The inclusion of adults with intellectual disabilities in health research - challenges, barriers and opportunities: a mixed-method study among stakeholders in England

BACKGROUND

The study aims to understand system barriers to research participation for people with intellectual disabilities.

METHODS

A mixed-methods approach examined the inclusivity of people with intellectual disabilities (IDs) in a random sample of National Institute for Health and Care Research (NIHR) studies conducted in 2019-2020. An online questionnaire (stage 1) was sent to the selected studies lead investigators. An expert by experience panel of 25 people with intellectual disabilities (IDs, stage 2), discussed the stage 1 feedback. Descriptive statistics for quantitative data and thematic analysis for qualitative data was conducted.

RESULTS

Of 180 studies reviewed, 131 studies (78%) excluded people with IDs. Of these, 45 (34.3%) study researchers provided feedback. Seven (20%) of the 34 studies which included people with IDs gave feedback. Of all respondents over half felt their study had some relevance to people with IDs. A minority (7.6%) stated their study had no relevance. For a quarter of respondents (23.5%), resource issues were a challenge. Qualitative analysis of both stages produced four overarching themes of Research design and delivery, Informed consent, Resource allocation, and Knowledge and skills.

CONCLUSION

Health research continues to exclude people with IDs. Researchers and experts by experience identified non-accessible research design, lack of confidence with capacity and consent processes, limited resources such as time and a need for training as barriers. Ethics committees appear reluctant to include people with cognitive deficits to 'protect' them. People with IDs want to be included in research, not only as participants but also through coproduction.

What place does nurse-led research have in the COVID-19 pandemic?

AIM

Reflect upon the visibility of nursing-led research during the COVID-19 pandemic.

BACKGROUND

The emerging SARS-CoV-2 infection has galvanized collaborative and multidisciplinary efforts in clinical and research practice worldwide. The scarce evidence-base to manage patients with COVID-19 has included limited nurse-led research.

INTRODUCTION

Clinical research nurses have greatly contributed to the delivery of COVID-19 research, yet the number of COVID-19 nursing-led research papers appears to be limited, with even fewer nurse-led research projects funded.

METHODS

Authors' views and PubMed search on 'COVID-19 and nursing'.

FINDINGS

There is a dearth of nursing-led research. Most papers describe the nursing contribution to COVID-19 care, changes in nursing working arrangements and emotional burden. There are opportunities to explore the consequences to vulnerable population groups of public health measures implemented to stop the progress of the COVID-19 pandemic.

DISCUSSION

Workforce gaps, limited integration in research structures and clinical redeployment may have hampered nurse-led research. COVID-19 may exacerbate staffing deficits by disrupting the education pipeline, obstructing the transition from clinical to academic practice, particularly in areas where clinical academic roles are yet to emerge.

CONCLUSION

The absence of nurse-led research in COVID-19 can be explained by chronic, underlying factors and the features of the pandemic response. Emerging models of care, effective staffing and inequalities related to COVID-19 appear obvious research areas. Nursing leadership needs to strengthen its political voice and lobbying skills to secure nurse-led research funding.

IMPLICATIONS FOR NURSING POLICY

Embracing international nursing research, strengthening collaborations and lobbying policymakers for investment in nurse-sensitive research would enhance the response to COVID-19.

The feasibility of using the EQ-5D-3L with adults with mild to moderate learning disabilities within a randomized control trial: a qualitative evaluation

Background

In trials incorporating a health economic evaluation component, reliable validated measures for health-related quality of life (HRQOL) are essential. The EQ-5D is the preferred measure for cost-effectiveness analysis in UK trials. This paper presents a qualitative evaluation of the use of the EQ-5D-3L in a feasibility randomised control trial with participants who had a mild- to  moderate learning disability and type 2 diabetes.

Methods

Researchers administered the EQ-5D-3L to 82 participants at baseline and 77 at follow-up. After each interview, researchers rated the ease of administering the EQ-5D-3L and made free-text entries on the administration experience. For a subset of 16 interviews, researchers audio-recorded more detailed journal entries. Ease of administration data were analysed using descriptive statistics. Free-text responses were subject to a basic content analysis. The EQ-5D-3L-related journal entries were transcribed, coded and analysed thematically.

Results

Over half of participants were perceived to experience difficulty answering some or all of the items in the EQ-5D-3L (60% at baseline; 54% at follow-up). Analysis of the free-text entries and audio journals identified four themes that question the use of the EQ-5D-3L in this population. The first theme is related to observations of participant intellectual ability and difficulties, for example, in understanding the wording of the measure. Theme 2 is related to the normalisation of adjustments for impairments, which rendered the measure less sensitive in this population. Theme 3 is related to researcher adaptation and non-standard administration. An overarching fourth theme was identified in that people with learning disabilities were viewed as ‘unreliable witnesses’ by both researchers and supporters.

Conclusions

It is recommended that the EQ-5D-3L should not be used in isolation to assess health-related quality of life outcomes in trials research in adults with a learning disability. Further research is required to develop and evaluate a version of the EQ-5D appropriate for this population in trials research. It is unrealistic to expect that adjustments to the wording alone will deliver an appropriate measure: supporter or researcher involvement will almost always be required. This requirement needs to be factored into the development and administration guidelines of any new version of the EQ-5D for adults with a learning disability.

Trial registration

Current Controlled Trials ISRCTN41897033 [registered 21 January 2013].

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0357-6) contains supplementary material, which is available to authorized users.

Health Promotion and Wellness Initiatives Targeting Chronic Disease Prevention and Management for Adults with Intellectual and Developmental Disabilities: Recent Advancements in Type 2 Diabetes

PURPOSE OF REVIEW

The aim of this paper was to review the recent international developments in health promotion and wellness initiatives targeting chronic disease prevention and management for adults with intellectual and developmental disabilities (IDD) targeting type 2 diabetes (T2D).

RECENT FINDINGS

There has been one diabetes prevention program (STOP) and two self-management T2D education programs (DESMOND-ID; OK diabetes) adapted for this population. All three programs have been adapted from other theoretically informed and tested programs developed for the general population. Each program has employed co-design and co-production techniques with all stakeholders. The three programs all target the high-risk lifestyle factors that can lead to T2D and contribute to poor glycaemia control, and have undertaken randomized-feasibility studies, the results of which are promising.

SUMMARY

This paper shows that any health promotion and wellness initiatives need to be tailored and reasonable adjustments made in order to address this population's cognitive impairments and communication difficulties.

Randomized controlled feasibility trial of supported self-management in adults with Type 2 diabetes mellitus and an intellectual disability: OK Diabetes

AIMS

To undertake a feasibility randomized controlled trial of supported self-management vs treatment as usual in a population of adults with obesity, Type 2 diabetes and an intellectual disability.

METHODS

We conducted an individually randomized feasibility trial. Participants were adults aged >18 years with a mild or moderate intellectual disability, living in the community with Type 2 diabetes, on any therapy other than insulin. Participants had mental capacity to consent to research and the intervention. Inclusion criteria included HbA_1c > 48 mmol/mol (6.5%), BMI >25 kg/m² , or self-reported physical activity below national guideline levels. The experimental intervention was standardized supported self-management delivered by diabetes specialist nurses plus treatment as usual, compared with treatment as usual alone. Feasibility outcomes included: recruitment and retention; intervention acceptability and feasibility; data collection and completeness for physiological state and values for candidate primary outcomes (HbA_1c and BMI).

RESULTS

A total of 82 participants (89% of those contacted and eligible) were randomized. All supported self-management sessions were completed by 35/41 participants (85%); only four completed no sessions. Data on the follow-up candidate primary outcomes HbA_1c and BMI were obtained for 75/82 (91%) and 77/82 participants (94%), respectively. The mean baseline HbA_1c was 56±16.5 mmol/mol (7.3±1.5%) and the mean BMI was 34±7.6 kg/m² .

CONCLUSIONS

Adherence to supported self-management and willingness to have blood taken for outcome measurement was good. A definitive randomized controlled trial is feasible in this population. (Trial registration: Current Controlled Trials ISRCTN41897033).

Characterizing adults with Type 2 diabetes mellitus and intellectual disability: outcomes of a case-finding study

AIMS

To report the results of a case-finding study conducted during a feasibility trial of a supported self-management intervention for adults with mild to moderate intellectual disability and Type 2 diabetes mellitus, and to characterize the study sample in terms of diabetes control, health, and access to diabetes management services and support.

METHODS

We conducted a cross-sectional case-finding study in the UK (March 2013 to June 2015), which recruited participants mainly through primary care settings. Data were obtained from medical records and during home visits.

RESULTS

Of the 325 referrals, 147 eligible individuals participated. The participants' mean (sd) HbA1c concentration was 55 (15) mmol/mol [7.1 (1.4)%] and the mean (sd) BMI was 32.9 (7.9) kg/m2 , with 20% of participants having a BMI >40 kg/m2 . Self-reported frequency of physical activity was low and 79% of participants reported comorbidity, for example, cardiovascular disease, in addition to Type 2 diabetes. The majority of participants (88%) had a formal or informal supporter involved in their diabetes care, but level and consistency of support varied greatly. Post hoc exploratory analyses showed a significant association between BMI and self-reported mood, satisfaction with diet and weight.

CONCLUSIONS

We found high obesity and low physical activity levels in people with intellectual disability and Type 2 diabetes. Glycaemic control was no worse than in the general Type 2 diabetes population. Increased risk of morbidity in this population is less likely to be attributable to poor glycaemic control and is probably related, at least in part, to greater prevalence of obesity and inactivity. More research, focused on weight management and increasing activity in this population, is warranted.

Neutron diffraction analysis of residual stresses near unannealed welds in anhydrous ammonia nurse tanks

Neutron diffraction analysis was employed to measure residual stresses near welds in used anhydrous ammonia nurse tanks. Tensile residual stresses contribute to stress corrosion cracking of nurse tanks, which can cause tanks to release toxic ammonia vapor. The analysis showed that tensile residual stresses were present in the tanks measured, and the magnitudes of these stresses approached the yield strength of the steel. Implications for agricultural safety and health are discussed.

BRCA1 dysfunction in sporadic basal-like breast cancer

Basal-like breast cancers form a distinct subtype of breast cancer characterized by the expression of markers expressed in normal basal/myoepithelial cells. Breast cancers arising in carriers of germline BRCA1 mutations are predominately of basal-like type, suggesting that BRCA1 dysfunction may play a role in the pathogenesis of sporadic basal-like cancers. We analysed 37 sporadic breast cancers expressing the basal marker cytokeratin 5/6, and age- and grade-matched controls, for downregulation of BRCA1. Although BRCA1 promoter methylation was no more common in basal-like cancers (basal 14% vs controls 11%, P=0.72), BRCA1 messenger RNA expression was twofold lower in basal-like breast cancers compared to matched controls (P=0.008). ID4, a negative regulator of BRCA1, was expressed at 9.1-fold higher levels in basal-like breast cancer (P<0.0001), suggesting a potential mechanism of BRCA1 downregulation. BRCA1 downregulation correlated with the presence of multiple basal markers, revealing heterogeneity in the basal-like phenotype. Finally, we found that 63% of metaplastic breast cancers, a rare type of basal-like cancers, had BRCA1 methylation, in comparison to 12% of controls (P<0.0001). The high prevalence of BRCA1 dysfunction identified in this study could be exploited in the development of novel approaches to targeted treatment of basal-like breast cancer.

Exclusion of an extracolonic disease modifier locus on chromosome 1p33–36 in a large Swiss familial adenomatous polyposis kindred

Familial adenomatous polyposis (FAP), an autosomal dominantly inherited colorectal cancer predisposition syndrome, displays considerable inter- and intrafamilial phenotypic heterogeneity, which represents a major problem in genetic counselling of APC mutation carriers. The Min mouse model indicated a putative disease modifier locus on chromosome 4, which is syntenic to human chromosome 1p35-36. This finding was subsequently supported by parametric and nonparametric linkage analyses in FAP families, however, without identifying functional variants in candidate genes. Recently, germline mutations in the base-excision repair gene MYH (1p33-34) have been described in patients with multiple adenomas, pointing to a possible role as disease modifier in FAP. Here, we present critical reassessment of one of the largest FAP kindreds published, which was previously used in linkage mapping of 1p35-36. In this family, all affected members harbour the same APC germline mutation (5945delA), but display marked phenotypic variability, in particular regarding the occurrence of extracolonic disease that segregates in several branches of the family tree. Using updated clinical information, additional mutation carriers and polymorphic markers, fine mapping of the critical region as well as mutation analysis of the MYH gene were performed. These investigations allowed us to significantly exclude (i) the 1p33-36 region as a modifier locus and (ii) MYH as a modifier gene for extracolonic disease in this FAP kindred. Our results do not eliminate 1p33-36 from suspicion in other families, but clearly indicate that in our family linkage analysis of further putative candidate regions is necessary to identify a disease modifier locus in FAP.

Protecting the integrity of clinical laboratory test results

The authors' inspection reports demonstrate that the improper alteration of patient data is not a rare aberration in private commercial clinical laboratories. Although laboratory surveyors could be trained to recognize this problem, the availability of unprotected test systems makes even trained inspectors ineffectual. Both regulatory agencies and professional accrediting agencies should be concerned that their surveyors may be placing a seal of approval on what are, in reality, compromised or even fabricated data. In proposing the regulations discussed in this paper, the FDA sought to "preserve the integrity of the agency's enforcement process." This goal will remain unattainable, however, until a mechanism has been devised to secure the original raw data produced by all of the analytical systems being used not only in clinical laboratories but also in environmental laboratories, pharmaceutical laboratories, etc. Laboratories, as well as regulatory agencies and accrediting bodies, need to be concerned on behalf of the patient, but laboratories may also need to be concerned on their own behalf. In the coming era of unprecedented cost constraints and competitive bidding, unscrupulous testing facilities or groups of such facilities could have a significant edge over their conscientious competitors if the issues raised here continue to be ignored. Although the analytical data management systems provide tremendous benefits, some have serious problems in ensuring the security of their data. However, if regulatory agencies, accrediting bodies, professional organizations, and the analyzer vendors make a united commitment, the problem of securing the integrity of analytical data could eventually be resolved. It is hoped that such a commitment will be made in the near future.

The association between lameness and fertility in dairy cows

One thousand, four hundred and ninety-one lactations in 770 Friesian, Holstein and Ayrshire crossbred cows have been used to study the associations between lameness and fertility. Lameness was associated with a longer interval between calving and first service and a longer interval between calving and conception. The largest increases in these intervals, of 17 and 30 days, respectively, occurred in cows with either sole or white line lesions occurring between 36 and 70 days after calving. The conception rate during the 63 days before a diagnosis of lameness was made was lower (31 per cent) than at other times (40 per cent).

Effect of wet weather on lameness in dairy cattle

The incidence of lameness in cows recorded by five veterinary practices over one year and one practice over four years was plotted with rainfall and potential soil moisture deficit. Correlation coefficients calculated between lameness, rainfall and potential soil moisture deficit over two-week periods showed the incidence of lameness in summer to be significantly related to the potential soil moisture deficit in the same two-week period and rainfall in the previous two-week period. Differences in patterns of lameness incidence among practices and years were also partly explained by differences in rainfall and potential soil moisture deficit; however, these effects were small compared with those of other factors that affect lameness incidence such as herd size, age and stage of lactation.

Short-term associations between disease and milk yield of dairy cows

Short-term associations between disease and milk yield were studied in 1594 lactations occurring between 1977 and 1982 in 732 Friesian, Ayrshire and Holstein crossbred cows. Statistically significant differences in milk yield between one week before and one week after clinical diagnosis were observed for ketosis (5.1 kg/d), hypomagnesaemia (4.1 kg/d), mastitis occurring after peak yield (2.1 kg/d) and lameness (1.1 kg/d). Milk yield declined for as much as 2-4 weeks before diagnosis of disease, and total losses in milk yield associated with ketosis or hypomagnesaemia were estimated to be 60-70 kg. No significant differences were found for endometritis or for mastitis when it occurred before peak yield. Milk yield was suppressed for about 4 weeks after calvings with retained placenta, but there were no corresponding effects of dystocia or hypocalcaemia on milk yield. It is suggested that if automatic daily milk recording is available it may be possible to detect deviations from normal, and hence detect subclinical disease 2 or more weeks before its clinical appearance.

Effects of stage of lactation, month, age, origin and heart girth on lameness in dairy cattle

Lameness in herds during one year was commonest in the first month of lactation (15 per cent of all cases). Leg lesions were particularly common at this time (24 per cent of all cases of leg lesions) but white line abscess and sole ulcer were more common a month later. Foul-in-the-foot was one of the two most common lesions at all stages of pregnancy and lactation, and white line abscess the most common (20 per cent of all lesions) in late lactation. Both sole ulcer and underrun heel had lower incidence in the second half of the year than the first. White line abscess was particularly common in March and November although there were significant interactions between month and veterinary practice; foul-in-the-foot was most common in October. Susceptibility to lameness increased with age; 10-year-old cows were over four times more likely to develop lameness than three-year-old cows. This was due particularly to increased incidence with age of white line abscess and sole ulcer and, to a lesser extent, underrun heel. In contrast, foul-in-the-foot and leg lesions showed little change with age. Whereas these lesions accounted for 68 per cent of the total in cows up to two years old, they accounted for only 15 per cent of all lesions in cows over 10 years old. White line abscess was slightly commoner in cows with large heart girths.

Effects of season, herd size, management system and veterinary practice on the lameness incidence in dairy cattle

The incidence of lameness in herds visited by veterinary practitioners in winter (0.87 cases per 100 cows per month) was greater than in summer (0.71 cases per 100 cows per month). The relative proportions of leg lesions and underrun heel were higher, and those of foul-in-the-foot, interdigital hyperplasia and foreign body in the sole were lower in winter than in summer. In winter, leg lesions and aseptic laminitis were most common in cows housed in cowsheds, white line abscess in cows in strawyards and sole ulcer in cows in either cowsheds or cubicles with concrete yards. The overall incidence of lesions was lower in strawyard accommodation (0.71 cases per 100 cows per month) than in cubicles with yards (0.93 cases per 100 cows per month). Veterinary practitioners saw proportionally fewer cases of foul-in-the-foot but proportionally more cases of sole ulcer in larger than in smaller herds. The animal incidence of lameness ranged from 1.7 to 11.4 per cent among practices; in 20 practices which recorded a total of at least 100 lesions in both summer and winter there was a large variation in the proportions observed of each lesion. A principal component analysis contrasted those practices which tended to see mainly cases of white line abscess, white line separation, foul-in-the-foot and leg lesions with those which saw mainly cases of underrun heel, interdigital hyperplasia, punctured sole with pus and sole ulcer. Twenty-nine per cent of cases of underrun heel and 22 per cent of cases of both deep sepsis and interdigital hyperplasia occurred in conjunction with another lesion.

Use of COSREEL clinical codes in large animal veterinary practice

COSREEL, a computerised animal health recording system with a versatile coding system for recording diagnoses, symptoms and medical and surgical treatments, has been tested by veterinary surgeons in practice. The codes were found to be logical and generally easy to use. The application of these codes, with particular reference to their use in infertility investigations, is illustrated.

Use of COSREEL, a computerised recording system, for herd health management of two dairy herds

COSREEL, a computerised animal health recording system, has been used since October 1980 by two agricultural colleges for the management of their dairy herds. Each college and the veterinary practice which served the college has had its own typewriter terminal connected to a remote computer. Management and milk data have been coded and entered at the college and clinical data at the veterinary practice. An average of just over one management and veterinary event per week has been coded for every three cows in milk. Error rates were on average 11 per cent by one pair of users and 4 per cent by the other pair. COSREEL has provided a valuable aid to the management of the health of the two herds, and the regular use of pregnancy diagnosis, infertility investigation and oestrus detection action lists resulted in a considerable improvement in herd fertility at the two colleges.

COSREEL: computerised recording system for herd health information management

COSREEL (Computer System for Recording Events affecting Economically important Livestock) is an animal health recording system which has been designed for the management of cattle, sheep and pigs kept at the ARC Institute for Research on Animal Diseases. Unlike other, numerical, coding systems for the recording of disease, COSREEL has a versatile alpha-numeric coding system which can record diagnosis of disease, local and general symptoms, medical and surgical treatment, vaccination and antiserum therapy, therapeutic management changes and tests with their results. The system is used for recording management, veterinary and milk data, and is a terminal based system using a remote computer. Various lists for action are produced for both herd managers and clinicians including weekly reports of the production and fertility status of individual cows, and lists of cows due for pregnancy diagnosis or infertility investigation. This paper describes the general features of COSREEL, gives examples of the way diagnoses are coded and discusses the future potential of such a system for the development of a central data base for epidemiological analysis.

Survey of lameness in British dairy cattle

During 1977 a survey was undertaken by practising veterinary surgeons of the incidence of different lesions causing lameness in dairy cattle. Forty-eight veterinary practices participated and they treated 7526 cases of lameness in 1821 herds. The average incidence of lameness among all cows was 5.5 per cent and the annual incidence among practices ranged from 1.8 to 11.8 per cent. Most lesions (88.3 per cent) occurred in the feet; the commonest were foul of the foot (16.7 per cent), white line abscess (15.6 per cent), sole ulcer (13.6 per cent), punctured sole and pus (10.4 per cent) and underrun heel (8.7 per cent). These proportions varied in different parts of the country. Eighty-four per cent of foot lesions occurred in the hind feet and of these lesions 85 per cent occurred in the outer claw; 42 per cent of foot lesions occurred in abnormally shaped claws. The remaining 11.7 per cent of lesions occurred in the legs and trunk, 76 per cent of which occurred in the hindlimb. Trauma was the main cause of leg lesions, which occurred most frequently in the joints and ligaments.

Manganese metabolism in cows and goats

When 54MnCl2 was incubated with fresh bovine or caprine serum for 20 h and the serum subjected to electrophoresis at pH 9.5, the 54Mn bound to transferrin and alpha2-macroglobulin in proportions which varied with the temperature of incubation and the temperature of electrophoresis. Between 0 and 37 degrees C, the higher the temperature of incubation the larger the proportion bound to transferrin and the lower the proportion bound to alpha2-macroglobulin. The temperature at which electrophoresis was performed had little effect on the proportion of 54Mn bound to transferrin, but increasing temperature reduced the proportion of 54Mn bound to alpha2-macroglobulin. Mn2+ did not bind to purified transferrin in vitro in the absence of an oxidising agent. In the presence of permanganate, Mn3+ was formed and chelated by transferrin at physiological pH. In fresh serum this oxidation step may be performed by ceruloplasmin or molecular oxygen. Mn2+ was bound reversibly to alpha2-macroglobulin but this protein played no part in the oxidation of divalent manganese and had no effect on the protein binding of trivalent manganese. Manganese in the divalent state, either free as Mn2+ or bound to alpha2-macroglobulin, is removed from blood plasma very efficiently by the liver. However, the manganic-transferrin complex normally found in circulation is not rapidly removed from plasma. The liver can remove large amounts of excess manganous manganese which it presumably excretes; the small essential fraction of the manganese absorbed is oxidised to the trivalent state and bound to transferrin.

Iron dynamics in the ruminant

We have compared the plasma clearance rate of radioactive iron in cows both as ferric chloride and as iron specifically bound to transferrin. We have also repeated the transfusion experiment of Dern et al. (Dern, R.J., Monti A. and Glynn, M.F. (1963) J. Lab. Clin. Med. 61,280-291) using goats. The results show that neither non-specificity bound iron (Bates, F.W. and Schlabach, M.R. (1973) J. Biol. Chem. 248, 3228-3232) nor the iron bound to the two different sites in transferrin (Awai, M., Chipman, B. and Brown, E.B. (1975) J. Lab. Clin. Med. 85,769-784) can be identified as distinguishable iron pools by this technique.

A variant of prothrombin induced in cattle by prolonged administration of warfarin

Cows on long term Warfarin therapy produce a form of prothrombin which, although it binds to barium citrate, has a low biological activity. Activation experiments on this form of prothrombin show that it is only slowly converted to thrombin in the presence of Ca2+, although the thrombin produced has normal activity. Further experiments show that the Fragment 1 region of the molecule has a reduced calcium binding capacity. The results indicate the existance of a partially carboxylated form of prothrombin.

The influence of dietary protein upon blood composition in dairy cows

Diets of different protein content were fed to dairy cows in two experiments of seven months and 12 months duration. Significant differences in the mean concentrations of serum urea, albumin and copper and of blood haemoglobin and packed cell volume were observed between cows receiving the various diets. The greatest differences occurred when cows were in mid-lactation. It was concluded that concentrations of urea in the serum of the cows were reflecting dietary protein intake and that concentrations of albumin, haemoglobin and PCV during lactation were affected by long-term protein status. The possible significance of the results is discussed in relation to previous reports indicating interrelationships between protein and copper metabolism, and in relation to the recommended protein content of diets for cows.