Training direct care staff to empower adults with intellectual disabilities and their families to reduce overmedication

Objectives People with intellectual and developmental disabilities (IDD) and autism are subject to restrictive practices like physical restraint and the overuse of psychotropic medications for challenging behavior. People with disabilities and their families are often not involved in shared decision-making for prescription and other care planning, which may violate the UN Human Rights Charter. Methods One way of reducing overmedication is by empowering adults with IDD and their family caregivers to collaborate in the decision to use medications. SPECTROM (https://spectrom.wixsite.com/project), a training program for direct care workers, was developed to help reduce the overmedication of these people. This article presents ideas on how SPECTROM resources could empower adults with IDD and their families to influence their care decisions, including psychotropic prescribing. Results Information provided in 32 easy-read leaflets in SPECTROM on psychotropic medications can be used to improve shared decision-making involving people with IDD and their families. Similarly, the Yellow Passport, an easy-read health record, could help information sharing among care service providers, thus improving their health care. SPECTROM has one module devoted to effectively engaging with people with IDD to improve their communication and help them with their skills building. Conclusions Currently, very limited evidence exists on the effects of SPECTROM to empower individuals with IDD and their families in reducing psychotropic medications for challenging behaviors. In addition to the two pilot studies on SPECTROM from UK and Australia, further research is needed to explore the evidence supporting the above suggestions

Randomised controlled trials of antidepressant and anti-anxiety medications for people with autism spectrum disorder: a systematic review and meta-analysis.

Background Although used widely the current evidence for the efficacy of antidepressant and antianxiety medications for people with autism spectrum disorder (ASD) is limited and conflicting. Aims We have carried out a systematic review and meta-analysis of the RCTs that assessed the effectiveness of these medications in people with ASD. Method We have searched the following databases: Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, DARE, and ClinicalTrials.gov. Additionally, we have hand-searched 11 relevant journals. We used the Cochrane Risk of Bias and Jadad score to assess the quality of each included RCT. We have carried out a meta-analysis using a random-effects model. Results We have included 15 RCTs (13 on antidepressants and two on antianxiety medications) that included a total of 958 people with ASD. Data showed contradictory findings among the studies with larger studies mostly showing a non-significant difference in outcomes between the treatment and the placebo group. Meta-analysis of pooled Yale-Brown Obsessive Compulsive Scale and Clinical Global Impression Scale data from nine studies (60%) did not show any statistically significant intergroup difference on either of the outcome measures. The adverse effects reported were mild and, in most studies, their rates did not show any significant intergroup difference. Conclusions Given the methodological flaws in the most included studies and contradictory findings it is difficult to draw any definitive conclusion about the effectiveness of either antidepressant or antianxiety medications to treat either ASD core symptoms or associated behaviors. Robust large-scale RCTs are needed in the future to address this issue

Short-term PsychoEducation for Carers To Reduce Over Medication of people with intellectual disabilities (SPECTROM): study protocol

Introduction Psychotropic medications that are primarily licenced for the treatment of psychiatric disorders are used widely (32%–85%) among people with intellectual disabilities (ID) often for the management of problem (challenging) behaviour in the absence of a psychiatric disorder. Care staff play a pivotal role in the prescribing process. Currently, no staff training programme exists to address the issue of overprescribing of psychotropic medication in people with ID, thus highlighting an urgent need for developing a psychoeducational programme (PEP) specifically designed to address this issue. We propose to develop a PEP for care staff using the methodology described in the UK Medical Research Council guide for complex interventions. Methods and analysis The development of the PEP will involve (1) gathering information on available relevant training programmes, (2) running four focus groups with care staff and other professionals to establish the content and format of the PEP, and (3) organising a co-design event involving all relevant stakeholders to discuss the format of the PEP. A core project team will develop the PEP under guidance from the PEP Development Group which will consist of 10–12 relevant stakeholder representatives. Feedback from selected stakeholders on a draft PEP will allow us to refine the PEP before implementation. The PEP will have web-based modules supplemented by face to face training sessions. When the final draft is ready, we will field test the PEP on six to eight care staff from community care homes for people with ID. After completing the field test, we will run a focus group involving participants in the PEP to get feedback on the PEP. Ethics and dissemination Ethics approval for this study was waived by the UK Health Regulatory Authority as the study does not collect any patient related information and only include care staff outside the UK NHS. This will be the first ever such universally freely available PEP supported by training manual and slides

Spatiotemporal Variability of Drought and its Relationships to ENSO and IOD Indices in Somaliland

Drought is one of Somaliland’s most prevalent natural hazards, causing serious socioeconomic and environmental harm. This study investigated the spatial and temporal variability of drought and its relationships with El Niño Southern Oscillation (ENSO) and Indian Ocean Dipole (IOD) indices using the Standardized Evapotranspiration Index (SPEI) from 1981 to 2020. The Mann-Kendall trend test and Sen's slope estimator were used to assess the trends of annual and seasonal SPEI time series. The Empirical Orthogonal Function (EOF) was employed to examine the dominant modes of the SPEI series, and Pearson and partial correlation analyses were performed to investigate the associations between significant modes of drought variability and ENSO and IOD indices. The results demonstrated a statistically significant downward trend of SPEI (increasing drought) at 99% confidence level. The EOF analysis indicated two spatially distinct zones of drought variability in the west and east of the country. Drought variability had a statistically significant negative correlation with ENSO in the summer and winter seasons, and with IOD in the winter season and annual time series. The findings of this study will provide important information for drought risk assessment, mitigation, and predictability in Somaliland. Keywords: Drought, Standardized Precipitation Index, ENSO, IOD, Somalilan

Causes of and alternatives to medication for behaviours that challenge in people with intellectual disabilities: direct care providers' perspectives

Behaviours that challenge (BtC), such as aggression and self-injury, are manifested by many people with intellectual disabilities (ID). National and international guidelines recommend non-pharmacological psychosocial intervention before considering medication to address BtC. Support staff play a pivotal role in the prescription process. Using coproduction, we developed a training programme for support staff, called SPECTROM, to give them knowledge and empower them to question inappropriate prescriptions and ask for the discontinuation of medication if appropriate and instead look for ways to help people with ID when they are distressed without relying on medication. We have presented data from two focus groups that we conducted during the development of SPECTROM: one that included support staff, and another that had service managers and trainers. In these focus groups, we explored participants’ views on the use of medication to address BtC with a particular emphasis on the causes of and alternatives to medication for BtC. Along with the participants’ views, we have also presented how we have addressed these issues in the SPECTROM resources

Ethical prescribing of psychotropic medications for people with neurodevelopmental disorders

Objectives People with neurodevelopmental disorders (NDDs) such as intellectual and developmental disabilities (IDD) and autism are subjected to restrictive practices like physical restraint and the overuse of psychotropic medications for challenging behaviour in the absence of a psychiatric disorder. This practice may lead to human rights violations. Rational and evidence-based shared decision-making for person-centred planning will help reduce this practice. Methods We have discussed in this paper the issue of the overmedication of people with NDD, explaining how this practice may violate the United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD). Results We have discussed how the following UN CRPD Articles may be affected by overmedication, including Article 15 (degrading treatment or punishment), 16 (abuse), 17 (the integrity of the person), and 25 (health). The other Articles that may be indirectly affected by this practice are 5 (equality and non-discrimination), 9 (accessibility), 19 (independent living and community inclusion), 21 (access to information), 24 (education), 26 (rehabilitation), 27 (work and employment), 28 (adequate living standard), and 30 (participation in recreation and leisure). Conclusions Overmedication of people with NDD, particularly the off-licence use of psychotropics for challenging behaviour, the side effects of these medications impacting the person’s quality of life are likely to violet several UN Articles on Rights of Persons with Disabilities. Following the right guidelines may help reduce these human rights violations

Characterisation of the vasodilation effects of DHA and EPA, n-3 PUFAs (fish oils), in rat aorta and mesenteric resistance arteries

Background and Purpose Increasing evidence suggests that the omega-3 polyunsaturated acids (n-3 PUFA), docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), are beneficial to cardiovascular health, promoting relaxation of vascular smooth muscle cells and vasodilation. Numerous studies have attempted to study these responses, but to date there has not been a systematic characterisation of both DHA and EPA mediated vasodilation in conduit and resistance arteries. Therefore, we aimed to fully characterise the n-3 PUFA-induced vasodilation pathways in rat aorta and mesenteric artery. Methods Wire myography was used to measure the vasomotor responses of freshly dissected rat mesenteric artery and aorta. Arteries were pre-constricted with U46619 and cumulative concentrations of either DHA or EPA (10 nM-30 μM) were added. The mechanisms by which n-3 PUFA relaxed arteries were investigated using inhibitors of vasodilator pathways, which include: nitric oxide synthase (NOS; L-NAME), cycloxygenase (COX; indomethacin), cytochrome P450 epoxygenase (CYP450; clotrimazole); and calcium-activated potassium channels (KCa), SKCa (apamin), IKCa (TRAM-34) and BKCa (paxilline). Results Both DHA- and EPA-induced relaxations were partially inhibited following endothelium removal in rat mesenteric arteries. Similarly, in aorta EPA-induced relaxation was partially suppressed due to endothelium removal. CYP450 also contributed to EPA-induced relaxation in mesenteric artery. Inhibition of IKCa partially attenuated DHA-induced relaxation in aorta and mesenteric artery along with EPA-induced relaxation in mesenteric artery. Furthermore, this inhibition of DHA- and EPA-induced relaxation was increased following the additional blockade of BKCa in these arteries. Conclusions This study provides evidence of heterogeneity in the vasodilation mechanisms of DHA and EPA in different vascular beds. Our data also demonstrates that endothelium removal has little effect on relaxations produced by either PUFA. We demonstrate IKCa and BKCa are involved in DHA-induced relaxation in rat aorta and mesenteric artery; and EPA-induced relaxation in rat mesenteric artery only. CYP450 derived metabolites of EPA may also be involved in BKCa dependent relaxation. To our knowledge this is the first study indicating the involvement of IKCa in n-3 PUFA mediated relaxation

The F waves study in young healthy individuals

Background: The F wave is a CMAP (compound muscle action potential) evoked by a supramaximal stimulation of a motor nerve. F waves are particularly useful for the diagnoses of polyneuropathies at an early stage and proximal nerve lesions.Methods: Healthy males (n=64) and females (n=26) medical students of BPKIHS with age 20 to 24 years were enrolled. Anthropometric parameters; F wave latencies, persistence and chronodispersion of bilateral median, ulnar and tibial nerves were recorded in Neurophysiology Lab II of BPKIHS. Descriptive analysis was done.Results: Mean age, height and weight of the subjects were 21.64±1.19 years, 165.61±5.4cms and 64.07±5.5kg. Mean minimum F wave latencies (ms) of right median, ulnar and tibial nerves were 24.09±1.95, 24.02±1.76, 44.34±3.02 while on the left side were 23.92±1.96, 24.11±1.92, 44.07±2.83 respectively. F persistence was above 80%. F chronodispersion (ms) for right and left median, ulnar and tibial nerves were 2.77±0.70, 2.79±0.65, 2.71±0.67, 2.80±0.56, 3.48±0.73 and 3.45±0.64 respectively.Conclusions: Maximum and minimum F wave latencies, F chronodispersion and F persistence were derived for both sexes in an age group of 20-24 years

Anagen hair follicles transplanted into mature human scars remodel fibrotic tissue

Despite the substantial impact of skin scarring on patients and the healthcare system, there is a lack of strategies to prevent scar formation, let alone methods to remodel mature scars. Here, we took a unique approach inspired by how healthy hairbearing skin undergoes physiological remodelling during the regular cycling of hair follicles. In this pilot clinical study, we tested if hair follicles transplanted into human scars can facilitate tissue regeneration and actively remodel fibrotic tissue, similar to how they remodel the healthy skin. We collected full-thickness skin biopsies and compared the morphology and transcriptional signature of fibrotic tissue before and after transplantation. We found that hair follicle tranplantation induced an increase in the epidermal thickness, interdigitation of the epidermal-dermal junction, dermal cell density, and blood vessel density. Remodelling of collagen type I fibres reduced the total collagen fraction, the proportion of thick fibres, and their alignment. Consistent with these morphological changes, we found a shift in the cytokine milieu of scars with a long-lasting inhibition of pro-fibrotic factors TGFβ1, IL13, and IL-6. Our results show that anagen hair follicles can attenuate the fibrotic phenotype, providing new insights for developing regenerative approaches to remodel mature scars