARMS versus SIPS

Background. Several psychometric instruments are available for the diagnostic interview of subjects at ultra high risk (UHR) of psychosis. Their diagnostic comparability is unknown. Methods. All referrals to the OASIS (London) or CAMEO (Cambridgeshire) UHR services from May 13 to Dec 14 were interviewed for a UHR state using both the CAARMS 12/2006 and the SIPS 5.0. Percent overall agreement, kappa, the McNemar-Bowker χ (2) test, equipercentile methods, and residual analyses were used to investigate diagnostic outcomes and symptoms severity or frequency. A conversion algorithm (CONVERT) was validated in an independent UHR sample from the Seoul Youth Clinic (Seoul). Results. There was overall substantial CAARMS-versus-SIPS agreement in the identification of UHR subjects (n = 212, percent overall agreement = 86%; kappa = 0.781, 95% CI from 0.684 to 0.878; McNemar-Bowker test = 0.069), with the exception of the brief limited intermittent psychotic symptoms (BLIPS) subgroup. Equipercentile-linking table linked symptoms severity and frequency across the CAARMS and SIPS. The conversion algorithm was validated in 93 UHR subjects, showing excellent diagnostic accuracy (CAARMS to SIPS: ROC area 0.929; SIPS to CAARMS: ROC area 0.903). Conclusions. This study provides initial comparability data between CAARMS and SIPS and will inform ongoing multicentre studies and clinical guidelines for the UHR psychometric diagnostic interview.

Predictors of functional outcome in individuals at high clinical risk for psychosis at six years follow-up

BACKGROUND

The long-term functional status of subjects at ultra high risk for psychosis (HR) is relatively under investigated. This study explores baseline predictors of long-term functional outcome in HR subjects who did not convert to psychosis during a 6 years follow-up period.

METHODS

A total of 154 HR were followed up for an average of 6 years. The primary outcome variable was global assessment of functioning at the last follow-up visit as assessed with the Global Assessment of Functioning tool. A multinomial logistic regression was performed to identify potential predictors of functional outcome.

RESULTS

Baseline and follow-up data on functioning was available for 92 HR. Twenty-four (43%) individuals who did not convert to psychosis reported poor functioning at follow-up. Baseline scores in the GAF (Exp(b) = 0.857; 95% CIs: 0.75/0.97), employment status (Exp(b) = 0.029; 95% CIs: 0.00/0.268), and CAARMS total scores (Exp(b) = 1.976; 95% CIs: 1.00/1.14) predicted functional outcome in HR subjects at 6 years.

CONCLUSIONS

Despite the preventive treatments received, many individuals who did not convert to full-blown psychosis in the longer term do not functionally remit. These individuals are lower functioning, unemployed and have higher symptom loading at the time of their presentation to the prodromal clinic. Our study suggests the need for innovative treatments targeting long term functional status beyond the prevention of psychosis onset in the HR population.

Outreach and support in south London (OASIS), 2001-2011: ten years of early diagnosis and treatment for young individuals at high clinical risk for psychosis

INTRODUCTION

Prevention of psychosis has become a major objective of modern clinical psychiatry. An increasing number of new services have been established in Europe and in the world. The OASIS team has become an established model where clinical practice and research are fully integrated in the field of preventative interventions in psychosis.

METHOD

Comprehensive analysis of different clinical and service measures describing the 2001-2011 implementation of the OASIS team.

RESULTS

Over the last decade, the OASIS team has received a total of 1102 referrals, mostly young males from ethnic minorities. After the assessment, 35% were diagnosed with an At Risk Mental State (ARMS) while 32% were already psychotic. Within the ARMS, 70% met the inclusion criteria for the attenuated psychotic symptoms subgroup, 1% met the inclusion criteria for the genetic deterioration syndrome, 9% met inclusion criteria for a brief and self-limited intermittent psychotic episode and the others met inclusion criteria for more than one subgroup. Most of them had at least one comorbid diagnosis, mainly relating to anxiety and depressive domains. The majority of the OASIS clients received cognitive behavioural therapy alone or in combination with antidepressants/antipsychotics. Over the 2-year follow-up time, 44 subjects (15.2%) developed a frank psychotic episode.

CONCLUSIONS

The OASIS service represents one of the largest and most established prodromal services in the world. The burden of research evidence and the translational impact produced on the clinical practice support the OASIS as a model for the development of similar services.

'Mom by choice, single by life's circumstance...' Findings from a large scale survey of the experiences of single mothers by choice

There has been a rise in recent years in the number of women choosing to have a child without the involvement of a partner. These women, often referred to as 'single mothers by choice' or 'choice mothers' differ from single mothers who find themselves parenting alone following divorce or separation. The present study collected data on the motivations and experiences of 291 single mothers by choice using online questionnaires. The findings showed that women often sought advice from others and made practical changes before becoming choice mothers. The most common method used to have a child was sperm donation with most opting for an anonymous donor. The majority felt that it was important for their child to have a male role model, and most ensured that their child had a male figure in their lives. Many choice mothers expressed some concern about their child of growing up without a father, although this did not necessarily mean that they wished to form a relationship in the future. Single mothers by choice are a distinct group of single mothers and more detailed studies are required to focus on issues that are of most relevance to them.

Ready or Not?

This study examined emerging adults' criteria for marriage readiness and explored how these criteria are associated with their current attitudes and behaviors. This article establishes the psychometric value of the Criteria for Marriage Readiness Questionnaire and reports on a study of 788 emerging adults recruited from five college sites across the country. Results showed that marriage readiness is viewed by emerging adults as a process of developing interpersonal competencies, making life-long commitments, and acquiring capacities to care for others. These findings suggest that many emerging adults regard becoming an adult and becoming ready for marriage as two distinct transitions in life, with the first involving a shift from being cared for by others to taking care of oneself and the second consisting of a transition from self-care to caring for others. Results also showed that young people's criteria for marriage readiness are associated with individual differences in their current risk taking and family formation values.

"If you want me to treat you like an adult, start acting like one!" Comparing the criteria that emerging adults and their parents have for adulthood

The purpose of this study was (a) to identify the criteria parents of emerging adults consider necessary and important for their children to achieve adulthood, (b) to compare parents' criteria for adulthood with the criteria espoused by emerging adults, and (c) to examine how these criteria might differ on the basis of gender of the parent and gender of the child. Participants included 392 unmarried college students, ages 18-25, and at least 1 of their parents (271 fathers, 319 mothers). Results revealed that (a) as did their children, most parents did not yet view their children as adults, (b) there was disagreement between children and their parents in the emphasis they placed on various criteria for adulthood, (c) mothers and fathers did not always agree on the importance of various criteria, and (d) the gender of both the parent and the child played a role in the criteria parents deemed important for adulthood. Taken together, the findings suggest that parents and children view the transition to adulthood differently, which might have implications for the parent-child relationship during this period of development.

Factors associated with the wish to hasten death: a study of patients with terminal illness

BACKGROUND

There is considerable debate regarding the clinical issues surrounding the wish to hasten death (WTHD) in the terminally ill. The clinical factors contributing to the WTHD need further investigation among the terminally ill in order to enhance understanding of the clinical assessment and treatment needs that underlie this problem. A more detailed understanding may assist with the development of appropriate therapeutic interventions.

METHOD

A sample of terminally ill cancer patients (N = 256) recruited from an in-patient hospice unit, home palliative care service and a general hospital palliative care consulting service from Brisbane Australia between 1998-2001 completed a questionnaire assessing psychological (depression and anxiety), social (family relationship, social support, level of burden on others) and the impact of physical symptoms. The association between these factors and the WTHD was investigated.

RESULTS

A high WTHD was reported by 14 % of patients. A discriminant function analysis revealed that the following variables were associated with a high WTHD (P < 0.001): higher levels of depressive symptoms, being admitted to an in-patient hospice setting, a greater perception of being a burden on others, lower family cohesion, lower levels of social support, higher levels of anxiety and greater impact of physical symptoms.

CONCLUSIONS

Psychological and social factors are related to a WTHD among terminally ill cancer patients. Greater attention needs to be paid to the assessment of psychological and social issues in order to provide appropriate therapeutic interventions for terminally ill patients.

Terminally ill cancer patients' wish to hasten death

This exploratory study investigated factors associated with the wish to hasten death among a sample of terminally ill cancer patients. Semi-structured interviews conducted on a total of 72 hospice and home palliative care patients were subjected to qualitative analysis using QSR-NUDIST. The main themes to emerge suggested that patients with a high wish to hasten death had greater concerns with physical symptoms and psychological suffering, perceived themselves to be more of a burden to others, and experienced higher levels of demoralization, while also reporting less confidence in symptom control, fewer social supports, less satisfaction with life experiences and fewer religious beliefs when compared with patients who had a moderate or no wish to hasten death. The implications of these findings will be discussed.

Police perceptions of the mental health services and the mentally ill

AIM

To explore police officers' perceptions of the mentally ill and of their working relationship with mental health services.

METHOD

A survey of 200 randomly selected front-line police officers was carried out over the summer of 1996/1997.

RESULTS

The survey revealed that police identified people in the community as mentally ill, dealt with those so identified and related to the mental health services in a variety of ways. However, the survey uncovered a degree of frustration at the limitations of the Mental Health Act 1992 and the limited options available to the police in cases where individuals can not be committed. In addition, the survey suggests that many incidents involving the police and a person with a mental illness do not involve crime.

CONCLUSIONS

Although the police are generally happy with the dealings they have with providers of mental health services, when police are dealing with those identified as mentally ill they are placed in the dilemma of having to liaise with other agencies and bodies about something that is not a police problem and for which they have little training. It would appear that there is some merit in identifying, or lobbying for, agencies who could provide support for those people who require help but who do not fulfil committal criteria.

Multicenter clinical trial and laboratory utilization of an enzymatic detection method for gonococcal antigens

Seven institutions participated in a comparative study evaluating standard culture method and a new enzyme immunoassay (EIA, Gonozyme, Abbott Diagnostics) for the detection of Neisseria gonorrhoeae. Five hundred twenty-three patients were entered from hospitals of various sizes representing different population densities, ethnic and economic sectors, and gonococcal prevalence. Statistical analysis showed sensitivity, specificity, and positive and negative predictive values of 80.3%, 94.6%, 66.2%, and 97.3% for the total population tested. For the high-prevalence (greater than 15%) population the respective values were as follows: 78.6%, 91.5%, 68.8%, and 94.7%. Specimens from females had a lower sensitivity than those from males. In the low-prevalence population (less than 10%) results were as follows: 100%, 97.8%, 50%, and 100%. A cost comparison emphasized the benefit of the Gram's stain and culture. It also indicated that, unless batched or assayed at high volume, Gonozyme is not cost competitive for laboratories using standard culture methods. The impact of the EIA method, in general, and Gonozyme, specifically, on the microbiology section also was investigated. Integration would require altering of established work patterns and loss of flexibility and freedom of standard plating technics. The fact that Gonozyme is a "presumptive" test limits it to being a complementary assay, not an alternative. The authors conclude that Gonozyme is optimally suited to a high-volume laboratory, screening a low-prevalence female outpatient population, where specimen transport is a problem and gonococcal resistance to penicillin has not been demonstrated. This would include sexually transmitted disease clinics, reference laboratories, and state health departments.

Septicemia caused by Capnocytophaga in a granulocytopenic patient with glossitis

A patient receiving immunosuppressive treatment for multiple myeloma became granulocytopenic, and acute glossitis developed. Blood cultures were positive for Capnocytophaga, a fastidious Gram-negative bacillus that is known to be part of the normal oral flora and a pathogen for periodontitis. The infection responded to treatment with antibiotics, including penicillin G, to which the organism was sensitive. This is one of the first reports of Capnocytophaga septicemia, and suggests that this organism may be an important pathogen in immunosuppressed patients with oral mucosal lesions.