Nutrition knowledge and influence on diet in the carer-client relationship in residential care settings for people with intellectual disabilities.

People with intellectual disabilities generally have poorer health outcomes compared with those who do not, including outcomes related to nutrition-related non-communicable diseases. Carers support people with intellectual disabilities in many aspects including habitual shopping and preparation of food, but their own nutrition knowledge and the influence this may have on dietary intakes of clients is unknown. We explored the nutrition knowledge of carers of people with intellectual disabilities in residential care settings, their dietary habits and their influence on clients' food shopping and preparation and therefore the diet consumed by their clients. Ninety-seven carers belonging to a large independent care sector organisation specialising in the care of people with an intellectual disability completed a validated general nutrition knowledge and behaviour questionnaire. Seventeen carers from the residential care settings were interviewed to contextualise practice. Knowledge about key dietary recommendations scored highly. Carers who had more work experience were found to have higher scores in 'making everyday food choices' (p = 0.034). Daily consumption of fruit and vegetables (at least one portion per day) was observed (for fruit by 46% of the carers and for vegetables by 60% of the carers), whilst most carers reported avoiding consuming full-fat dairy products, sugary foods and fried foods. The concept of a healthy diet; typical dietary habits of clients; role in food acquisition; and training in nutrition emerged as themes from the interviews. Carers discussed various topics including the importance of a balanced diet, cooking fresh foods and control of food portion sizes for clients relative to the care philosophy of a client-centred approach, which encapsulates client autonomy. Gaps in knowledge around specific nutrients, making healthy choices and cooking skills remain. Carers have an influence on clients' dietary choices; they are able to provide healthy meals and share good dietary habits with clients. Further training in nutrition is recommended for impact on clients' health.

Move&Connect-Youth: A Virtual Group Intervention for Youth Experiencing Persisting Symptoms After Concussion.

Move&Connect-Youth (M&C-Y) is an interdisciplinary virtual group intervention for youth experiencing persisting symptoms after concussion (PSAC) that includes psychoeducation, active rehabilitation, and goal-setting. Using an intervention mapping framework, this paper describes the iterative development of M&C-Y and findings from initial feasibility testing. Ten youth participated in M&C-Y completing pre-intervention demographic questionnaires and semi-structured exit interviews to understand participants' experience and gather feedback. M&C-Y was feasible based on apriori criteria and findings from interviews provided insights related to: (1) intervention structure, (2) intervention engagement, and (3) intervention takeaways. M&C-Y is a meaningful, feasible, and engaging intervention for youth with PSAC.

The effects of diet and chronic exercise on skeletal muscle ghrelin response.

Background: Recent findings indicate that ghrelin, particularly the unacylated form (UnAG), acutely stimulates skeletal muscle fatty acid oxidation (FAO) and can preserve insulin signaling and insulin-stimulated glucose uptake in the presence of high concentrations of saturated fatty acids. However, we recently reported that the stimulatory effect of ghrelin on FAO and subsequent ability to protect insulin stimulated glucose uptake was lost following 6-weeks (6w) of chronic high fat feeding. In the current study we examined the effects of both short-term 5 day (5d) and chronic 6w high-fat diet (HFD) on muscle ghrelin response, and whether exercise training could prevent the development of muscle ghrelin resistance with 6w of HFD. Methods and Results: Soleus muscle strips were isolated from male rats to determine the direct effects of acylated (AG) and UnAG isoforms on FAO and glucose uptake. A 5d HFD did not alter the response of soleus muscle to AG or UnAG. Conversely, 6w of HFD was associated with a loss of ghrelin's ability to stimulate FAO and protect insulin stimulated glucose uptake. Muscle response to UnAG remained intact following the 6w HFD with chronic exercise training. Unexpectedly, muscle response to both AG and UnAG was also lost after 6w of low-fat diet (LFD) consumption. Protein content of the classic ghrelin receptor, GHS-R1a, was not affected by diet or training. Corticotropin-releasing hormone receptor-2 (CRF-2R) content, a putative receptor for ghrelin in muscle, was significantly decreased in soleus from 6w HFD-fed animals and increased following exercise training. This may explain the protection of UnAG response with training in HFD-fed rats but does not explain why ghrelin response was also lost in LFD-fed animals. Conclusions: UnAG protects muscle glucose uptake during acute lipid oversupply, likely due to its ability to stimulate FAO. This effect is lost in 6w HFD-fed animals but protected with exercise training. Unexpectedly, ghrelin response was lost in 6w LFD-fed animals. The loss of ghrelin response in muscle with a LFD cannot be explained by a change in putative ghrelin receptor content. We believe that the sedentary nature of the animals is a major factor in the development of muscle ghrelin resistance and warrants further research.

Underlying Thinking Pattern Profiles Predict Parent-Reported Distress Responses in Autism Spectrum Disorder.

Appreciating autistic neurodiversity is important when supporting autistic people who experience distress. Specifically, use of a profiling model can reveal less visible autistic differences, including strengths and abilities. Binary logistic regressions showed that the likelihood of extreme distress responses could be interpreted based on parent-reported autistic thinking pattern profiles for 140 young people. Perspective-taking (specifically empathy), extreme demand avoidance, and over-sensory sensitivity each contributed to the combined regression models. From the clinical perspective of autism as a multi-dimensional and inter-connected construct, there may be implications for planning support and building positive self-understanding. Individually tailored adjustments and support strategies may be identified more easily after delineating variables found across four core aspects: sensory coherence, flexible thinking, perspective-taking, and regulation.

Regulation of adipose tissue lipolysis by ghrelin is impaired with high-fat diet feeding and is not restored with exercise.

Ghrelin is released from the stomach as an anticipatory signal prior to a meal and decreases immediately after. Previous research has shown that both acylated (AG) and unacylated (UnAG) ghrelin blunt adrenoreceptor-stimulated lipolysis in rat white adipose tissue (WAT) ex vivo. We investigated whether acute or chronic consumption of a high fat diet (HFD) impaired the ability of ghrelin to regulate adipose tissue lipolysis, and if this impairment could be restored with exercise. After 5 days (5d) of a HFD, or 6 weeks (6 w) of a HFD (60% kcal from fat) with or without exercise training, inguinal and retroperitoneal WAT was collected from anesthetized rats for adipose tissue organ culture. Samples were treated with 1 µM CL 316,243 (CL; lipolytic control), 1 µM CL+150 ng/ml AG or 1 µM CL+150 ng/ml UnAG. Incubation media and tissue were collected after 2 hours. Colorometric assays were used to determine glycerol and free fatty acid (FFA) concentrations in media. Western blots were used to quantify the protein content of lipolytic enzymes and ghrelin receptors in both depots. CL stimulated lipolysis was evidenced by increases in glycerol (p < 0.0001) and FFA (p < 0.0001) concentrations in media compared to control. AG decreased CL-stimulated glycerol release in inguinal WAT from 5d LFD rats (p = 0.0097). Neither AG nor UnAG blunted lipolysis in adipose tissue from 5d or 6 w HFD-fed rats, and exercise did not restore ghrelin's anti-lipolytic ability in 6 w HFD-fed rats. Overall, this study demonstrates that HFD consumption impairs ghrelin's ability to regulate adipose tissue lipolysis.

HIV Antivirals Affect Endothelial Activation and Endothelial-Platelet Crosstalk.

RATIONALE: People living with HIV on effective antiretroviral therapy are at increased risk of cardiovascular complications, possibly due to off-target drug effects. Some studies have associated antiretroviral therapy with increased risk of myocardial infarction and endothelial dysfunction, but a link between endothelial function and antiretrovirals has not been established. OBJECTIVE: To determine the effects of antiretrovirals in common clinical use upon in vitro endothelial function to better understand cardiovascular risk in people living with HIV. METHODS AND RESULTS: Human umbilical cord vein endothelial cells or human coronary artery endothelial cells were pretreated with the antiretrovirals abacavir sulphate (ABC), tenofovir disoproxil fumarate, or tenofovir alafenamide. Expression of adhesion molecules, ectonucleotidases (CD39 and CD73), tissue factor (TF), endothelial-derived microparticle (EMP) numbers and phenotype, and platelet activation were evaluated by flow cytometry. TF and ectonucleotidase activities were measured using colourimetric plate-based assays. ABC-treated endothelial cells had higher levels of ICAM (intercellular adhesion molecule)-1 and TF expression following TNF (tumor necrosis factor)-α stimulation. In contrast, tenofovir disoproxil fumarate and tenofovir alafenamide treatment gave rise to greater populations of CD39+CD73+ cells. These cell surface differences were also observed within EMP repertoires. ABC-treated cells and EMP had greater TF activity, while tenofovir disoproxil fumarate- and tenofovir alafenamide-treated cells and EMP displayed higher ectonucleotidase activity. Finally, EMP isolated from ABC-treated cells enhanced collagen-evoked platelet integrin activation and α-granule release. CONCLUSIONS: We report differential effects of antiretrovirals used in the treatment of HIV upon endothelial function. ABC treatment led to an inflammatory, prothrombotic endothelial phenotype that promoted platelet activation. In contrast, tenofovir disoproxil fumarate and tenofovir alafenamide conferred potentially cardioprotective properties associated with ectonucleotidase activity. These observations establish a link between antiretrovirals and specific functional effects that provide insight into cardiovascular disease in people living with HIV.

Unacylated ghrelin stimulates fatty acid oxidation to protect skeletal muscle against palmitate-induced impairment of insulin action in lean but not high-fat fed rats.

BACKGROUND: Ghrelin is a gut hormone that spikes in circulation before mealtime. Recent findings suggest that both ghrelin isoforms stimulate skeletal muscle fatty acid oxidation, lending to the possibility that it may regulate skeletal muscle's handling of meal-derived substrates. It was hypothesized in the current study that ghrelin may preserve muscle insulin response during conditions of elevated saturated fatty acid (palmitate) availability by promoting its oxidation. METHODS AND RESULTS: Soleus muscle strips were isolated from male rats to determine the direct effects of ghrelin isoforms on fatty acid oxidation, glucose uptake and insulin signaling. We demonstrate that unacylated ghrelin (UnAG) is the more potent stimulator of skeletal muscle fatty acid oxidation. Both isoforms of ghrelin generally protected muscle from impaired insulin-mediated phosphorylation of AKT Ser473 and Thr308, as well as downstream phosphorylation of AS160 Ser588 during high palmitate exposure. However, only UnAG was able to preserve insulin-stimulated glucose uptake during exposure to high palmitate concentrations. The use of etomoxir, an irreversible inhibitor of carnitine palmitoyltransferase (CPT-1) abolished this protection, strongly suggesting that UnAG's stimulation of fatty acid oxidation may be essential to this protection. To our knowledge, we are also the first to investigate the impact of a chronic high-fat diet on ghrelin's actions in muscle. Following 6 wks of a high-fat diet, UnAG was unable to preserve insulin-stimulated signaling or glucose transport during an acute high palmitate exposure. UnAG was also unable to further stimulate 5' AMP-activated protein kinase (AMPK) or fatty acid oxidation during high palmitate exposure. Corticotropin-releasing hormone receptor-2 (CRF-2R) content was significantly decreased in muscle from high-fat fed animals, which may partially account for the loss of UnAG's effects. CONCLUSIONS: UnAG is able to protect muscle from acute lipid exposure, likely due to its ability to stimulation fatty acid oxidation. This effect is lost in high-fat fed animals, implying a resistance to ghrelin at the level of the muscle. The underlying mechanisms accounting for ghrelin resistance in high fat-fed animals remain to be discovered.

Regulation of adipose tissue and skeletal muscle substrate metabolism by the stomach-derived hormone, ghrelin.

Ghrelin is a stomach-derived hormone and a potent appetite stimulant. Ghrelin has recently harbored interest as a potential regulator of carbohydrate and lipid metabolism in skeletal muscle and adipose tissue; however, in vivo ghrelin administration is confounded by secondary effects. The assessment of the direct metabolic effects of acylated (AG) and unacylated (UnAG) ghrelin is a relatively new area of research. In isolated adipocytes and muscle, ghrelin has demonstrated antilipolytic effects. In muscle, ghrelin has been shown to acutely stimulate fat oxidation, which may protect the muscle from the insulin-desensitizing effects of high fatty acid concentrations. The effects of ghrelin directly on muscle glucose uptake are controversial. Whether ghrelin can be utilized therapeutically for conditions such as type 2 diabetes will depend on our better understanding of ghrelin's independent effects on muscle and adipose tissue metabolism, and whether this can predict ghrelin's effects when administered in vivo.

Nurses' experiences of communicating respect to patients: Influences and challenges.

BACKGROUND: Respectful care is central to ethical codes of practice and optimal patient care, but little is known about the influences on and challenges in communicating respect. RESEARCH QUESTION: What are the intra- and inter-personal influences on nurses' communication of respect? RESEARCH DESIGN AND PARTICIPANTS: Semi-structured interviews with 12 hospital-based UK registered nurses were analysed using interpretative phenomenological analysis to explore their experiences of communicating respect to patients and associated influences. ETHICAL CONSIDERATIONS: The study was approved by the Institutional ethics board and National Health Service Trust. FINDINGS: Three interconnected superordinate themes were identified: 'private self: personal attitudes', 'outward self: showing respect' and 'reputational self: being perceived as respectful'. Respectful communication involved a complex set of influences, including attitudes of respect towards patients, needs and goals, beliefs around the nature of respectful communication, skills and influencing sociocultural factors. A tension between the outward self as intended and perceived presented challenges for nurses' reputational self as respectful, with negative implications for patient care. DISCUSSION: The study offers an in-depth understanding of intra- and inter-personal influences on communicating respect, and sheds light on challenges involved, helping provide practical insights to support respectful care. CONCLUSION: Findings stress the need for improved conceptualisations of respect in healthcare settings to formally recognise the complex attitudinal and socially constructed nature of respect and for appropriate professional training to improve its communication.

Understanding violence when the perpetrator has an intellectual disability: The perceptions of professionals.

AIM: The research sought to enhance professional understanding of the violence perpetrated by some people with an intellectual disability. BACKGROUND: The violent behaviour exhibited by some people with intellectual disabilities remains poorly understood, particularly with regard to a clear and informative definition. DESIGN: A qualitative study investigated the views and perceptions of professionals working directly with people with an intellectual disability in different settings. METHODS: Twenty-two semi-structured interviews were undertaken with professionals from a variety of backgrounds, and four themes were generated through data analysis. FINDINGS: Themes produced comprised the degree of intellectual disability, impulsivity, intentionality and unpredictability. Findings indicated tension between understanding violence as purposeful and explaining it in relation to the intellectual disability and/or additional conditions. CONCLUSION: Intellectual disability is central to understanding the impact of the other three themes, though there is a professional reluctance to use such knowledge as evidence to inform practice.

IL-12 and IL-4 activate a CD39-dependent intrinsic peripheral tolerance mechanism in CD8(+) T cells.

Immune responses to protein antigens involve CD4(+) and CD8(+) T cells, which follow distinct programs of differentiation. Naïve CD8 T cells rapidly develop cytotoxic T-cell (CTL) activity after T-cell receptor stimulation, and we have previously shown that this is accompanied by suppressive activity in the presence of specific cytokines, i.e. IL-12 and IL-4. Cytokine-induced CD8(+) regulatory T (Treg) cells are one of several Treg-cell phenotypes and are Foxp3(-) IL-10(+) with contact-dependent suppressive capacity. Here, we show they also express high level CD39, an ecto-nucleotidase that degrades extracellular ATP, and this contributes to their suppressive activity. CD39 expression was found to be upregulated on CD8(+) T cells during peripheral tolerance induction in vivo, accompanied by release of IL-12 and IL-10. CD39 was also upregulated during respiratory tolerance induction to inhaled allergen and on tumor-infiltrating CD8(+) T cells. Production of IL-10 and expression of CD39 by CD8(+) T cells was independently regulated, being respectively blocked by extracellular ATP and enhanced by an A2A adenosine receptor agonist. Our results suggest that any CTL can develop suppressive activity when exposed to specific cytokines in the absence of alarmins. Thus negative feedback controls CTL expansion under regulation from both nucleotide and cytokine environment within tissues.

A qualitative investigation into nurses' perceptions of factors influencing staff injuries sustained during physical interventions employed in response to service user violence within one secure learning disability service.

AIMS AND OBJECTIVES: The aim of the study was to examine learning disability nurses' perceptions of incidents involving physical intervention, particularly factors contributing to injuries sustained by this group. BACKGROUND: This article reports on a qualitative study undertaken within one secure NHS Trust to respond to concerns about staff injuries sustained during physical interventions to prevent incidents of service user violence from escalating out of control. The context of the study relates to increasing debate about the most effective approaches to incidents of violence and agression. DESIGN: A qualitative research design was utilized for the study. METHODS: Semi-structured interviews were undertaken with 20 participants, two from each of the 10 incidents involving staff injury sustained during physical intervention. RESULTS: Four themes were produced by the analysis, the first, knowledge and understanding, contextualized the other three, which related to the physical intervention techniques employed, the interpretation of the incident and the impact on staff. CONCLUSION: Service user violence consistently poses nurses with the challenge of balancing the need to respond in order to maintain the safety of everyone whilst simultaneous supporting and caring for people with complex needs. This study highlights the need for further exploration of the contributory factors to the escalation of potentially violent situations. RELEVANCE TO CLINICAL PRACTICE: Services may have good systems in place for responding to and managing service user violence but appear less effective in understanding the reasons for and developing strategies to prevent violence occurring.

Working with people with learning disabilities in varying degrees of security: nurses' perceptions of competencies.

AIM: To identify and discuss the competencies required by learning disability nurses to work effectively with people with an offending background in low, medium, high secure and community settings. BACKGROUND: Research into the competencies required by nurses working with individuals with an offending background, particularly those with a learning disability, is limited. There is some uncertainty as to whether there should be differentiation according to specific setting. DESIGN: A qualitative study addressing the perceptions of nurses on the knowledge, skills and competencies required to effectively work with people with learning disabilities and an offending background in different settings. METHODS: Seven focus groups were conducted across the four settings to inform the construction of the semi-structured interview schedule. Thirty-nine interviews were subsequently undertaken with nurses across settings to develop a fuller understanding of the competencies and ascertain if these were influenced by the specific setting where the nurses worked. Data were collected over 1-year in 2010 and analysed using a structured thematic analysis supported by the software package MAXqda. FINDINGS: The thematic analysis produced four over-arching competencies: knowledge assimilation and application; team working; communication skills; and decision-making. A further competency around personal attributes constitutes the basis of a future paper. CONCLUSION: The first three competencies combine well to inform the work of nurses and appear transferable across settings, but the fourth appears more complicated, specifically in terms of the role of risk in supporting or detracting from decision-making capacity.

'Tolerating violence': a qualitative study into the experience of professionals working within one UK learning disability service.

AIMS AND OBJECTIVES: To explore this complexity further, enhancing understanding of professionals' experience of violence and reasons for non-reporting with regard to people with a learning disability. BACKGROUND: This article reports on a qualitative follow-up study to a whole-population survey investigating the under-reporting of violence within one learning disability service. The survey had identified a pronounced level of under-reporting but suggested an unexpected degree of complexity around the issue, which warranted further study. DESIGN: A qualitative research design was employed. METHODS: Semi-structured interviews were conducted with 22 professionals working in learning disability services; data were subsequently transcribed verbatim and subject to stringent thematic analysis. RESULTS: The findings confirmed that the decision to report an incident or not was complicated by professional interpretation of violence. Three themes were produced by the analysis: the reality of violence, change over time and (zero) tolerance. CONCLUSION: The study indicates that both experience of violence and ways of understanding it in relation to learning disability are shared across professional groups, although nurses are both more inured and generally more accepting of it. The study suggests that the relationship between learning disability nurses and service users with a propensity for violence is complicated by issues of professional background and concerns about the pertinence of zero tolerance. RELEVANCE TO CLINICAL PRACTICE: The availability of effective protocols and procedures is important, but services need also to acknowledge the more ambiguous aspects of the therapeutic relationship to fully understand under-reporting of service user violence in the context of learning disability.

The lived experience of UK street-based sex workers and the health consequences: an exploratory study.

The complex, difficult lives and subsequent health issues of street-based female sex workers are well documented. This paper explores the health needs of a group of sex workers in one geographical locality in the north-west of England. Interviews were conducted with a number of women currently engaged in sex work, with the aim of identifying factors maintaining them in this work and examining their experience of health and health-related services. A thematic analysis revealed considerable life circumstance complexity, with violence, drugs, alcohol and housing problems being prevalent factors. The combination of such factors compounds the likelihood of the women's social exclusion. Other themes related to the casual perception the women had of their own health needs, their generally poor experience of services and the demonstrable impact of one specific service in supporting a group so reluctant to engage. The study suggests poor understanding of the complex needs of street-based sex workers by both services and professionals, particularly a failure to engage with the reality of these women's lives and the factors that maintain them in this work.

Violence and under-reporting: learning disability nursing and the impact of environment, experience and banding.

AIMS AND OBJECTIVES: The study explores the implications of a survey into the discrepancy between actual and reported incidents of violence, perpetrated by service users, within the learning disability division of one mental health NHS Trust. BACKGROUND: Violence within the NHS continues to constitute a significant issue, especially within mental health and learning disability services where incidence remains disproportionately high despite the context of zero tolerance. DESIGN: A whole-population survey of 411 nurses working within a variety of settings within the learning disability division of one mental health NHS Trust. METHODS: A questionnaire was administered to learning disability nursing staff working in community, respite, residential, assessment and treatment and medium secure settings, yielding a response rate of approximately 40%. CONCLUSIONS: There were distinct differences in the levels of violence reported within specific specialist services along with variation between these areas according to clinical environment, years of experience and nursing band. The study does not support previous findings whereby unqualified nurses experienced more incidents of violence than qualified nurses. The situation was less clear, complicated by the interrelationship between years of nursing experience, nursing band and clinical environment. The conclusions suggest that the increased emphasis on reducing violent incidents has been fairly successful with staff reporting adequate preparation for responding to specific incidents and being well supported by colleagues, managers and the organisation. The differences between specific clinical environments, however, constituted a worrying finding with implications for skill mix and staff education. RELEVANCE TO CLINICAL PRACTICE: The study raises questions about the relationship between the qualified nurse and the individual with a learning disability in the context of violence and according to specific circumstances of care delivery. The relationship is clearly not a simple one, and this group of nurses' understanding and expectations of tolerance requires further research; violence is clearly never acceptable, but these nurses appear reluctant to condemn and attribute culpability.

Daniel's story: self-injury and the case study as method.

This article explores the value of case study methodology as a means of investigating the relationship between people with learning disabilities and self-injury. One life story might appear to be of limited value in this regard; however, it is argued that it might not only be of use in demonstrating the development of an isolated self-injuring career, but there may also be insights into its entrenchment in the lives of others. The telling of one story might serve as a filter, through which the interventions of medication, mechanical restraint and behaviourism can be observed over time. Furthermore, studying one life in some detail might be used to illustrate broader concerns about the context of the transition from institutional to community care. The restrictions of such an approach are acknowledged, particularly in the telling of a story where the main character's words cannot be heard, but maybe that is also the point of undertaking research about those at the margins of society.

People with learning difficulties who engage in self-injury.

This article represents some of the findings of the author's research into the relationship between self-injury and learning disability. It identifies the key theoretical discourses associated with the phenomenon, before elaborating on the main principles of each and identifying resultant intervention strategies. These interventions, psychotropic medication, mechanical restraint, and the behavioural approach are subsequently described. Case-study methodology was employed since this enabled the examination over time of these intervention strategies in the lives of individuals fulfilling the necessary criteria of persistent self-injury and significant communication difficulties. The findings of the research suggest a frequently piecemeal approach to self-injury, with arbitrary selection of behavioural intervention approaches, a continued reliance on powerful medication, and ambivalence concerning the use of mechanical restraint. Nurses were often skilled in working from a behavioural perspective, but were hindered by complex family circumstances and a failure to gain the confidence of direct care staff. There was also a lack of appreciation about the relationship between the individual and his/her self-injury, and recognition of the nature of the intransigence.