Autistic spectrum disorder without intellectual impairment in adult mental health services - fostering new perspectives and enhancing existing services.

Autistic spectrum disorder (ASD) is a neuro-developmental disability with multi-systemic impacts. Individuals with ASD without intellectual impairment (DSM-V) or Aspergers (DSM-IV) are often particularly vulnerable to mental health problems such as anxiety disorders including social phobia and generalised anxiety disorder, depressive disorders and psychosis. Adults with ASD without intellectual impairment suffer higher rates of physical and psychiatric morbidity, display a poorer ability to engage with treatment and have a lower chance of recovery compared with the general population. It is widely acknowledged that adults with suspected ASD without intellectual impairment and co-morbid mental health problems are often not best supported through adult mental health services and often require more tailored supports. This review seeks to (a) increase awareness in the area of undiagnosed cases of ASD without intellectual impairment in adult mental health settings and (b) highlights the importance of identifying this population more efficiently by referring to best practice guidelines. The value of future research to examine the benefit of having a team of specialist staff within adult mental health teams who have received ASD training and who are supported to work with the 'core difficulties' of ASD is discussed and a model for the same is proposed. It is proposed that a specialist team could form a 'hub' for the development of expertise in ASD, which when adequately resourced and funded could reach across an entire region, offering consultancy and diagnostic assessments and interventions.

The changing incidence of childhood-onset type 1 diabetes in Wales: Effect of gender and season at diagnosis and birth.

AIMS: Determinants of the changing incidence of childhood-onset type 1 diabetes remain uncertain. We determined the recent time-trend of type 1 diabetes incidence in Wales and explored the role of vitamin D by evaluating the influence of season both at diagnosis and at birth. METHODS: Data from all Welsh paediatric units 1990-2019, and from primary care to determine ascertainment. RESULTS: Log-linear modelling indicated a non-linear secular trend in incidence with peak and subsequent decline. The peak occurred around June 2010: 31∙3 cases/year/100,000 children aged < 15y. It occurred earlier in children younger at diagnosis and earlier in boys. There were more cases in males aged <2y and >12y but more in females aged 9-10 y. More were diagnosed in winter. Also, children born in winter had less risk of future diabetes. CONCLUSIONS: The risk of developing type 1 diabetes before age 15y in Wales is no longer increasing. The data on season are consistent with a preventative role for vitamin D both during pregnancy and later childhood. Metereological Office data shows increasing hours of sunlight since 1980 likely to increase vitamin D levels with less diabetes. Additional dietary supplementation with vitamin D might further reduce the incidence of type 1 diabetes.

Driving and Psychotropic Medications: What Do Psychiatrists and Service Users Really Know?

Aims We ascertained the level of psychotropic medication use among drivers from a sample population and examined whether psychiatrists and mental health service users are sufficiently informed about the effects of medications on driving ability and about drug-driving legislation and guidelines in Ireland. Methods This cross-sectional survey included a convenience sample of 50 service users aged 18 and over who presented to the acute psychiatric unit in Portlaoise, Laois-Offaly Mental Health Services (LOMHS) for urgent psychiatric assessment, along with a survey of 37 doctors working with LOMHS. Results Almost half of surveyed service users (46%) reported that they currently drive, with the majority of these (78%) driving most days. Sixty-one percent (61%) of drivers reported taking psychotropic medication, with 64% of these taking more than one medication. Of 17 doctors who returned questionnaires, 8 (47%) reported that driving and medication use is a common concern in their practice, while only 1 (6%) had received training in relation to assessing medical fitness to drive. Overall, 94% (16) of clinicians and 54% of service users (rising to 71% for service users who drive and take medication) expressed a need for more information about this topic. Conclusion In this sample, the majority of mental health service users who drive do so while taking prescribed medications and they are unclear on the implications. Furthermore, there are significant deficits in training for psychiatrists in the area of assessing medical fitness to drive. Therefore, considering the potential serious risks involved, there is a clear need for more information and training about this topic for both clinicians and service users alike.

Lead alters intracellular protein signaling and suppresses pro-inflammatory activation in TLR4 and IFNR-stimulated murine RAW 264.7 cells, in vitro.

Lead (Pb) is a persistent environmental pollutant that has a structure and charge similar to many ions, such as calcium, that are essential for normal cellular function. Pb may compete with calcium for protein binding sites and inhibit signaling pathways within the cell affecting many organ systems including the immune system. The aim of the current study was to assess whether the calcium/calmodulin pathway is a principal target of environmentally relevant Pb during pro-inflammatory activation in a RAW 264.7 macrophage cell line. RAW 264.7 cells were cultured with 5 µM Pb(NO3)2, LPS, rIFNγ, or LPS+rIFNγ for 12, 24, or 48 hr. Intracellular protein signaling and multiple functional endpoints were investigated to determine Pb-mediated effects on macrophage function. Western blot analysis revealed that Pb initially modulated nuclear localization of NFκB p65 and cytoplasmic phosphorylation of CaMKIV accompanied by increased phosphorylation of STAT1ß at 24 hr. Macrophage proliferation was significantly decreased at 12 hr in the presence of Pb, while nitric oxide (NO) was significantly reduced at 12 and 24 hr. Cells cultured with Pb for 12, 24, or 48 hr exhibited altered cytokine levels after specific stimuli activation. Our findings are in agreement with previous reports suggesting that macrophage pro-inflammatory responses are significantly modulated by Pb. Further, Pb-induced phosphorylation of CaMKIV (pCaMKIV), observed in the present study, may be a contributing factor in metal-induced autophagy noted in our previous study with this same cell line.

Prevalence of preoperative anaemia in patients having first-time cardiac surgery and its impact on clinical outcome. A retrospective observational study.

The prevalence of anaemia is increasing globally. It has a close association with perioperative blood transfusion which, in turn, results in an increased risk of postoperative complications. Undesirable effects are not only limited to short-term, but also have long-term implications. Despite this, many patients undergo cardiac surgery with undiagnosed and untreated anaemia. We designed a retrospective, observational study to estimate the prevalence of anaemia in patients having cardiac surgery in Auckland District Health Board, blood transfusion rates and associated clinical outcome. Two hundred of seven hundred and twelve (28.1%) patients were anaemic. Red blood cell (RBC) transfusion rates were significantly higher in the anaemic group compared to the non-anaemic group (160 (80%) vs. 192 (38%), p-value <0.0001, RR (CI 95%) 2.133 (1.870-2.433)). Transfusion rates for fresh frozen plasma (FFP), cryoprecipitate and platelets were also higher in the anaemic group. Anaemia was significantly associated with the development of new infection (14 (7%) vs. 15 (2.9%), p-value 0.0193, RR (CI 95%) 2.389 (1.175-4.859)), prolonged ventilation time (47.01 hours vs. 23.59 hours, p-value 0.0076) and prolonged intensive care unit (ICU) stay (80.23 hours vs. 50.27, p-value 0.0011). Preoperative anaemia is highly prevalent and showed a clear link with significantly higher transfusion rates and postoperative morbidity. It is vital that a preoperative management plan for the correction of anaemia should be sought to improve patient safety and outcome.

Delirium: a key challenge for perioperative care.

Delirium is highly prevalent, occurring in 20% of acute hospital inpatients and up to 62% of surgical patients. It is a significant predictor of poor outcomes including mortality and institutionalisation, however it is often viewed as simply a marker of underlying illness and is frequently overlooked in older adults. Although delirium is commonly comorbid with dementia, it represents a more urgent diagnosis, requiring prompt intervention. Delirium presents most commonly with hypoactive features (e.g. withdrawal and reduced spontaneous movement and speech). The common stereotype of hyperactive delirium tremens (e.g. agitation, hallucinations), although more visible, is less common. All presentations share acute disimprovement of cognitive function. Delirium is a highly predictable and preventable occurrence, however a major barrier to improving delirium care and impacting upon outcomes is that it remains poorly detected, particularly in surgical populations and especially in patients with hypoactive presentations. Routine ward-based screening for delirium, particularly in high-risk populations, and improved staff awareness of the significance of the problem can improve detection rates. Preventative strategies, particularly multicomponent approaches, have been most efficacious in improving patient outcomes. Optimising perioperative risk factors can lead to reduced incidence. Appropriate treatment of delirium requires thorough investigation, management of the underlying illness, avoidance of complications and simplification of the care environment. Studies suggest a role for pharmacological prophylaxis, particularly in relation to anaesthetic and sedative agents used intra- and post-operatively. Furthermore, gathering evidence suggests that judicious use of antipsychotic medications may be helpful in delirium prevention and treatment.

Loneliness and vascular biomarkers: the Dublin Healthy Ageing Study.

BACKGROUND: Loneliness has been associated with poor physical health and a link has been suggested between the presence of loneliness, cardiovascular health and inflammatory markers. OBJECTIVE: To investigate the association between vascular disease biomarkers and loneliness in a community-dwelling non-demented elderly population. DESIGN: cross-sectional community based assessment. PARTICIPANTS: 466 subjects with mean age 75.45 (SD, 6.06) years. 208 (44.6%) were male. RESULTS: Higher levels of HbA1c, but not other vascular biomarkers were independently associated with being lonely. CONCLUSION: Loneliness was associated with raised levels of HbA1c in a community dwelling elderly population. The mechanism for this association has yet to be elucidated but may reflect an abnormal stress response in people who are lonely.

Loneliness and cognition in older people: the Dublin Healthy Ageing study.

INTRODUCTION: While several studies have found a link between impaired cognition and social isolation, few have examined the relationship between cognition and loneliness. Loneliness has been thought to increase the risk of development of Alzheimer's dementia. AIM: The aims of this study were to explore the relationship between loneliness and cognition and to determine whether specific cognitive domains are associated with loneliness. DESIGN: Cross-sectional community-based study. PARTICIPANTS: This study included 466 community-dwelling subjects with mean age 75.45 (SD 6.06) years, of which 208(44%) were males. RESULTS: Loneliness was significantly associated with impaired global cognition independent of social networks and depression. The domains of psychomotor processing speed and delayed visual memory were specifically associated with self-reported loneliness. CONCLUSION: This cross-sectional study demonstrated an association between loneliness and specific aspects of cognition independent of depression, social networks and other demographics. The mechanism for this association is unclear and warrants further investigation.

Chlorine dioxide inactivation of bacterial threat agents.

AIMS: To evaluate the efficacy of chlorine dioxide (ClO(2)) against seven species of bacterial threat (BT) agents in water. METHODS AND RESULTS: Two strains of Bacillus anthracis spores, Yersinia pestis, Francisella tularensis, Burkholderia pseudomallei, Burkholderia mallei and Brucella species were each inoculated into a ClO(2) solution with an initial concentration of 2.0 (spores only) and 0.25 mg l(-1) (all other bacteria) at pH 7 or 8, 5 or 25°C. At 0.25 mg l(-1) in potable water, six species were inactivated by at least three orders of magnitude within 10 min. Bacillus anthracis spores required up to 7 h at 5°C for the same inactivation with 2.0 mg l(-1) ClO(2). CONCLUSIONS: Typical ClO(2) doses used in water treatment facilities would be effective against all bacteria tested except B. anthracis spores that would require up to 7 h with the largest allowable dose of 2 mg l(-1) ClO(2). Other water treatment processes may be required in addition to ClO(2) disinfection for effective spore removal or inactivation. SIGNIFICANCE AND IMPACT OF STUDY: The data obtained from this study provide valuable information for water treatment facilities and public health officials in the event that a potable water supply is contaminated with these BT agents.

Associations between holotranscobalamin, vitamin B12, homocysteine and depressive symptoms in community-dwelling elders.

BACKGROUND: Vitamin B12 and homocysteine have been shown to be associated with depression or depressive symptoms, but the relationship has not been universal. Both vitamin B12 and homocysteine may exert an effect via vascular mechanisms; it is possible that other mechanisms apply. Holotranscobalamin is a novel, more accurate measure of tissue vitamin B12. OBJECTIVES: To examine associations between vitamin B12, serum folate, holotranscobalamin, homocysteine and depressive symptoms in a sample of healthy elderly. METHODS: Cross-sectional, observational community based study. RESULTS: Lower levels of holotranscobalamin and vitamin B12 were associated with higher levels of depressive symptoms when controlled for Mini-mental state examination scores and psychosocial and cardiovascular risk factors. Homocysteine was not associated with depressive symptoms when biological and psychosocial covariates were included. CONCLUSIONS: It is possible that low levels of vitamin B12 or holotranscobalamin are associated with depressive symptoms via mechanisms other than vascular pathology.

Chlorine disinfection of Francisella tularensis.

AIMS: To determine the range of free available chlorine (FAC) required for disinfection of the live vaccine strain (LVS) and wild-type strains of Francisella tularensis. METHODS AND RESULTS: Seven strains of planktonic F. tularensis were exposed to 0·5 mg·l(-1) FAC for two pH values, 7 and 8, at 5 and 25°C. LVS was inactivated 2 to 4 times more quickly than any of the wild-type F. tularensis strains at pH 8 and 5°C. CONCLUSIONS: Free available chlorine residual concentrations routinely maintained in drinking water distribution systems would require up to two hours to reduce all F. tularensis strains by 4 log10. LVS was inactivated most quickly of the tested strains. SIGNIFICANCE AND IMPACT OF THE STUDY: This work provides contact time (CT) values that are useful for drinking water risk assessment and also suggests that LVS may not be a good surrogate in disinfection studies.

Vitamin B12 status, homocysteine and mortality amongst community-dwelling Irish elders.

BACKGROUND: Vitamin B12 deficiency is associated with hyperhomocysteinaemia, which is associated with atherosclerosis and increased mortality. High levels of vitamin B12 have also been associated with increased mortality in certain patient populations. AIMS: We examined vitamin B12 and homocysteine status and mortality rates in a population of Irish community-dwelling elders over a 3-year period. METHODS: Prospective, community-based observational cohort study. RESULTS: Subjects in the highest quartile of homocysteine had increased mortality rates (14.68 vs. 7.32%, relative risk 2.09). This relationship was attenuated when controlled for the presence or absence of a history of stroke or myocardial infarction. There was no relationship between vitamin B12 status and mortality during the observation period. CONCLUSION: Vitamin B12 levels are not associated with death rates in Irish community-dwelling elders. Homocysteine levels are associated with mortality and may act via the mechanism of atherosclerotic disease.

UV light inactivation of bacterial biothreat agents.

Seven species of bacterial biothreat agents were tested for susceptibility to UV light (254 nm). All gram-negative organisms tested required <12 mJ/cm(2) for a 4-log(10) reduction in viability (inactivation). Tailing off of the B. anthracis spore inactivation curves began close to the 2-log(10) inactivation point, with a fluence of approximately 40 mJ/cm(2), and 3-log(10) inactivation still was not achieved with a fluence of 120 mJ/cm(2).

The attitudes and practices of general practitioners regarding dementia diagnosis in Ireland.

BACKGROUND: The diagnosis of dementia poses difficulties for general practitioners (GPs) particularly when access to specialist diagnostic services is delayed. Ireland is soon to witness an increase in numbers of people presenting with dementia, yet little is known about the service needs of GPs when attempting to diagnose dementia. OBJECTIVES: To detail the service needs of GPs, especially their training needs, access to diagnostic resources such as CT and MRI brain scans and access to specialist services such as Old Age Psychiatry (OAP), Geriatric Medicine (GM) and Neuropsychology (NP). METHODS: The paper is based on survey data collected from a sample of GPs (n = 300) registered with the Irish College of General Practitioners (ICGP) and on qualitative data collected from a Focus Group (n = 7). RESULTS: GPs were more likely to blame themselves than either the health care system, their patients or family members for the late presentation of dementia in primary care. Stigma was a major obstacle preventing GPs from being more proactive in this area. Rural GPs felt geographically disadvantaged accessing diagnostic services and both rural and urban GPs experienced considerable time delays accessing specialist diagnostic services. CONCLUSIONS: Findings provide compelling evidence that training and access to diagnostic services are only two of several different structural and ideological obstacles that GPs encounter when attempting to diagnose dementia. Future educational supports for GPs need to be developed which concentrate on these areas.

Occupational therapy for patients with Parkinson's disease.

BACKGROUND: Despite drug and surgical therapies for Parkinson's disease, patients develop progressive disability. It has both motor and non-motor symptomatology, and their interaction with their environment can be very complex. The role of the occupational therapist is to support the patient and help them maintain their usual level of self-care, work and leisure activities for as long as possible. When it is no longer possible to maintain their usual activities, occupational therapists support individuals in changing and adapting their relationship with their physical and social environment to develop new valued activities and roles. OBJECTIVES: To compare the efficacy and effectiveness of occupational therapy with placebo or no interventions (control group) in patients with Parkinson's disease. SEARCH STRATEGY: Relevant trials were identified by electronic searches of MEDLINE (1966-April 2007), EMBASE (1974-2000), CINAHL (1982-April 2007), Psycinfo (1806-April 2007), Ovid OLDMEDLINE (1950-1965), ISI Web of Knowledge (1981-April 2007), National Library for Health (NLH) (April 2007), Nursing, Midwifery and Allied Health (NMAP) (April 2007), Intute: Medicine (December 2005), Proquest Nursing Journals (PNJ, 1986 - April 2007); rehabilitation databases: AMED (1985-April 2007), MANTIS (1880-2000), REHABDATA (1956-2000), REHADAT (2000), GEROLIT (1979-2000); English language databases of foreign language research and third world publications: Pascal (1984-2000), LILACS (1982- April 2007), MedCarib (17th Century-April 2007), JICST-EPlus (1985-2000), AIM (1993-April 2007), IMEMR (1984-April 2007), grey literature databases: SIGLE (1980-2000), ISI-ISTP (1982-April 2007), DISSABS (1999-2000), Conference Papers Index (CPI, 1982-2000) and Aslib Index to Theses (AIT, 1716- April 2006), The Cochrane Controlled Trials Register (Issue 2, 2007), the CenterWatch Clinical Trials listing service (April 2007), the metaRegister of Controlled Trials (mRCT, April 2007), Current controlled trials (CCT) (April 2007), ClinicalTrials.gov (April 2007), CRISP (1972-April 2007), PEDro (April 2007), NIDRR (April 2007) and NRR (April 2007) and the reference lists of identified studies and other reviews were examined. SELECTION CRITERIA: Only randomised controlled trials (RCT) were included, however those trials that allowed quasi-random methods of allocation were allowed. DATA COLLECTION AND ANALYSIS: Data was abstracted independently by two authors and differences were settled by discussion. MAIN RESULTS: Two trials were identified with 84 patients in total. Although both trials reported a positive effect from occupational therapy, all of the improvements were small. The trials did not have adequate placebo treatments, used small numbers of patients and the method of randomisation and concealment of allocation was not specified in one trial. These methodological problems could potentially lead to bias from a number of sources reducing the strength of the studies further. AUTHORS' CONCLUSIONS: Considering the significant methodological flaws in the studies, the small number of patients examined, and the possibility of publication bias, there is insufficient evidence to support or refute the efficacy of occupational therapy in Parkinson's disease. There is now a consensus as to UK current and best practice in occupational therapy when treating people with Parkinson's disease. We now require large well designed placebo-controlled RCTs to demonstrate occupational therapy's effectiveness in Parkinson's disease. Outcome measures with particular relevance to patients, carers, occupational therapists and physicians should be chosen and the patients monitored for at least six months to determine the duration of benefit. The trials should be reported using CONSORT guidelines.

A new infusion syringe label system designed to reduce task complexity during drug preparation.

A new safety-orientated drug infusion label was studied and was compared with conventional methods by prospectively collecting incident reports from November 1998 to November 2003. Anaesthetists were asked to return an incident form for every anaesthetic (87% response rate), the vast majority indicating that no error had occurred. One error was reported with the use of the new label. However, this was due to an incorrect patient weight being recorded in the notes, and the dose was correct for the information available. Therefore, this data point was not included in the analysis. Seven errors were reported in the calculation of dosage using conventional infusion labels during 18 491 anaesthetics compared with no calculation errors in 10 655 anaesthetics with the new label (p = 0.045, Chi-squared test). Despite the difficulties of demonstrating significant benefit from safety initiatives in medicine, these data suggest that targeted system redesign can be effective inreducing error.