Adverse effects of exposure to armed conflict on pregnancy : a systematic review

Exposure to armed conflict has manifold implications for both military and civilian populations. Prenatal stress has detrimental effects on both obstetric outcomes, fetal development and the development of an individual later in life. As well as causing stress to the mother, armed conflicts can decimate local infrastructures making it increasingly difficult to access antenatal and general healthcare. The present review is particularly salient in light of the many ongoing current conflicts. It examines the impacts of exposure to armed conflicts on the pregnancy outcomes.A thorough literature search was carried out on three databases using MeSH and truncation terms. 13 studies were included in the final analysis relating to mothers exposed to armed conflicts since 1990.The studies include data from 1 172 151 patients: mothers from Libya, Bosnia, Herzegovina, Israel, Palestine, Kosovo, Yugoslavia, Nepal, Somalia, Iraq, Kuwait and Afghanistan. There is evidence of an increased risk of mothers giving birth to babies of low birth weight as reported in nine included studies. All have a degree of bias, with four at lower and five at higher risk of bias, either not adjusting for confounders or not employing robust measures of exposure to conflict. Further evidence suggested an increase in the incidence of miscarriage, stillbirth, prematurity, congenital abnormalities, miscarriage and premature rupture of membranes among mothers exposed to armed conflict.Despite the varying degrees of bias which must be considered for the available evidence, the data with the lowest risk of bias suggest a relationship between exposure to armed conflict and low birth weight. In light of the current level of displacement experienced by such populations, the identification of pregnancies at risk could improve the efficacy of antenatal care. Clinicians should consider additional ultrasound scanning where appropriate to monitor for restricted growth in such pregnancies

Epilepsy and challenging behaviour in adults with intellectual disability: A systematic review

Background: Epilepsy and challenging behaviour are both highly prevalent in the intellectual disability (ID) population and it is thus crucial to understand any possible associations between the two. Method: PsycINFO, MEDLINE, Embase, CINAHL and Web of Science were searched for quantitative data about epilepsy and any forms of challenging behaviour in adults with ID. Results: A total of 25 articles were included in the review. Overall the evidence suggests that while epilepsy is not a good explanatory variable for the presence of challenging behaviour; the relationship is complex. However, for some people with epilepsy and for certain types of challenging behaviour a link may exist. Conclusions: Given the possible link between epilepsy-related factors such as seizure type and specific subgroups of challenging behaviour, investigating these relationships further and particularly exploring how to best measure challenging behaviour in people with epilepsy could be of great clinical benefit

Optimal position and distribution mode for on-site hydrogen electrolyzers in onshore wind farms for a minimal levelized cost of hydrogen (LCoH)

Storing energy is a major challenge in achieving a 100 % renewable energy system. One promising approach is the production of green hydrogen from wind power. This work proposes a method for optimizing the design of wind–hydrogen systems for existing onshore wind farms in order to achieve the lowest possible levelized cost of hydrogen (LCoH). This is done by the application of a novel Python-based optimization model that iteratively determines the optimal electrolyzer position and distribution mode of hydrogen for given wind farm layouts. The model includes the costs of all required infrastructure components. It considers peripheral factors such as existing and new roads, necessary power cables and pipelines, wage and fuel costs for truck transportation, and the distance to the point of demand (POD). Based on the results, a decision can be made whether to distribute the hydrogen to the POD by truck or pipeline. For a 23.4 MW onshore wind farm in Germany, a minimal LCoH of EUR 4.58 kgH2-1 at an annual hydrogen production of 241.4 tH2a-1 is computed. These results are significantly affected by the position of the electrolyzer, the distribution mode, varying wind farm and electrolyzer sizes, and the distance to the POD. The influence of the ratio of electrolyzer power to wind farm power is also investigated. The ideal ratio between the rated power of the electrolyzer and the wind farm lies at around 10 %, with a resulting capacity factor of 78 % for the given case. The new model can be used by system planners and researchers to improve and accelerate the planning process for wind–hydrogen systems. Additionally, the economic efficiency, hence competitiveness, of wind–hydrogen systems is increased, which contributes to an urgently needed accelerated expansion of electrolyzers. The results of the influencing parameters on the LCoH will help to set development goals and indicate a path towards a cost-competitive green wind–hydrogen system.</p

Positive behaviour support training for staff for treating challenging behaviour in people with intellectual disabilities: a cluster RCT

BACKGROUND: Preliminary studies have indicated that training staff in Positive Behaviour Support (PBS) may help to reduce challenging behaviour among people with intellectual disability (ID). OBJECTIVE: To evaluate whether or not such training is clinically effective in reducing challenging behaviour in routine care. The study also included longer-term follow-up (approximately 36 months). DESIGN: A multicentre, single-blind, two-arm, parallel-cluster randomised controlled trial. The unit of randomisation was the community ID service using an independent web-based randomisation system and random permuted blocks on a 1 : 1 allocation stratified by a staff-to-patient ratio for each cluster. SETTING: Community ID services in England. PARTICIPANTS: Adults (aged > 18 years) across the range of ID with challenging behaviour [≥ 15 Aberrant Behaviour Checklist - Community total score (ABC-CT)]. INTERVENTIONS: Manual-assisted face-to-face PBS training to therapists and treatment as usual (TAU) compared with TAU only in the control arm. MAIN OUTCOME MEASURES: Carer-reported changes in challenging behaviour as measured by the ABC-CTover 12 months. Secondary outcomes included psychopathology, community participation, family and paid carer burden, family carer psychopathology, costs of care and quality-adjusted life-years (QALYs). Data on main outcome, service use and health-related quality of life were collected for the 36-month follow-up. RESULTS: A total of 246 participants were recruited from 23 teams, of whom 109 were in the intervention arm (11 teams) and 137 were in the control arm (12 teams). The difference in ABC-CTbetween the intervention and control arms [mean difference -2.14, 95% confidence interval (CI) -8.79 to 4.51;p = 0.528] was not statistically significant. No treatment effects were found for any of the secondary outcomes. The mean cost per participant in the intervention arm was £1201. Over 12 months, there was a difference in QALYs of 0.076 in favour of the intervention (95% CI 0.011 to 0.140 QALYs) and a 60% chance that the intervention is cost-effective compared with TAU from a health and social care cost perspective at the threshold of £20,000 per QALY gained. Twenty-nine participants experienced 45 serious adverse events (intervention arm,n = 19; control arm,n = 26). PBS plans were available for 33 participants. An independent assessment of the quality of these plans found that all were less than optimal. Forty-six qualitative interviews were conducted with service users, family carers, paid carers and service managers as part of the process evaluation. Service users reported that they had learned to manage difficult situations and had gained new skills, and carers reported a positive relationship with therapists. At 36 months' follow-up (n = 184), the mean ABC-CTdifference between arms was not significant (-3.70, 95% CI -9.25 to 1.85;p = 0.191). The initial cost-effectiveness of the intervention dissipated over time. LIMITATIONS: The main limitations were low treatment fidelity and reach of the intervention. CONCLUSIONS: Findings from the main study and the naturalistic follow-up suggest that staff training in PBS as delivered in this study is insufficient to achieve significant clinical gains beyond TAU in community ID services. Although there is an indication that training in PBS is potentially cost-effective, this is not maintained in the longer term. There is increased scope to develop new approaches to challenging behaviour as well as optimising the delivery of PBS in routine clinical practice. TRIAL REGISTRATION: This study is registered as NCT01680276. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 22, No. 15. See the NIHR Journals Library website for further project information

A library of quantitative markers of seizure severity

OBJECTIVE: Understanding fluctuations in seizure severity within individuals is important for determining treatment outcomes and responses to therapy, as well as assessing novel treatments for epilepsy. Current methods for grading seizure severity rely on qualitative interpretations from patients and clinicians. Quantitative measures of seizure severity would complement existing approaches, for electroencephalographic (EEG) monitoring, outcome monitoring, and seizure prediction. Therefore, we developed a library of quantitative EEG markers that assess the spread and intensity of abnormal electrical activity during and after seizures. METHODS: We analysed intracranial EEG (iEEG) recordings of 1009 seizures from 63 patients. For each seizure we computed 16 markers of seizure severity that capture the signal magnitude, spread, duration, and post-ictal suppression of seizures. RESULTS: Quantitative EEG markers of seizure severity distinguished focal vs. subclinical seizures across patients. In individual patients 53% had a moderate to large difference (ranksum r>0.3, p<0.05) between focal and subclinical seizures in three or more markers. Circadian and longer-term changes in severity were found for the majority of patients. SIGNIFICANCE: We demonstrate the feasibility of using quantitative iEEG markers to measure seizure severity. Our quantitative markers distinguish between seizure types and are therefore sensitive to established qualitative differences in seizure severity. Our results also suggest that seizure severity is modulated over different timescales. We envisage that our proposed seizure severity library will be expanded and updated in collaboration with the epilepsy research community to include more measures and modalities. © 2023 International League Against Epilepsy

Biodynamic lighting conditions preserve nocturnal melatonin production in pregnant women during hospitalization: A randomized prospective pilot study

Background and purposeMaternal circadian rhythms are important for maintaining maternal and fetal homeostasis. The maternal circadian system coordinates the internal clock of the fetus with environmental lighting conditions via the melatonin signal. The intensity and wavelength of daylight influence nocturnal melatonin production. This study aims to evaluate the effect of environmental lighting conditions on melatonin production in pregnant women with reduced mobility during hospitalization.MethodsWe installed a human-centric lighting system with biodynamic effects (BDL, biodynamic lighting) in the patient rooms. The pregnant women in the patient rooms with standard indoor conditions served as a control group. The illuminance (lux) and dose of effective circadian irradiation (Hec) were recorded every 10 seconds by light dosimeters (Lucerne University, Switzerland) attached to the patients` clothing.ResultsWe analyzed the illuminance status of 47 pregnant women with a median (IQR) gestational age of 29.9 (25.4-32.3) weeks of gestation. The median illuminance in the control group was significantly lower (p&lt;0.05) than in the BDL group in the morning and afternoon from day 1 to 5. BDL patients had a significantly higher effective circadian irradiation in the morning. The effective circadian irradiation showed a significant daily rhythm only in the BDL group. The BDL group had a significantly higher melatonin production on day 3 (p=0.006) and day 5 (p=0.012) than the control group median (IQR) nocturnal 6-Sulfatoxymelatonin excretion 15840 (10140-22160) ng/12h vs. 6141 (2080-11328) ng/12h on day 3 and 18780 (11320-23562) ng/12h vs. 6380 (3500-17600) ng/12h on day 5).ConclusionWe have demonstrated that dramatically altered lighting conditions of hospitalized pregnant women may be optimized by installing biodynamic lighting systems in the patient rooms resulting in the maintenance of nocturnal melatonin production in pregnant women

Can wrist-worn devices and a smartphone application influence arm activity in children with unilateral cerebral palsy? A proof-of-concept study

Aim: To determine whether a wrist-worn triaxial accelerometer-based device and software (including smartphone application), incorporating feedback, is feasible, acceptable, and can lead to increased affected upper limb use during everyday activities in children with unilateral cerebral palsy (UCP). Methods: Study design: Mixed methods proof of concept study. Participants: Children aged 8–18 years with UCP; age-matched typically developing controls (“Buddies”), therapists. Intervention: Baseline (2 weeks): devices recorded arm activity. Active feedback (6 weeks): devices also gave vibratory prompts if affected arm activity fell below pre-set personalised thresholds (UCP group only; control group continued as per Baseline). Final 2 weeks: as baseline. Both groups accessed a smartphone application providing feedback on relative arm motion throughout the study. Assessment and analysis: ABILHAND-Kids questionnaires and MACS classifications captured baseline participant characteristics (UCP group). Accelerometer data was used to calculate relative arm activity (signal vector magnitude) corrected for time worn/day, and trends in relative arm activity examined using single case experimental design (both groups). In-depth interviews with families, “Buddies” and therapists assessed feasibility and acceptability of implementation. A framework approach was used for qualitative data analysis. Results: We recruited 19 participants with UCP; 19 buddies; and 7 therapists. Five participants (two with UCP) did not complete the study. Baseline mean (stdev) ABILHAND-Kids score of children with UCP who completed the study was 65.7 (16.2); modal MACS score was II. Qualitative analysis demonstrated acceptability and feasibility of the approach. Active therapist input for this group was minimal. Therapists appreciated the potential for summary patient data to inform management. Arm activity in children with UCP increased in the hour following a prompt (mean effect size z = 0.261) for the non-dominant hand, and the dominant hand (z = 0.247). However, a significant increase in affected arm activity between baseline and intervention periods was not demonstrated. Discussion: Children with UCP were prepared to wear the wristband devices for prolonged periods. Whilst arm activity increased bilaterally in the hour following a prompt, increases were not sustained. Delivery of the study during the COVID-19 pandemic may have negatively influenced findings. Technological challenges occurred but could be overcome. Future testing should incorporate structured therapy input

Epilepsy, anti-seizure medication, intellectual disability and challenging behaviour – Everyone’s business, no one’s priority

Purpose People with Intellectual Disability (ID) and epilepsy are more likely to experience psychiatric conditions, challenging behaviour (CB), treatment resistance and adverse effects of anti-seizure medications (ASM) than those without. This population receives care from various professionals, depending on local care pathways. This study evaluates the training status, confidence, reported assessment and management practices of different professional groups involved in caring for people with ID, epilepsy and CB. Methods A cross sectional survey using a questionnaire developed by expert consensus which measured self-reported training status, confidence, and approaches to assessment and management of CB in people with ID and epilepsy was distributed to practitioners involved in epilepsy and/or ID. Results Of the 83 respondents, the majority had either a psychiatry/ID (n = 39), or Neurology/epileptology background (n = 31). Psychiatry/ID and Neurology/epileptology had similar confidence in assessing CB in ID-epilepsy cases, but Psychiatry/ID exhibited higher self-rated confidence in the management of these cases. While assessing and managing CB, Psychiatry/ID appeared more likely to consider mental health aspects, while Neurology/epileptology typically focused on ASM. Conclusion Psychiatry/ID and Neurology/epileptology professionals had varying training levels in epilepsy, ID and CB, had differing confidence levels in managing this patient population, and considered different factors when approaching assessment and management. As such, training opportunities in ID should be offered to neurology professionals, and vice versa. Based on the findings, a best practice checklist is presented, which aims to provide clinicians with a structured framework to consider causal explanations for CB in this population