Transitions for older people with learning disabilities and behaviours that challenge others, and their family carers: a merged protocol for two rapid scoping reviews of evidence

BACKGROUND

There are over 1 million adults with a learning disability in the UK, of whom approximately 20% displaying behaviours that challenge others. Two thirds of people with learning disabilities live in the family home. As they and their family carers age, both are likely to face particular difficulties and stresses, but there is little understanding of their experiences and needs. To address this evidence gap, our main objective is to undertake two rapid scoping reviews that will collectively focus on the health and social care needs, experiences, service interventions and resources of older people with learning disabilities and behaviours that challenge others, and their family carers. Both reviews will focus on issues relating to forward planning and transitions to different care contexts. The study is part of a research project funded by the National Institute for Health Research No.129491.

METHODS

We propose to address the need for evidence via two rapid scoping reviews. We will include published and unpublished (grey) literature, encompassing empirical research, policy and practice guidance and lay resources to support decision-making. We will search multiple electronic databases, hand search references lists, and use expert guidance to identify potential evidence. The following databases were used for research and grey literature: CINAHL; Healthcare Management Information Consortium (HMIC); NHS Evidence; Scopus; Turning Evidence Into Practice (TRIP); Web of Science (WoS); Google (first 5 pages); and Google Scholar (first 5 pages). For RR2, additional intended databases are the Carer Research Knowledge Exchange Network (CAREN) and Social Care Institute for Excellence (SCIE). Two reviewers will independently screen all citations and full-text articles for inclusion. One reviewer will extract data, with an independent review undertaken by the research team. Critical appraisal will depend on the nature of included evidence. Narrative synthesis will be collaboratively developed, with descriptive information presented in tables summarising study characteristics and thematic analysis of findings presented in the main text. Dissemination will be through journal publication, conference presentations and written short-form, easy-read versions of articles and audio-video clips for lay audiences.

DISCUSSION

We will consider the strengths and limitations of our reviews, considering their impact on findings. We will summarise the main findings and provide an interpretation linked to the review questions and objectives. We will consider the implications of our findings for policy and practice, as well as future research addressing the support of older people with learning difficulties and behaviours that challenge others, and their family carers, in the context of transition to different care contexts in the UK. The protocol has been registered as Vseteckova, J., Jordan, J., Tilley, E., Larkin, M., Ryan, S., and Wallace, L. (2021, December 4). Transitions for older people with learning disabilities and behaviours that challenge others, and their family carers: a merged protocol for two rapid scoping reviews of evidence. Retrieved from osf.io/jzrn9.

Real-world outcomes of unrestricted direct-acting antiviral treatment for hepatitis C in Australia: The South Australian statewide experience

In March 2016, the Australian government offered unrestricted access to direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) to the entire population. This included prescription by any medical practitioner in consultation with specialists until sufficient experience was attained. We sought to determine the outcomes and experience over the first twelve months for the entire state of South Australia. We performed a prospective, observational study following outcomes of all treatments associated with the state's four main tertiary centres. A total of 1909 subjects initiating DAA therapy were included, representing an estimated 90% of all treatments in the state. Overall, SVR12 was 80.4% in all subjects intended for treatment and 95.7% in those completing treatment and follow-up. 14.2% were lost to follow-up (LTFU) and did not complete SVR12 testing. LTFU was independently associated with community treatment via remote consultation (OR 1.50, 95% CI 1.04-2.18, P = .03), prison-based treatment (OR 2.02, 95% CI 1.08-3.79, P = .03) and younger age (OR 0.98, 95% CI 0.97-0.99, P = .05). Of the 1534 subjects completing treatment and follow-up, decreased likelihood of SVR12 was associated with genotype 2 (OR 0.23, 95% CI 0.07-0.74, P = .01) and genotype 3 (OR 0.23, 95% CI 0.12-0.43, P ≤ .01). A significant decrease in treatment initiation was observed over the twelve-month period in conjunction with a shift from hospital to community-based treatment. Our findings support the high responses observed in clinical trials; however, a significant gap exists in SVR12 in our real-world cohort due to LTFU. A declining treatment initiation rate and shift to community-based treatment highlight the need to explore additional strategies to identify, treat and follow-up remaining patients in order to achieve elimination targets.

Low-cost struvite production using source-separated urine in Nepal

This research investigated the possibility of transferring phosphorus from human urine into a concentrated form that can be used as fertilizer in agriculture. The community of Siddhipur in Nepal was chosen as a research site, because there is a strong presence and acceptance of the urine-diverting dry toilets needed to collect urine separately at the source. Furthermore, because the mainly agricultural country is landlocked and depends on expensive, imported fertilizers, the need for nutrient security is high. We found that struvite (MgNH(4)PO(4)·6H(2)O) precipitation from urine is an efficient and simple approach to produce a granulated phosphorus fertilizer. Bittern, a waste stream from salt production, is a practical magnesium source for struvite production, but it has to be imported from India. Calculations show that magnesium oxide produced from locally available magnesite would be a cheaper magnesium source. A reactor with an external filtration system was capable of removing over 90% of phosphorus with a low magnesium dosage (1.1 mol Mg mol P), with coarse nylon filters (pore width up to 160±50 μm) and with only one hour total treatment time. A second reactor setup based on sedimentation only achieved 50% phosphate removal, even when flocculants were added. Given the current fertilizer prices, high volumes of urine must be processed, if struvite recovery should be financially sustainable. Therefore, it is important to optimize the process. Our calculations showed that collecting the struvite and calcium phosphate precipitated spontaneously due to urea hydrolysis could increase the overall phosphate recovery by at least 40%. The magnesium dosage can be optimized by estimating the phosphate concentration by measuring electrical conductivity. An important source of additional revenue could be the effluent of the struvite reactor. Further research should be aimed at finding methods and technologies to recover the nutrients from the effluent.

Recovery of struvite from stored human urine

In previous work, synthetic urine was used as a readily available proxy for real urine for determining the factors which affect the recovery of struvite from urine. Based on these findings with synthetic urine, we recovered struvite from real urine and, thus, showed that a) the synthetic urine served as an adequate model for determining the processes which affect struvite precipitation, and b) high quality struvite can be recovered from real human urine. For urine solutions diluted up to four times, an average of 23% of phosphorus and 80% of magnesium was precipitated naturally; the remaining supernatant was then dosed with magnesium to recover the phosphorus still in solution. The struvite recovered was approximately 99% pure regardless of storage conditions although full strength urine was best for struvite recovery since it contains the greatest mass of harvestable phosphorus. We conclude that synthetic urine can be used as a proxy for real urine when investigating struvite recovery provided the synthetic mixture is consistent with the expected composition in the specific context.

Effects of storage on phosphorus recovery from urine

In laboratory experiments using synthetic urine the effect of temperature, faecal contamination, dilution and headspace on urine to be used as a feedstock for struvite recovery were examined. The effects of adding different quantities of magnesium on the amount of phosphorus that could be removed from solution was also examined. An average of 62% of phosphorus could be removed in the form of struvite when magnesium was added to the urine solution after ureolysis had forced the precipitation of calcium and magnesium minerals. Dilution and the presence of faecal urease were found to affect the rate of ureolysis but not the purity of the struvite recovered. These results indicate that, by simply storing urine until it achieves a pH of 8 or greater, struvite can be recovered from source-separated urine with only a magnesium addition.

Occult stenosis of the common carotid artery complicating mandibular reconstruction with a fibular free flap

An unsuspected severely stenosed common carotid artery that compromised a free flap for mandibular reconstruction is described. To our knowledge no one has advocated the assessment of the carotid tree before transfer of free tissue. We suggest that patients with several risk factors for peripheral vascular disease should have colour flow duplex imaging of the carotid system if transfer of free tissue is being considered.

CT demonstration of pituitary stalk relapse in childhood acute lymphoblastic leukaemia

Central nervous system relapse in childhood acute lymphoblastic leukaemia (ALL) occurs in 8% (all risks). Leptomeningeal infiltration is the usual form of relapse and pituitary stalk involvement is rarely found. We report the CT demonstration of pituitary stalk relapse with endocrine evidence of disruption of the hypothalamo-pituitary axis.