Diabetes in adults with intellectual disability: prevalence and associated demographic, lifestyle, independence and health factors.

BACKGROUND: As people with intellectual disabilities (ID) are now living longer, they are more at risk of developing non-communicable diseases, including type 2 diabetes mellitus. However, understanding of factors associated with diabetes for targeted management and prevention strategies is limited. This study aimed to investigate prevalence of diabetes in adults (aged ≥18 years) with ID and its relationship with demographic, lifestyle, independence and health factors. METHOD: This was a cross-sectional analysis of interview data from 1091 adults with ID from the Leicestershire Learning Disability Register from 1 January 2010 to 31 December 2016. Logistic regression models were used to identify factors associated with diabetes in the study population. RESULTS: The study population did not have healthy lifestyles: just under half reported having lower physical activity levels than people without ID of a similar age; one-quarter consumed fizzy drinks daily; and 20% consumed five or more fruit and/or vegetables per day. Prevalence of carer/self-reported diabetes was 7.3% (95% confidence interval 5.9-9.0). After adjustment, diabetes was positively associated with South Asian ethnicity (P = 0.03) and older age groups (P < 0.001). Diabetes was less common in people living with family members (P = 0.02). We did not find a relationship between any of the lifestyle, independence and health factors investigated. CONCLUSIONS: A significant proportion of people with ID are living with diabetes. Diabetes management and prevention strategies should be tailored to individuals' complex needs and include consideration of lifestyle choices. Such strategies may want to focus on adults of South Asian ethnicity and people living in residential homes where prevalence appears to be higher.

Multimorbidity and lifestyle factors among adults with intellectual disabilities: a cross-sectional analysis of a UK cohort.

BACKGROUND: Multimorbidity [two or more conditions in addition to intellectual disability (ID)] is known to be more common among people with ID. However, the relationship between multimorbidity and lifestyle factors is currently unknown. The aim of this study was to determine the prevalence of multimorbidity in a population of adults with ID. We also aimed to identify risk factors, including lifestyle factors, for multimorbidity in this population. METHODS: This was a cross-sectional analysis using data from a diabetes screening study of 920 adults aged 18-74 years with ID living in Leicestershire, UK. We described comorbidities and the prevalence of multimorbidity in this population. We explored the relationship between multimorbidity and age, gender, ethnicity, severity of ID, socio-economic status, physical activity, sedentary behaviour, fruit and vegetable consumption and smoking status using multiple logistic regression. RESULTS: The prevalence of multimorbidity was 61.2% (95% CI 57.7-64.7). Multimorbidity was independently associated with being female (P < 0.001) and severe/profound ID (P = 0.004). Increasing age was of borderline significance (P = 0.06). Individuals who were physically inactive or sedentary were more likely to be multimorbid, independent of ability to walk, age, gender, severity of ID, ethnicity and socio-economic status (adjusted OR = 1.91; 95% CI 1.23-2.97; P = 0.004 and OR = 1.98; 95% CI 1.42-2.77; P < 0.001). After excluding probable life-long conditions (autism spectrum conditions, attention deficit hyperactivity disorders, epilepsy, cerebral palsy and other paralytic syndromes) as contributing comorbidities, the effect of sedentary behaviour, but not physical activity, remained (P = 0.004). We did not observe a relationship between multimorbidity, fruit and vegetable consumption and smoking status. CONCLUSIONS: Multimorbidity presents a significant burden to people with ID. Individuals who were physically inactive or sedentary were more likely to be multimorbid, but further work is recommended to explore the relationship between multimorbidity and lifestyle factors using standardised objective measures.

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.

Development of a multi-component lifestyle intervention for preventing type 2 diabetes and cardiovascular risk factors in adults with intellectual disabilities.

Background: We report on the development of the 'STOP Diabetes' education programme, a multi-component lifestyle behaviour change intervention for the prevention of type 2 diabetes and cardiovascular risk factors in adults with intellectual disabilities (ID). Methods: We combined qualitative stakeholder interviews with evidence reviews to develop the intervention, guided by the MRC Framework and informed by intervention mapping and two existing diabetes prevention programmes. We conducted two pilot cycles drawing on additional stakeholder interviews to inform and refine the intervention. Results: The STOP Diabetes education programme employed a theoretical framework, using sound learning and behavioural principles and concrete kinaesthetic methods, to provide the grounding for innovative games and activities to promote health behaviour change in adults with ID. Qualitative data also suggested that two educators and one support person delivering a programme of one carer session followed by seven 2.5-h sessions over 7 weeks was acceptable to service users, carers and educators and appeared to benefit the participants. Conclusions: The STOP Diabetes education programme was successfully developed and is suitable for a definitive randomized controlled trial.

Type 2 diabetes and glucose intolerance in a population with intellectual disabilities: the STOP diabetes cross-sectional screening study.

BACKGROUND: Adults with intellectual disabilities (ID) may be at increased risk of developing type 2 diabetes and cardiovascular disease, due to lifestyle factors, medications and other diagnosed conditions. Currently, there is lack of evidence on prevalence and prevention in this population. The aim of this study was to conduct a diabetes screening programme to determine prevalence of previously undiagnosed type 2 diabetes and impaired glucose regulation in people with ID. METHODS: Screening was conducted in a variety of community settings in Leicestershire, UK. Adults with ID were invited via: general practices; the Leicestershire Learning Disability Register; ID psychiatric services; and some people directly contacted the research team due to publicity about the study. Screening involved collection of anthropometric, biomedical and questionnaire data. Type 2 diabetes and impaired glucose regulation were defined according to (venous) fasting plasma glucose or HbA1c, following current World Health Organisation criteria. RESULTS: Nine hundred thirty adults (29% of those approached) participated. Mean age was 43 years, 58% were male and 16% of South Asian ethnicity. Most participants were either overweight or obese (68%). Diabetes status was successfully assessed for 675 (73%) participants: Nine (1.3%, 95% confidence interval 0.6 to 2.5) were found to have undiagnosed type 2 diabetes, and 35 (5.2%, 95% confidence interval 3.6 to 7.1) had impaired glucose regulation. Key factors associated with abnormal glucose regulation included the following: non-white ethnicity and a first degree family history of diabetes. CONCLUSIONS: Results from this large multi-ethnic cohort suggest a low prevalence of screen-detected (previously undiagnosed) type 2 diabetes and impaired glucose regulation in adults with ID. However, the high levels of overweight and obesity we found emphasise the need for targeted lifestyle prevention strategies, which are specifically tailored for the needs of people with ID.

The effect of antiobesity drugs on waist circumference: a mixed treatment comparison.

AIM: To use meta-analytic techniques to quantitatively evaluate the efficacy of orlistat and lorcaserin in the treatment of people who are overweight and obese. METHODS: We identified publications from searches of electronic databases and extracted data from studies that compared orlistat or lorcaserin to lifestyle advice (standard care), placebo, sibutramine, rimonabant or metformin and collected information on waist circumference change or withdrawals due to adverse events (AEs). A mixed treatment comparison (MTC) meta-analysis was performed on the data extracted. RESULTS: Orlistat was found to be significantly better than placebo and standard care in reducing waist circumference at 6 and 12 months; orlistat reduced waist circumference by -6.96 cm [95% credible interval (CrI): -8.93, -4.96 cm] compared to standard care at 6 months. The results suggested that lorcaserin reduced waist circumference by a greater amount than all other interventions at 12 months, for example, lorcaserin lead to a greater reduction of -2.45 cm (95% CrI: -4.99, 0.08 cm) in comparison to placebo, although these differences were not statistically significant. Although data were very limited, metformin reduced waist circumference by a greater amount (-2.11 cm, 95% CI: -1.00, -3.22 cm) than orlistat at 6 months. On average, 6.5% of patients on orlistat and 5.4% of those on lorcaserin discontinued their treatment due to AEs at 12 months. CONCLUSIONS: Orlistat should be considered as an addition to lifestyle interventions in the treatment of obesity. Lorcaserin has recently been approved by the US Food and Drug Administration (FDA) and these results suggest that it is similar in both efficacy and safety compared to orlistat.

The association between body mass index and health-related quality of life: influence of ethnicity on this relationship.

AIMS: The association between obesity and a poorer health-related quality of life (HRQL) has previously been explored. The influence of ethnicity on this relationship has less frequently been considered. We aimed to explore the relationship between body mass index (BMI) and HRQL in a mixed population of White European (WE) and South Asian (SA) ethnicity. METHODS: Cross-sectional data were analysed (n = 4989, 16% SA) from a population-based diabetes screening study. BMI categories were based on ethnic-specific cut-points. HRQL was categorized low (<0.848) or high (≥0.848) according to the median EQ5D score. Logistic regression was used to examine the relationship between BMI and HRQL. Interaction analysis was conducted to determine the effect of ethnicity. RESULTS: Overweight (OR = 1.22, 95% CI: 1.10-1.41, p < 0.001) and obese people (OR = 1.81, 95% CI: 1.56-2.10, p < 0.001) had increased odds of having a low HRQL compared to normal weight people. After adjusting for potential confounders, age, gender, ethnicity, deprivation score, fruit and vegetable intake, physical activity, cardiovascular disease, chronic kidney disease and smoking, this association was strengthened further. However, for obese people, SA ethnicity significantly reduced the risk of having a low HRQL when compared to WEs (adjusted OR = 0.58, 95% CI: 0.34-0.97). CONCLUSIONS: Our findings provide further evidence of an association between increasing BMI and low HRQL but suggest that SA ethnicity modifies this relationship. These results could have important health implications and are a basis for further research.

A systematic review and mixed treatment comparison of pharmacological interventions for the treatment of obesity.

The study aims to compare anti-obesity interventions in a single evidence synthesis framework. Electronic databases were searched for randomized controlled trials of orlistat, rimonabant or sibutramine reporting weight or body mass index (BMI) change from baseline at 3, 6 or 12 months. A mixed treatment comparison was used to combine direct and indirect trial evidence. Ninety-four studies involving 24,808 individuals were included; 83 trials included data on weight change and 41 on BMI change. All results are in comparison with placebo. The active drugs were all effective at reducing weight and BMI. At 3 months, orlistat reduced weight by -2.65 kg (95% credibility interval -4.00 kg, -1.31 kg). For sibutramine, 15 mg gave a greater reduction than 10 mg at 12 months, -6.35 kg versus -5.42 kg, respectively. Rimonabant reduced weight by -11.23 kg at 3 months and -4.55 kg at 12 months. Lifestyle advice alone also reduced weight at 6 and 12 months, but was less effective than the pharmacological interventions. In conclusion, modest weight reductions were seen for all pharmacological interventions. Those interventions which have now been withdrawn from use (sibutramine and rimonabant) seem to be the most effective, implying that there may be a place in clinical practice for similar drugs if side effects could be avoided.

What is the clinical effectiveness and cost-effectiveness of using drugs in treating obese patients in primary care? A systematic review.

BACKGROUND: Obesity [defined as a body mass index (BMI) ≥ 30 kg/m(2)] represents a considerable public health problem and is associated with a significant range of comorbidities and an increased mortality risk. The primary aim of the management of obesity is to achieve weight reduction in the interests of health. For obese patients who cannot achieve or maintain a healthy weight by non-pharmacological means, drug therapy is recommended in combination with non-pharmacological interventions such as dietary modifications and exercise. OBJECTIVE: To evaluate the clinical effectiveness and cost-effectiveness of three pharmacological interventions in obese patients. DATA SOURCES: Clinical effectiveness data used in the meta-analysis were sourced from articles identified in a systematic review of the literature. Data used to inform transitions to obesity-related comorbidities were derived from the General Practice Research Database (GPRD). The results of the meta-analysis and GPRD analyses informed the economic model supplemented by data from the Health Survey for England and other UK-specific data sourced from the literature. REVIEW METHODS: A systematic literature review was conducted of the clinical effectiveness and cost-effectiveness of orlistat, sibutramine and rimonabant within their licensed indications for the treatment of obese patients. Electronic bibliographic databases including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library databases and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched in January 2009, and the reference lists of relevant articles were checked. Studies were included if they compared orlistat, sibutramine or rimonabant with lifestyle and/or exercise advice (standard care), placebo or metformin. RESULTS: Overall, 94 studies involving 24,808 individuals were included in the clinical meta-analysis. Eighty-three trials included data on weight change, 41 included data on BMI change and 45 and 36 studies reported on 5% and 10% body weight loss, respectively. Overall, the results show that the active drug interventions are all effective at reducing weight and BMI compared with placebo. In the case of sibutramine, the higher dose (15 mg) resulted in a greater reduction than the lower dose (10 mg). Generally, the data quality of the trials included was low with poor reporting of standard errors and standard deviations. Results from the BMI risk models derived from the GPRD showed consistent increases in risk with increasing BMI. Adjustments for key confounders, such as age, sex and smoking status, were found to be statistically significant at the 5% level, in all risk models. Applying linear models to estimate BMI trajectories, for the diabetic cohort, an average increase in BMI of 0.040 per year for both men and women was observed. The non-diabetic cohort model showed an increase in BMI of 0.175 per year for women and 0.145 per year for men. The results of the cost-effectiveness analyses suggest that sibutramine 15 mg dominates the other three active interventions and the net benefit analyses show that sibutramine 15 mg is the most cost-effective alternative for thresholds > £2000 per quality-adjusted life-year (QALY). However, both sibutramine and rimonabant have been withdrawn because of safety concerns relating to potential treatment-induced fatal adverse events. If the proportion of patients who experienced a fatal adverse event was > 1.8% (1.5%, 1.0%) for sibutramine 15 mg (sibutramine 10 mg, rimonabant) the treatment would not be considered cost-effective when using a threshold of £20,000 per QALY. LIMITATIONS: The clinical review did not include all possible lifestyle comparators, with the inclusion limited to only those trials included one of the active drug interventions. We also excluded all studies not reported in English. Although the clinical review included data from 94 studies, the quality of data was generally low, particularly in terms of the reporting of standard deviation. There was also inconsistency between the results of the mixed-treatment comparison (MTC) and the pair-wise analyses. CONCLUSION: The MTC of anti-obesity treatments shows that all the active treatments are effective at reducing weight and BMI. The economic results show that, compared with placebo, the treatments are all cost-effective when using a threshold of £20,000 per QALY, and, within the limitations of the data available, sibutramine 15 mg dominates the other three interventions. This work has highlighted many areas of methodological research that could be explored, including assessing inconsistencies within a network to determine differences between the results of pair-wise and MTC analyses; the use of meta-regression methods to look for effect modifiers; exploring the effect of local publication bias; and the use of joint models to analyse the repeated measures of BMI and the time-to-event processes simultaneously. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Effectiveness of interventions for reducing diabetes and cardiovascular disease risk in people with metabolic syndrome: systematic review and mixed treatment comparison meta-analysis.

AIMS: To review the evidence on interventions for reversing metabolic syndrome or preventing development of type 2 diabetes and cardiovascular disease in people with metabolic syndrome. METHODS: A systematic review and Bayesian mixed treatment comparison meta-analysis was conducted. Relevant electronic bibliographic databases were searched up to January 2010. Included studies were randomized controlled trials with a follow-up of ≥24 weeks and outcomes comparing incidence of diabetes and/or cardiovascular disease, or reversal of metabolic syndrome. RESULTS: A total of 16 studies met the inclusion criteria. Thirteen studies with outcome data for reversal of metabolic syndrome, involving 3907 participants, were included in the meta-analysis. Insufficient trials reported cardiovascular events/mortality, or incidence of type 2 diabetes, to conduct a meta-analysis for these outcomes. Interventions, alone or in combination, included lifestyle (diet and/or exercise) and pharmacological therapy. Using random-effect models, both lifestyle (odds ratio, OR 3.81; 95% confidence interval, CI 2.47-5.88) and pharmacological interventions (OR 1.59; 95% CI 1.04-2.45) were statistically superior compared with control for reversing metabolic syndrome. Using mixed treatment comparison methods, the probability that lifestyle interventions were the most clinically effective was 87%. CONCLUSIONS: Evidence suggests that both lifestyle and pharmacological interventions can reverse metabolic syndrome. However, there is a lack of data on whether these benefits are sustained and translate into longer term prevention of diabetes and/or cardiovascular disease.

Acute abdominal pain following fracture of a heterotopically formed bone incorporating a prolene mesh.

A case is presented of severe abdominal pain around a healed scar following fracture of a heterotopically formed bone. This should be considered an unusual differential diagnosis in patients with acute pain of unknown origin who had open abdominal surgery in the past. To our knowledge, we have also reported the first case of hetertopic bone formation incorporating a prolene mesh.

Day case haemorrhoidectomy.

OBJECTIVE: Day case haemorrhoidectomy in a District General Hospital. We have investigated the uptake and outcome of day case haemorrhoidectomy in a small district general hospital. METHOD: Case note review with completion of standard proforma for all patients undergoing haemorrhoidectomy as day case (same day admission and discharge) or inpatient over a 4-year period. RESULTS: Sixty patients underwent day case closed haemorrhoidectomy, 2 day case stapled haemorrhoidectomy and 1 day case open haemorrhoidectomy, whilst 18 patients were treated as in-patients. One patient required re-admission within 31 days for reactionary haemorrhage after day case surgery. None suffered acute urinary retention. Concomitant medical disease or emergency admission were the only reasons for exclusion from day case haemorrhoidectomy. Of the 18 patients treated as in-patients haemorrhoidectomy two had unplanned readmission. CONCLUSION: Closed haemorrhoidectomy with same day discharge should be offered to all patients that require surgical treatment of haemorrhoids and do not have other contra-indications to day case surgery.

Revision total elbow replacement using the Souter-Strathclyde prosthesis.

The Souter-Strathclyde prosthesis was used in 52 evisions of total elbow replacements (TERs) between August 1986 and May 1997. Of these, 50, carried out in 45 patients, were prospectively followed for a mean of 53 months (14 to 139). The procedure produced reliable relief of pain, and the range of movement was preserved. There was a considerable incidence of adverse events associated with revision (30%), and 12 further procedures have been required. Nonetheless, a revision is the preferred salvage procedure for failed primary arthroplasty in the absence of sepsis.

Cementless acetabular replacement in the young. A 5- to 10-year prospective study.

This article presents a prospective clinical and radiologic review of 55 total hip replacements in 50 patients in which the cementless Harris-Galante porous-coated acetabular component was used. All patients were 50 years of age or younger. The cups were inserted by 15 different surgeons. The minimum followup was 5 years, with a mean of 7 years. No acetabular component has been revised for loosening, and none have migrated. Three (5.5%) cups have progressive bone-component radiolucent lines, two (3.6%) of which are complete. Six (10.9%) acetabular liners have been replaced for excessive polyethylene wear, and an additional four (7.3%) show sufficient wear to produce obvious radiographic eccentricity of the femoral head. All of the revised liners had 32-mm femoral heads and an initial polyethylene thickness of less than 6 mm. Although the results reflect excellent fixation of this component in the medium term, the incidence of exchange of the polyethylene liner for excessive wear is unacceptably high. The reduction in polyethylene thickness associated with the use of a metal-backed component and a 32-mm articulation was one of the factors contributing to the accelerated wear patterns seen in this series.

Candida infection of a silicone metacarpophalangeal arthroplasty.

Fungal infections following joint arthroplasty are extremely rare. Only 16 cases of Candida prosthetic infections have been reported, involving the hip, knee or shoulder joints. We report a case of a silicone metacarpophalangeal joint replacement complicated by a Candida albicans infection.

Colon atresia and stenosis in Zimbabwe: case reports and a review of the literature.

Two neonates with colon atresia and one with colon stenosis presented in Harare over a six month period. The first patient was treated with a local resection and primary anastomosis for a type II colon atresia. The second had an excision of obstructing septum, widening coloplasty and cecostomy for a type I colon atresia. The third patient had a sigmoido-rectoplasty and cecostomy for a sigmoid colon stenosis. The third patient also had a cystic duplication of the small bowel. No other anomalies were noted. All three patients survived and were developing normally at six months post-operatively. A review of medical records at Harare and Parirenyatwa Hospitals revealed no other case of colon atresia in the last 10 years. The incidence by site of gastro-intestinal atresias in Zimbabwe is consistent with other reports.

Quality of life following surgery for abdominal aortic aneurysm.

Repair of abdominal aortic aneurysm (AAA) carries a considerable rate of morbidity and mortality, but little information exists on the quality of life following this procedure. During 1988 and 1989, in two hospitals, 211 patients (186 men and 25 women; median age 74 (range 48-87) years) underwent surgery for AAA. There were 77 ruptured aneurysms and 134 electively repaired. Of these, 38 patients died in hospital (27 ruptured, 11 elective); by the time of review a further eight (one ruptured, seven elective) had died from unrelated causes. Of the 165 survivors, 131 (45 ruptured, 86 elective) were reviewed and questioned as to their physical and mental state before and after surgery. Using the Rosser index, a value for quality of life before and after surgery was calculated (1.0, good; 0, dead). The value for the elective group was 0.94 before operation and 0.96 after, but in the ruptured group fell from 0.98 before surgery to 0.87 afterwards. This study shows that patients undergoing elective surgery for repair of AAA retain good quality of life. By contrast, patients surviving emergency surgery following this procedure seem to suffer a deterioration in life quality, which must be endured for the same expected lifetime as that for the elective group. These results support the need for a national AAA ultrasonographic screening programme.

Carbon dioxide pneumothorax occurring during laparoscopic cholecystectomy.

A previously fit patient underwent laparoscopic cholecystectomy. During the procedure arterial oxygen saturation fell and clinical examination revealed signs of a right pneumothorax confirmed by chest X ray. Aspiration of the pleural cavity and analysis of the gas removed showed it to be composed entirely of carbon dioxide. Possible mechanisms of entry of carbon dioxide into the pleural space are discussed.

Apparent traumatic perforation of the bowel in tetanus. A case report.

A case of severe tetanus complicated by intestinal perforation is described. Because of the nature of the treatment in tetanus, the diagnosis was missed for several weeks and the patient's life consequently put at great risk. The possibility that the perforation may have resulted from extreme intra-abdominal pressure changes during spasms is discussed as well as the difficulties of managing such complications in an intensive care unit.