Experiences of UK and Irish family carers of people with profound and multiple intellectual disabilities during the COVID-19 pandemic.

BACKGROUND: People with profound and multiple intellectual disabilities (PMID) have high and intensive support needs that ordinarily place significant strain on family carers. This was further heightened by the removal of many external supports during the COVID-19 pandemic. We sought to explore the experiences of family carers of people with PMID during the COVID-19 pandemic and understand what the longer-term impact might be on their lives. METHODS: Focus group interviews (n = 32) were conducted with family carers (n = 126) from the four countries of the UK and the Republic of Ireland. Participants were asked questions relating to their experiences of the COVID-19 pandemic, coping strategies, and challenges faced. All focus groups were conducted using the online platform, Zoom. These were audio recorded, transcribed verbatim and analysed employing inductive thematic analysis. FINDINGS: Three main themes were generated from the data including (1.0) COVID-19 as a double-edged sword (2.0), The struggle for support (3.0), Constant nature of caring. These included 11 subthemes. (1.1) 'COVID-19 as a catalyst for change', (1.2) 'Challenges during COVID-19: dealing with change', (1.3) 'Challenges during COVID-19: fear of COVID-19', (1.4); 'The online environment: the new normal' (2.1) 'Invisibility of male carers', (2.2) 'Carers supporting carers', (2.3) 'The only service you get is lip service: non-existent services', (2.4); 'Knowing your rights' (3.1) 'Emotional response to the caring role: Feeling devalued', (3.2) 'Emotional response to the caring role: Desperation of caring', (3.3) 'Multiple demands of the caring role.' CONCLUSIONS: The COVID-19 pandemic presented immense challenges to family carers of people with PMID but also provided some opportunities. Families had already struggled to receive many of the supports and services to which they were entitled to only to have these removed at the onset of the pandemic. The experiences of male carers have been largely absent from the literature with this research showing they want to be included in decision making and require tailored support services. Service providers should see the end of the COVID-19 pandemic as providing opportunity to re-examine current provision and design services with family carers. As the direct threat from COVID-19 diminishes and the experiences of those who lived through this period come to the fore, there is a need to re-examine current models and provision of support to family carers to better meet their needs.

Impact of the COVID-19 pandemic on family carers of those with profound and multiple intellectual disabilities: perspectives from UK and Irish Non-Governmental Organisations.

BACKGROUND: Family carers of people with profound and multiple intellectual disabilities (PMID) experienced a reduction in healthcare services due to the COVID-19 pandemic. Many subsequently turned to Non-Governmental Organisations who worked to support families. However, little research has sought to capture the experiences of family carers or identify effective interventions which might support them. To address these concerns we explored the views of Non-Governmental sector workers across the UK and Ireland who supported families people with PMID during the COVID-19 pandemic. We also sought to explore their views on the characteristics of online support programmes for family carers.  METHODS: This study employed a qualitative design using focus groups with participants (n = 24) from five Non-Governmental Organisations across the UK and Ireland. A focus group guide included questions on challenges, supports, coping and resources which helped during lockdown restrictions. Focus groups were held online, were audio recorded and transcribed verbatim. The resulting transcripts were pseudonymised and subjected to thematic analysis. FINDINGS: Four themes were identified (i) 'mental and emotional health', (ii) 'they who shout the loudest' (fighting for services), (iii) 'lack of trust in statutory services' and (iv) 'creating an online support programme'. Mental and emotional health emerged as the most prominent theme and included three subthemes named as 'isolation', 'fear of COVID-19' and 'the exhaustion of caring'. CONCLUSIONS: The COVID-19 pandemic has increased the vulnerability of family carers who were already experiencing difficulties in accessing services and supports for their families. While Non-Governmental Organisations have been a crucial lifeline there is urgent need to design services, including online support programmes, in partnership with family carers which adequately address their needs.

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.

Multiple traumatisation and subsequent psychopathology in people with intellectual disabilities and DSM-5 PTSD: a preliminary study.

BACKGROUND: Individuals with intellectual disability (ID) are at greater risk of exposure to traumatic life events compared with the non-ID population. Yet no study to date has examined the role of multiple traumatisation and subsequent psychopathology in people with ID. The aim of this study was to explore the association between multiple traumatisation and subsequent mental health. METHODS: A preliminary cross-sectional study involving 33 participants with DSM-5 post-traumatic stress disorder completed self-report questionnaires on exposure to traumatic life events and post-traumatic stress disorder symptoms, anxiety, depression and general distress. RESULTS: A proportion of 42.4% of the sample reported multiple traumatisation, including exposure to life events in both childhood and adulthood. Those who reported exposure to life events in childhood and adulthood reported significantly higher risk of harm, depression and general psychological distress compared with those who reported exposure to life events only in adulthood. CONCLUSIONS: Preliminary results indicate that more severe psychopathology is associated with multiple traumatisation in childhood and adulthood compared with trauma experienced solely in adulthood.

Pilot feasibility study examining a structured self-management diabetes education programme, DESMOND-ID, targeting HbA1c in adults with intellectual disabilities.

AIM: To report on the outcomes of a pilot feasibility study of a structured self-management diabetes education programme targeting HbA1c . METHODS: We conducted a two-arm, individually randomized, pilot superiority trial for adults with intellectual disability and Type 2 diabetes mellitus. A total of 66 adults with disabilities across the UK met the eligibility criteria. Of these, 39 agreed to participate and were randomly assigned to either the DESMOND-ID programme (n = 19) or a control group (n = 20). The programme consisted of seven weekly educational sessions. The primary outcome was HbA1c level, and secondary outcomes included BMI, diabetes illness perceptions, severity of diabetes, quality of life, and attendance rates. RESULTS: This study found that the DESMOND-ID programme was feasible to deliver. With reasonable adjustments, the participants could be recruited successfully, and could provide consent, complete the outcome measures, be randomized to the groups and attend most of the sessions, with minimal loss to follow-up. The fixed-effects model, the interaction between occasion (time) and condition, showed statistically significant results (0.05 level) for HbA1c ; however, the CI was large. CONCLUSION: This is the first published study to adapt and pilot a national structured self-management diabetes education programme for adults with intellectual disability. This study shows it is possible to identify, recruit, consent and randomize adults with intellectual disabilities to an intervention or control group. Internationally, the results of this pilot are promising, demonstrating that a multi-session education programme is acceptable and feasible to deliver. Its effectiveness should be further tested in an adequately powered trial.

Improving diabetes care for people with intellectual disabilities: a qualitative study exploring the perceptions and experiences of professionals in diabetes and intellectual disability services.

BACKGROUND: Globally, diabetes is increasing with concerns about the impact on outcomes, including premature death and the costs associated with managing the condition. Research indicates that adults with intellectual disabilities (ID) are two to three times more likely to develop diabetes; however, there has been limited focus on diabetes service utilisation in this population. The aim of this study is to explore the perceptions and experiences of diabetes and ID practitioners. METHODS: A series of 1:1 semi-structured interviews were undertaken in one Scottish health service area. In total, 29 qualitative interviews were conducted: 10 with diabetes practitioners from primary and secondary care, 14 from ID services and 5 from community care services regarding diabetes service provision for this population. Thematic content analysis was undertaken to identify the themes and subthemes. RESULTS: Three main themes were identified: (1) enabling access to services to meet diabetes-related care needs of people with ID; (2) communication and service improvements between staff, patients and across services; and (3) providing person-centred diabetes care and developing adapted resources to increase patient self-care. CONCLUSIONS: The findings of this study have important international implications in how diabetes practitioners plan and deliver services for people with ID and other vulnerable groups with limited cognitive ability and communication skills and difficulties in self-management. The findings highlight that access to diabetes education and adapted resources is needed, and if 'reasonable adjustments' are made to service provision and practice, people with ID can benefit from improved healthcare. Developing joint clinics to share knowledge and resources between diabetes and ID practitioners may improve service delivery and continuity of care, and thereby diminish the costs of not providing quality care.

Impact of emergency access targets on admissions to general medicine: a retrospective cohort study.

BACKGROUND: Emergency access targets have been implemented Australia-wide following recent retrospective cohort studies linking emergency department (ED) overcrowding and excess mortality. AIM: To examine the impact of ED access targets on the characteristics and health service utilisation of general medicine (GM) inpatients at the Royal Melbourne Hospital. METHODS: A retrospective cohort study was conducted on all patient episodes admitted from ED to GM units from January 2009 to December 2012 (n = 15562), compared in two cohorts for 24 months before (n = 7393) and after (n = 8169) the implementation of the '4-h rule'. The main outcome measures were age, comorbidity, clinical urgency at presentation (Australasian Triage Score), ED and inpatient length of stay, diagnosis at discharge, and in-hospital complications. RESULTS: After the implementation of the '4-h rule', there was an increased proportion of younger patients aged ≤50 years (7.7-9.1%), urgent Australasian Triage Scale 3 (45.6-49.7%) and semi-urgent Australasian Triage Scale 4 (21.8-27.6%) patients admitted to GM. On average, GM patients had fewer comorbid conditions (proportion with Charlson score ≥6 decreased from 14.2% to 11.9%), and higher proportions (21.8-24.7%) were admitted for less than 48 h. CONCLUSION: Implementation of a 4-h access target has been associated with changes to the characteristics of patients admitted to GM, including higher proportions of younger patients, with fewer comorbid conditions and lower clinical urgency at presentation, although the latter may be explained by a coincidental change in the way that ED patients were triaged, as well as a greater number of these patients presenting to ED overall.

Preferences of critical care registrars in fluid resuscitation of major trauma patients: concordance with current guidelines.

Fluid resuscitation of patients with major trauma remains a controversial topic. We hypothesised that current practice amongst critical care registrars at our centre might differ from current clinical guidelines. Sixty-six registrars from anaesthesia, intensive care and emergency medicine completed a survey giving their preferences for fluid resuscitation in major trauma patients. Most (85%) appropriately would choose a crystalloid (normal saline 68%, Hartmann's solution 17%), although intensive care registrars reported an early preference for colloids (20% of intensive care registrars would choose a colloid vs 0% of other departmental registrars, P < 0.01). Many responses indicated that the presence of an acidosis would not influence their choice of primary resuscitation fluid. Few participants were unfamiliar with the current practice of avoiding colloids as a primary resuscitation fluid in head-injured patients. Most (62%) would choose to transfuse trauma patients after 2 litres of crystalloid, although there was significant inter-departmental variation (P < 0.01). In addition, participants would transfuse an older patient (P=0.02) or an actively bleeding patient (P < 0.01) earlier than the younger or not visibly bleeding trauma patient. We concluded that our study demonstrated general consistency with current clinical guidelines but with interesting interdepartmental variations. We suggest that this type of study could enhance clinical practice by pointing to targeted additional learning opportunities.

The fear factor: drivers and barriers to follow-up screening for human papillomavirus-related anal cancer in men who have sex with men.

Human papillomavirus (HPV)-related anal cancer incidence is rising in men who have sex with men (MSM). Effective screening strategies exist, but many patients are lost to follow-up (LTF). We studied factors impacting screening compliance to recommended annual screening visits. Retrospective chart review identified MSM with anal dysplasia. MSM were grouped as regular screeners (regular to follow-up [RF]) (≥1 visit/year), lost to follow-up (LTF) (>1 year since previous screening) and LTF who then returned for screening (lost came back [LCB]). From June 2007 to March 2008, subjects completed a questionnaire in-person at the time of screening or via telephone (LTF). Questionnaires were completed after anal dysplasia diagnosis. One hundred and ninety-five MSM were enrolled (96 RF, 50 LTF and 49 LCB). RF were compliant for 4.8 years; LTF were lost for 2.3 years. LCB were previously lost for 5.6 years before returning. Mean knowledge score of screening procedures was larger in RF versus LTF (P < 0.001). MSM with more sexual partners in the past six months were more likely to be LCB versus LTF (P = 0.05). RF were more likely to describe their HPV diagnosis as 'upsetting' (P = 0.003). RF were more likely driven by physical symptoms versus LTF (P = 0.002). MSM with high-grade intraepithelial lesions (HSIL) were more likely to be RF versus those with low-grade intraepithelial lesions (P = 0.001. Positive predictors for screening compliance include an upsetting experience during the HPV diagnosis, physical symptoms driving the initial visit and HSIL. Engaging patients in a firm, salient approach may facilitate follow-up compliance.

Photosynthetic carbohydrate metabolism in the resurrection plant Craterostigma plantagineum.

The resurrection plant Craterostigma plantagineum (Hochst) is able to survive almost complete tissue dehydration when water is withheld from it, and then can rehydrate rapidly on rewatering. This ability is believed to be the result of the accumulation of sucrose in aerial tissues as a result of metabolism of 2-octulose. In this work the metabolic activity of well-watered Craterostigma plantagineum plants has been investigated. It is shown that Craterostigma makes raffinose series oligosaccharides as a product of photosynthesis and translocates them in the phloem. Evidence is also provided that 2-octulose is a product of photosynthesis and accumulates in the leaves over the light period and is mobilized at night. Thus 2-octulose acts as a temporary storage carbohydrate in leaves during photosynthesis in a similar fashion to starch in most C3 plants. Other potential roles of 2-octulose are discussed. Other than these observations Craterostigma plants are very similar to other C3 plants under these conditions.

Reactions of nurses and therapists in mainstream health services to contact with people who have learning disabilities.

Government policy in the United Kingdom is to make the National Health Service accessible to all citizens, including those who hitherto may have relied on specialist services. It is recognized that the attitudes of health professionals can be a major influence in making this happen. To date there has been a paucity of research studies involving nurses and therapists, two of the largest groupings of health care workers. The present study contrasted the reactions of nurses and therapists to their contact with people who have learning disabilities, with those of staff working in specialist services for this client group, and with students who are not involved in health services. Over 1000 respondents - mainly university students on undergraduate or post-graduate courses - completed a written questionnaire. Although nurses and therapists had significantly less contact with people who had learning disabilities during their work than did staff in specialist services, there were no differences in terms of contact in personal life. In both instances their contacts were higher than those reported for non-healthcare students. However both nurses and therapists were significantly less confident in working with a patient who had learning disabilities as opposed to one with physical disabilities. By contrast, willingness for social contacts did not vary across the four groups although respondents with previous personal contact were significantly more willing for this than those with no prior contact. The results confirm that the form of contact is a more salient variable on staff attitudes than contact per se. Hence, changed reactions are more likely to come about from successful contacts in a work rather than social environment. The implications are discussed for initial and post-qualifying training courses, especially for suitable placement experiences. Suggestions are made for future research that focuses on increasing the expertise and confidence of nurses and therapists in working with patients who have learning disabilities.

Phytoene synthase-2 enzyme activity in tomato does not contribute to carotenoid synthesis in ripening fruit.

The characteristic yellow fruit phenotype of the r,r mutant and Psy-1 (phytoene synthase-1) antisense tomatoes is due to a mutated or down-regulated phytoene synthase protein, respectively, resulting in the virtual absence of carotenoids. Based on detailed carotenoid determinations Psy-1 appeared to barely contribute to the formation of carotenoids in chloroplast-containing tissues. Despite the virtual absence of carotenoids in ripe fruit the formation of phytoene in vitro was detected in fruit of both mutants. When [14C]isopentenyl pyrophosphate (IPP) was used as the substrate for phytoene synthase a reduction (e.g. r,r mutant, 5-fold) in the formation of phytoene was observed with an accumulation (e.g. r,r mutant, 2-fold) of the immediate precursor geranylgeranyl pyrophosphate (GGPP). Contrastingly, reduced phytoene synthase activity was not detected when [3H]GGPP was used as the substrate. The profile of phytoene formation during ripening was also different in the down-regulated mutants compared to the wild-type. Using specific primers, RT-PCR analysis detected the presence of Psy-2 transcripts in the down-regulated mutants and wild-type throughout fruit development and ripening. These data were supported by the detection of phytoene synthase protein on western blots. Both GGPP formation and phytoene desaturation were elevated in these mutants. Therefore, it appears that despite the absence of carotenoids in ripe fruit, both the mutants have the enzymic capability to synthesize carotenoids in this tissue. Implications of the data with respect to the regulation of carotenoid formation and the channelling of prenyl lipid precursors in tomato (and its potential manipulation) are discussed.

A novel tomato gene that rapidly responds to wound- and pathogen-related signals.

The expression of a novel defence-related gene from tomato which responds rapidly to wound- and pathogen-related signals has been characterised. The gene, which encodes a protein with homology to glucosyl transferase enzymes, is expressed within 15 min of mechanical damage to tomato leaves, and responds to signals which differ from those on the systemin/jasmonic acid pathway typical of well-characterised wound-induced genes of tomato. Furthermore, expression of the gene is also rapidly and specifically induced during a resistance response elicited by the application of Avr9 avirulence peptide to tomato plants carrying the corresponding Cf9 resistance gene. Whilst expression can also be induced by the application of exogenous salicylic acid and related analogues to tomato plants, several lines of evidence suggest that elevated salicylic acid is not a causal signal in planta during either the wound or pathogen resistance response.

Expression of a tomato cDNA coding for phytoene synthase in Escherichia coli, phytoene formation in vivo and in vitro, and functional analysis of the various truncated gene products.

Full length and truncated cDNA expression constructs of the phytoene synthase (psy) gene from tomato have been ligated into a pUC8 cloning vector. One of the truncated constructs was introduced into Escherichia coli carrying the Erwinia uredovora GGPP synthase gene. This transformant produced 15,15'-cis-phytoene, which was identified on the basis of its UV and IR spectral data, from geranylgeranyl diphosphate. The function of this gene product was further confirmed by in vitro assay using cell-free extract of E. coli harboring the construct. On transformation with the above constructs together with a plasmid containing the carotenoid gene cluster from E. uredovora devoid of the phytoene synthase (crtB) gene, yellow, carotenoid-containing, E. coli colonies were produced. The amounts of carotenoids synthesized by the transformed cells, related to the steady-state levels of psy mRNA, varied depending upon the psy constructs. The full-length psy clone produced 16-fold less carotenoids per unit amount of RNA than cells containing phytoene synthase without the first 114 N-terminal amino acids. Removal of further amino acids from the N-terminus caused a large decrease in carotenogenesis. A Western blot of ripe fruit stroma with a monoclonal antibody raised against phytoene synthase revealed a single protein band of apparent molecular mass 38 kDa. Based upon this immunological evidence, we conclude that the size of the transit peptide of phytoene synthase from ripe tomato fruit is approximately 9 kDa, corresponding to about 80 amino acid residues.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotenoid Biosynthesis during Tomato Fruit Development (Evidence for Tissue-Specific Gene Expression).

Tomato (Lycopersicon esculentum Mill. cv Ailsa Craig) fruit, at five stages of development, have been analyzed for their carotenoid and chlorophyll (Chl) contents, in vitro activities of phytoene synthase, phytoene desaturase, and lycopene cyclase, as well as expression of the phytoene synthase (Psy) and phytoene desaturase (Pds) genes. During ripening, the total carotenoids increased with a concomitant decrease in Chl. Although the highest carotenoid content (consisting mainly of lycopene and [beta]-carotene) was found in ripe fruit, the greatest carotenogenic enzymic activities were found in green fruit. Phytoene synthase was located in the plastid stroma, whereas the metabolism of phytoene was associated with plastid membranes during all stages of fruit development. The in vitro products of phytoene desaturation altered from being predominantly phytofluence and [zeta]-carotene in chloroplasts to becoming mainly lycopene in chromoplasts. The expression of Psy was detected in breaker and ripe fruit, as well as flowers, but was not detectable by northern blot analysis in leaves or green fruits. The Pds gene transcript was barely detectable in green fruit and leaves but was expressed in flowers and breaker fruit. These results suggest that transcription of Psy and Pds is regulated developmentally, with expression being considerably elevated in chromoplast-containing tissues. Antiserum to the Synechococcus phytoene synthase cross-reacted with phytoene synthase of green fruit only on western blots and not with the enzyme from ripe fruit. In contrast, a monoclonal antibody to the Psy gene product only cross-reacted with phytoene synthase from ripe fruit. The enzymes from green and ripe fruit had different molecular masses of 42 and 38 kD, respectively. The absence of detectable Psy and Pds mRNA in green tissues using northern blot analyses, despite high levels of phytoene synthase and desaturase activity, lends support to the hypothesis of divergent genes encoding these enzymes.

Radial "high-performance" thin-layer chromatography used to assess fetal lung maturity.

A radial "high-performance" thin-layer chromatographic (HPTLC) method is described by which the percentages and ratios of phosphatidylinositol, sphingomyelin, lecithin, phosphatidylethanolamine, phosphatidylglycerol, and dimethyl phosphatidylethanolamine may be determined simultaneously. An additional method for radial HPTLC determination of saturated phosphatidylcholine is described. We report results of application of these methods to greater than 2000 specimens of amniotic fluid from both diabetic and nondiabetic cases.