Physical conditions and challenging behaviour in people with intellectual disability: a systematic review.

BACKGROUND: Challenging behaviour is a major problem among people with intellectual disabilities. Physical factors may be an important cause. The aim of the present systematic review was to determine the physical conditions associated with challenging behaviour. METHODS: A literature search was conducted in PubMed and the Cochrane systematic review database for empirical studies published between 1990 and 2008. The quality of all the studies that met the inclusion criteria was assessed using the SIGN-50 methodology checklists. RESULTS: The search identified 45 studies, which looked at general medical conditions, motor impairment, epilepsy, sensory impairment, gastrointestinal disease, sleep disorders, dementia and others. There were four high-quality observational studies, seven well-conducted observational studies, 21 observational studies of low methodological quality and 13 non-analytical studies. There were significant and independent associations between challenging behaviours and urinary incontinence, pain related to cerebral palsy and chronic sleep problems, and between self-injurious behaviour and visual impairment. No association was found with hearing impairment, bowel incontinence, mobility impairment or epilepsy. Many other physical conditions were not addressed at all. CONCLUSION: Medical conditions can play a role in challenging behaviour, and this should be evaluated in the clinical setting. So far, the level of evidence is generally low, and longitudinal studies are completely lacking. We recommend a systematic approach to research examining the role of physical conditions in challenging behaviour, the ultimate aim being to establish a basis for the development of clinical guidelines.

Pharmacokinetics of the novel antipsychotic agent risperidone and the prolactin response in healthy subjects.

The pharmacokinetics of a novel antipsychotic agent, risperidone, and the prolactin response were studied in 12 dextromethorphan-phenotyped healthy men after administration of 1 mg risperidone intravenously, intramuscularly, and orally. The formation of the equipotent major metabolite, 9-hydroxyrisperidone, exhibited CYP2D6-related polymorphism. The plasma area under the concentration-time curve from time zero to infinity ratio of 9-hydroxyrisperidone to risperidone averaged 3 (intravenous and intramuscular) and 6 (oral administration) in the extensive metabolizers and 0.2 in the poor metabolizers. Risperidone half-life was about 3 hours in extensive metabolizers and 22 hours in poor metabolizers. Risperidone absolute oral bioavailability was 66%. The pharmacokinetics of the active moiety (risperidone plus 9-hydroxyrisperidone) varied little among subjects (mean terminal half-life, 20 +/- 2 1/2 hours; absolute oral and intramuscular bioavailability, 100%). The prolactin response correlated best with the plasma active moiety, which showed little hysteresis. It is concluded that risperidone metabolic polymorphism on increased plasma prolactin is minimal and that the active moiety is clinically relevant.

Relationships between Ascaris infection and growth of malnourished preschool children in Kenya.

A longitudinal study in Ascaris-infected and noninfected children was conducted in two Kenyan villages. Anthropometric, clinical, and stool exams were performed three times at 14-week intervals. All children received an anthelmintic drug (levamisole) at the second examination. In the 14 weeks before deworming, children with Ascaris (n = 61) did not differ from controls (n = 125) in percentage expected weight gain. In the 14 weeks after deworming, previously infected children showed higher percentage expected weight gain than controls. Before deworming, there was a statistically significant (P less than 0.0005) decrease in triceps skinfold thickness in Ascaris-infected children versus controls. After deworming, skinfold increased significantly (P less than 0.0005) in previously infected children versus controls. Multiple regression analysis showed that Ascaris infection was by far the most important variable of those studied explaining decrease in skinfold thickness before and increase after deworming. It appears that even light Ascaris infections might adversely influence nutritional status, and deworming might enhance growth.

Gallium-67 uptake by a malignant fibrous histiocytoma: case report.

Avid 67Ga-citrate uptake was observed in a malignant fibrous histiocytoma of the mediastinum. The realtionships of the tumor to the heart and liver was shown by 99mTc-sulfur colloid liver-spleen scanning and 99mTc-pertechnetate angiography performed in conjunction with a 67Ga-citrate whole-body scan. This is the first report of 67Ga-citrate uptake by this unusual tumor.

A simplified approach to radionuclide venography: concise communication.

A simplified method has been developed for performing radionuclide venography. The method makes use of the scintillation camera and a synchronized whole-body scanning bed. This technique permits a more integrated presentation of the data and is performed in conjunction with a standard ventilation-perfusion lung study. The total amount of 99mTc tracer injected is 2 mCi.

The influence of reproductive status on rural Kenyan women's time use.

To determine the effects that pregnancy and infant care have on Embu women's commercial, agricultural and household activities, time use patterns were studied for women at different stages of pregnancy and lactation. Time allocation data were collected from 169 households, visited at random intervals over a year, by use of the spot observations technique. Detailed reproductive data were collected monthly, and household socioeconomic data quarterly. Analyses of Embu women's time use by reproductive status reveal that the demands of pregnancy and lactation require women to decrease the amount of time spent on subsistence agriculture, commercial activities, housework, and tending animals; and to devote more time to resting, breastfeeding, and child care. Agricultural and economic activities are curtailed especially in the 3rd trimester of pregnancy and the 1st period of lactation. This data provide insight into how pregnancy and lactation require women to adjust their time allocation between reproductive and farm labor activities. This decrease in time spent on subsistence agriculture, commercial activities, and household work increases the risk of household economic insecurity during the woman's reproductive years.

Skull growth from birth to adulthood in Gilbertese on Betio.

The growth of the skull from birth till adulthood was studied among Gilbertese from Betio. With few exceptions the average head circumference was bigger in males than in females, but rarely at statistically significant levels. After the age of six months the mean head circumference of the Gilbertese fell almost invariably below the third percentile of a North American standard. The rate of growth of the skull in Gilbertese was also smaller than in North Americans, both absolutely and relative to the head circumference at birth. The possible role of early protein-energy malnutrition remained obscure.

Infant feeding practices among middle income urban Africans and Indians in Kenya.

PIP: A longitudinal study conducted in Nairobi focused on 70 Africans, 35 Indian vegetarians, and 20 Indian non-vegetarians revealed significant differences between these 3 groups in terms of the choice of milk, breastfeeding duration, age of introduction of other foods to the infant's diet, and the choice of weaning foods. African mothers tended to exclusively breastfeed their infants for longer durations than either of the 2 groups of Indian mothers. At 6 weeks, 42% of African mothers, 19% of Indian vegetarian mothers, and no Indian nonvegetarian mothers were exclusively breastfeeding. Bottle feeding was widespread in all 3 groups; however, African mothers showed a pattern of mixed feeding (at 12 weeks, 68% of African infants were being fed both breast and formula milk), while Indian mothers tended to replace breastfeeding with bottle feeding (at 12 weeks, 10% of the vegetarian mothers and 19% of the non-vegetarian mothers were following this regimen). Indian nonvegetarian mothers made extensive use of formula, while their vegetarian counterparts relied more on cow's milk. All 3 groups introduced foods earlier than the recommended 4-6 months. By 18 weeks, 98% of African infants, 86% of Indian vegetarian infants, and 89% of Indian nonvegetarian infants were receiving semi-solid or solid foods in addition to milk. In all 3 groups, cereals were the most commonly introduced 1st food, followed by fruits and pureed vegetables. The use of commercial cereals was extensive, with 97% of African mothers, 90% of Indian vegetarian mothers, and 82% of Indian nonvegetarian mothers feeding such preparations to their 6-week-old infants. As the children grew older, use of commercial cereals decreased. Despite the differences in feeding practices, the pattern of weight gain was parallel for infants from all 3 study groups. Moreover, the mean energy and protein intakes of all 3 groups were 80% or more of recommended allowances.^ieng

District focus: oral rehydration, primary health care and the scientist.

PIP: The discovery that a solution of salt and sugar is an excellent way to treat and prevent dehydration was an important advance in the primary health care field, as it was expected that mothers, even illiterate mothers, could easily learn to prepare the solution at home, thus preventing serious consequences of untreated diarrhea. In addition to the low price, an important quality of this simple solution is that it gives the mother a sense of responsibility and the knowledge that she herself can do much to alleviate the suffering of her children. Unfortunately, the pharmaceutical industry and chemists were quick to realize that big profits can be made from oral rehydration and to package ready-made solutions. Consequently, there has been a movement away from teaching the mother how to make a simple solution at home, using salt, sugar, and water. The responsibility for this situation needs to be shared by both the scientist and the health worker. Scientists seem to have some difficulty accepting the fact that simple can be good and better is not always best. By adding 1.5 grams of potassium chloride or 2.9 grams of trisodium citrate to improve the mixture, it becomes a medicine, which only can be given/prescribed/sold by health personnel or chemists. The improved formula is good in a clinic setting, but in terms of primary health care and self-help this is not the best approach. The solution is being put beyond the reach of the poor child, certainly in the rural areas of the developing world. All health workers should know how to prepare a salt-sugar solution and also should show mothers/parents/caretakers how to make it. If one is serious about primary health care and self-help, it is best to return to using sugar and salt.^ieng

Opinions about breastfeeding amongst middle-income African and Indian women in Nairobi.

PIP: Attitudes troward breastfeeding were assessed among 100 African and Asian women who attended the prenatal clinic of a private hospital in Nairobi, Kenya. The women were subjects in an ongoing nutrition study, but the present study was based only on their responses to 11 questions on breastfeeding. The investigators sought to identify factors which either encouraged or discouraged breastfeeding. The results were expected to be of use in developing strategies to reverse the current trend toward bottle feeding. The women delivered at the hospital and were interviewed shortly after discharge, either in their home or during a postpartum clinic visit. The subjects ranged in age from 16-35 years, and the majority were primaparous. Both the Asian and African women had similar educational backgrounds. Most of the Asian women were housewives, and most of the Africa women were employed as clerks or secretaries. At the time of discharge from the hospital, only 44% of the infants of the African women and only 13% of the infants born to the Asian women were being exclusively breastfed. 9% of the African mothers and 18% of rthe Asian women did not breastfeed at all. The remaining infants either received bottle feeds after each breastfeed or were given bottle feeds in place of breastfeeds at least once a day. Hospital routines unintentionally promoted bottle feeding, made it difficult for the women to establish breastfeeding, and may have given the women the impression that breastfeeding should be supplemented with bottle feeding. The women were separated from their infants, breastfeeding times were rigidly scheduled, the infants were bottle fed prior to the 1st breastfeeding, supplemental feeds were provided, and bottles were presented to the women each time their infants were brought to them. The women were poorly informed about the value of breastfeeding. Only 52% of the African women and 33% of the Asian women were aware that breast milk by itself provided infants with sufficient nutrition for the first 4-6 months. 40% of the African women and 64% of the Asian women agreed that breastfeeding was better for the infant but that it also entailed a sacrifice on the part of the part of the mother. Most of the Asian women said that breastfeeding required privacy even when performed at home. African women were less concerned about privacy. The findings suggest that 1) expectant mothers need to be provicded with more information about breastfeeding, 2) mothers need more assistance in establishing breastfeeding and encouragement to continue breastfeeding, and 3) hospital routine need to be modified to create an environment conducive to breastfeeding.^ieng

Some nutritional aspects of pregnancy in rural Kenya.

PIP: In January 1978 a longitudinal study of pregnant women was begun in rural Machakos, Kenya in order to assess the relationship between food intake and nutritional status during pregnancy; outcome of pregnancy; lactation performance; and growth of the child during the first 2-3 years of life. Of a potential 1000 pregnancies, 881 women were seen at least once, and 97 women were examined 3 times. The weight gain during pregnancy was compared with that of middle and middle upper class urban pregnant women. The mean height of Machakos women was 156.4 cm and of the urban women 156.9 cm. Average weight gain during the second 1/2 of the pregnancy was 1.9 kg in rural, and 1.6 kg in urban women, as compared with 2.9 kg of a calculated standard. The average weight gain from 3.8 months until the end of pregnancy was 3.2 kg for rural women; according to the standard, this should have been 6.6 kg. Total weight gain during pregnancy of rural women is about 6.4 kg (12.3%) of pregravid weight; urban women gained 7.9 kg or 13.1% of their pregaravid weight. In spite of the low weight gain, the incidence of low birth weight was only 6.5%. The average newborn (rural) weighed 3190 g and the average urban newborn weighed 3266 g.^ieng

Feeding pattern, supplementary foods and growth of low birthweight and normal birthweight infants in Machakos, Kenya.

PIP: Feeding pattern, food consumption, and growth in weight were assessed for 168 low-birthweight and 187 normal birthweight infants in Machakos district, Kenya, an agricultural region 80 km East of Nairobi, between September 1977-December 1980. Birthweight was defined as the weight taken within 48 hours after birth, and the old WHO cutoff point of 2500 g or less was used to define low birthweight. It was planned to measure the infant's weight and food intake at 6-week inttervals during the 1st year; however, the number of measurements per infant ranged from 1 to 9. No differences were found in the breastfeeding pattern or the type of supplementary foods given to low birth weight (LBW) and normal birth weight (NBW) infants. At 6 weeks, 60% of the infants were exclusively breastfed. The number decreased over time, but only 1.7% were completely weaned before 52 weeks. At 5-6 months, and 10-12 months the energy intake from supplementary foods was 225 and 450 kcal (950 and 1900 kJ) respectively; at the same ages daily protein intake was 9 and 14 g respectively. Yet both groups followed their own growth channel, maintaining the difference in weight observed at birth. It is assumed, therefore, that LBW infants had a lower breast milk intake than NBW infants, as yield is influenced by vigor of suckeling and the nutritional status of the mother. No data is available for breast milk intake. However, in Machakos, LBW does carry a high mortality risk.^ieng

Vitamin A status of pregnant and lactating women as assessed by serum levels in Machakos area, Kenya.

PIP: In a sample of 100 pregnant and 106 lactating women, the serum levels of vitamin A, carotene, retinol-binding protein (RBP), and pre-albumin (PA) were analyzed. The study was in response to the problem of inadequate hepatic reserves and serum vitamin A levels of newborns. On the presumption that these levels are related to the Vitamin A status of mothers during pregnancy, and the Vitamin A content of breast milk during lactation, attention was given to the Vitamin A status of pregnant and lactating women in studies of maternal and child nutrition in Machakos. The women were selected at random from the total population of pregnant and lactating women with infants of 0-12 months. Blood was taken before the midday meal, centrifuged, and sera were deep frozen. Mean serum levels of the 4 biochemical parameters of vitamin A status were in the range for well-nourished population groups. Correlations of r=0.76-0.85 were found between RBP and PA, but between Vitamin A and RBP the correlation was r=0.32-0.40. Some seasonal variations reflected crop availability. A review of very little available literature shows that Vitamin A status of lactating women in Ethiopia is poorer among less privileged women. Dietary intake of retinol equivalents in West African countries being adequate, reported serum levels in these countries are also generally adequate. Xerophthalmia among young children in Machakos is rare, with the possible explanation that seasonal intake of carotene-rich foods is enough to replenish liver stores, and protein status (RBP and PA serum levels) is adequate as well.^ieng

Trauma of the ureter.

Thirty-three ureteric injuries were treated over a 2-year period. The majority of patients presented late. The most common modes of repair were either ureteroneocystostomy or transuretero-ureterostomy. Complications were few and of little significance.