Supporting active engagement of adults with intellectual disabilities in lifestyle modification interventions: a realist evidence synthesis of what works, for whom, in what context and why.

BACKGROUND: Lifestyle modification interventions for adults with intellectual disabilities have had, to date, mixed effectiveness. This study aimed to understand how lifestyle modification interventions for adults with intellectual disabilities work, for whom they work and in what circumstances. METHODS: A realist evidence synthesis was conducted that incorporated input from adults with intellectual disabilities and expert researchers. Following the development of an initial programme theory based on key literature and input from people with lived experience and academics working in this field, five major databases (MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA) and clinical trial repositories were systematically searched. Data from 79 studies were synthesised to develop context, mechanism and outcome configurations (CMOCs). RESULTS: The contexts and mechanisms identified related to the ability of adults with intellectual disabilities to actively take part in the intervention, which in turn contributes to what works, for whom and in what circumstances. The included CMOCs related to support involvement, negotiating the balance between autonomy and behaviour change, fostering social connectedness and fun, accessibility and suitability of intervention strategies and delivery and broader behavioural pathways to lifestyle change. It is also essential to work with people with lived experiences when developing and evaluating interventions. CONCLUSIONS: Future lifestyle interventions research should be participatory in nature, and accessible data collection methods should also be explored as a way of including people with severe and profound intellectual disabilities in research. More emphasis should be given to the broader benefits of lifestyle change, such as opportunities for social interaction and connectedness.

Lifestyle modification interventions for adults with intellectual disabilities: systematic review and meta-analysis at intervention and component levels.

BACKGROUND: Adults with intellectual disabilities (IDs) are susceptible to multiple health risk behaviours such as alcohol consumption, smoking, low physical activity, sedentary behaviour and poor diet. Lifestyle modification interventions can prevent or reduce negative health consequences caused by these behaviours. We aim to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with IDs. METHODS: A systematic review and meta-analysis were conducted. Electronic databases, clinical trial registries, grey literature and citations of systematic reviews and included studies were searched in January 2021 (updated February 2022). Randomised controlled trials and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity, sedentary behaviours and poor diet in adults (aged ≥ 18 years) with ID were included. Meta-analysis was conducted at the intervention level (pairwise and network meta-analysis) and the component-level (component network meta-analysis). Studies were coded using Michie's 19-item theory coding scheme and 94-item behaviour change taxonomies. Risk of bias was assessed using the Cochrane Risk of Bias (ROB) Version 2 and Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I). The study involved a patient and public involvement (PPI) group, including people with lived experience, who contributed extensively by shaping the methodology, providing valuable insights in interpreting results and organising of dissemination events. RESULTS: Our literature search identified 12 180 articles, of which 80 studies with 4805 participants were included in the review. The complexity of lifestyle modification intervention was dismantled by identifying six core components that influenced outcomes. Interventions targeting single or multiple health risk behaviours could have a single or combination of multiple core-components. Interventions (2 RCTS; 4 non-RCTs; 228 participants) targeting alcohol consumption and smoking behaviour were effective but based on limited evidence. Similarly, interventions targeting low physical activity only (16 RCTs; 17 non-RCTs; 1413 participants) or multiple behaviours (low physical activity only, sedentary behaviours and poor diet) (17 RCTs; 24 non-RCTs; 3164 participants) yielded mixed effectiveness in outcomes. Most interventions targeting low physical activity only or multiple behaviours generated positive effects on various outcomes while some interventions led to no change or worsened outcomes, which could be attributed to the presence of a single core-component or a combination of similar core components in interventions. The intervention-level meta-analysis for weight management outcomes showed that none of the interventions were associated with a statistically significant change in outcomes when compared with treatment-as-usual and each other. Interventions with core-components combination of energy deficit diet, aerobic exercise and behaviour change techniques showed the highest weight loss [mean difference (MD) = -3.61, 95% credible interval (CrI) -9.68 to 1.95] and those with core-components combination dietary advice and aerobic exercise showed a weight gain (MD 0.94, 95% CrI -3.93 to 4.91). Similar findings were found with the component network meta-analysis for which additional components were identified. Most studies had a high and moderate risk of bias. Various theories and behaviour change techniques were used in intervention development and adaptation. CONCLUSION: Our systematic review is the first to comprehensively explore lifestyle modification interventions targeting a range of single and multiple health risk behaviours in adults with ID, co-produced with people with lived experience. It has practical implications for future research as it highlights the importance of mixed-methods research in understanding lifestyle modification interventions and the need for population-specific improvements in the field (e.g., tailored interventions, development of evaluation instruments or tools, use of rigorous research methodologies and comprehensive reporting frameworks). Wide dissemination of related knowledge and the involvement of PPI groups, including people with lived experience, will help future researchers design interventions that consider the unique needs, desires and abilities of people with ID.

An app with brief behavioural support to promote physical activity after a cancer diagnosis (APPROACH): study protocol for a pilot randomised controlled trial.

BACKGROUND: There are multiple health benefits from participating in physical activity after a cancer diagnosis, but many people living with and beyond cancer (LWBC) are not meeting physical activity guidelines. App-based interventions offer a promising platform for intervention delivery. This trial aims to pilot a theory-driven, app-based intervention that promotes brisk walking among people living with and beyond cancer. The primary aim is to investigate the feasibility and acceptability of study procedures before conducting a larger randomised controlled trial (RCT). METHODS: This is an individually randomised, two-armed pilot RCT. Patients with localised or metastatic breast, prostate, or colorectal cancer, who are aged 16 years or over, will be recruited from a single hospital site in South Yorkshire in the UK. The intervention includes an app designed to encourage brisk walking (Active 10) supplemented with habit-based behavioural support in the form of two brief telephone/video calls, an information leaflet, and walking planners. The primary outcomes will be feasibility and acceptability of the study procedures. Demographic and medical characteristics will be collected at baseline, through self-report and hospital records. Secondary outcomes for the pilot (assessed at 0 and 3 months) will be accelerometer measured and self-reported physical activity, body mass index (BMI) and waist circumference, and patient-reported outcomes of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, and habit strength for walking. Qualitative interviews will explore experiences of participating or reasons for declining to participate. Parameters for the intended primary outcome measure (accelerometer measured average daily minutes of brisk walking (≥ 100 steps/min)) will inform a sample size calculation for the future RCT and a preliminary economic evaluation will be conducted. DISCUSSION: This pilot study will inform the design of a larger RCT to investigate the efficacy and cost-effectiveness of this intervention in people LWBC. TRIAL REGISTRATION: ISRCTN registry, ISRCTN18063498 . Registered 16 April 2021.

The effect of messaging on the acceptance of swaps to reduce the energy content of snacks and non-alcoholic drinks ordered in an experimental online workplace canteen: A randomised controlled trial.

Finding effective ways to increase acceptance of lower-energy swaps offered for snacks and non-alcoholic drinks may reduce population energy intake. We examined whether incrementally increasing the tangibility of information accompanying swaps offered increased their acceptance. UK adults (n = 3481) selected a sweet snack, a savoury snack, and a drink in an experimental online canteen after being equally randomised to receive one of four messages when swaps were offered; a control message providing no specific information, a vague calorie message, an exact numeric-calories message or, a physical activity calorie equivalent (PACE). Primary outcomes were the between-group differences in (i) the odds that a sweet, savoury, or drink swap would be accepted and (ii) the energy content for each type of item ordered. Compared with control, the numeric-calories and PACE messages significantly increased the odds of accepting a sweet snack swap. All interventions significantly increased the odds of accepting savoury swaps compared with control. Only the PACE message significantly increased the odds of drink swap acceptance. The numeric-calories and PACE messages significantly reduced the energy content of sweet snacks. All interventions significantly reduced the energy content of savoury snacks. None of the intervention messages significantly reduced the energy content of drinks compared with control. Increasing the tangibility of information provided when offering swaps increased swap acceptance. PACE messaging was the most promising.

Prenatally diagnosed congenital diaphragmatic hernia: optimal mode of delivery?

OBJECTIVE: To evaluate if the delivery mode of infants with prenatally diagnosed congenital diaphragmatic hernia (CDH) affects the outcome. STUDY DESIGN: Data from the CDH Study Group database of infants with prenatal diagnosis between 2001-2015 were divided into four delivery mode groups: vaginal spontaneous, vaginal induced, elective caesarean section, and emergent caesarean section. Outcomes were analyzed in relation to the time of day of delivery and the gestational age at birth. RESULTS: A total of 3906 cases of prenatally diagnosed CDH were assessed, with an overall survival of 64%. There were no differences in patient characteristics, requirement for extracorporeal membrane oxygenation, length of hospital stay or intubation, requirement for O2 at 30 days or overall survival. The time of day at birth did not affect the outcome. There was no difference in outcome between the different delivery modes at similar gestational age (GA) at birth, with worse outcomes at lower GA. CONCLUSIONS: Neither the mode nor time of delivery seems to affect the overall outcome for patients with prenatally diagnosed CDH. Outcome is strongly associated with the GA at birth.

Quantification of maceration changes using post mortem MRI in fetuses.

BACKGROUND: Post mortem imaging is playing an increasingly important role in perinatal autopsy, and correct interpretation of imaging changes is paramount. This is particularly important following intra-uterine fetal death, where there may be fetal maceration. The aim of this study was to investigate whether any changes seen on a whole body fetal post mortem magnetic resonance imaging (PMMR) correspond to maceration at conventional autopsy. METHODS: We performed pre-autopsy PMMR in 75 fetuses using a 1.5 Tesla Siemens Avanto MR scanner (Erlangen, Germany). PMMR images were reported blinded to the clinical history and autopsy data using a numerical severity scale (0 = no maceration changes to 2 = severe maceration changes) for 6 different visceral organs (total 12). The degree of maceration at autopsy was categorized according to severity on a numerical scale (1 = no maceration to 4 = severe maceration). We also generated quantitative maps to measure the liver and lung T2. RESULTS: The mean PMMR maceration score correlated well with the autopsy maceration score (R(2) = 0.93). A PMMR score of ≥4.5 had a sensitivity of 91%, specificity of 64%, for detecting moderate or severe maceration at autopsy. Liver and lung T2 were increased in fetuses with maceration scores of 3-4 in comparison to those with 1-2 (liver p = 0.03, lung p = 0.02). CONCLUSIONS: There was a good correlation between PMMR maceration score and the extent of maceration seen at conventional autopsy. This score may be useful in interpretation of fetal PMMR.

Diagnostic accuracy and limitations of post-mortem MRI for neurological abnormalities in fetuses and children.

AIM: To compare the diagnostic accuracy of non-invasive cerebral post-mortem magnetic resonance imaging (PMMRI) specifically for cerebral and neurological abnormalities in a series of fetuses and children, compared to conventional autopsy. MATERIALS AND METHODS: Institutional ethics approval and parental consent was obtained. Pre-autopsy cerebral PMMRI was performed in a sequential prospective cohort (n = 400) of fetuses (n = 277; 185 ≤ 24 weeks and 92 > 24 weeks gestation) and children <16 years (n = 123) of age. PMMRI and conventional autopsy findings were reported blinded and independently of each other. RESULTS: Cerebral PMMRI had sensitivities and specificities (95% confidence interval) of 88.4% (75.5 to 94.9), and 95.2% (92.1 to 97.1), respectively, for cerebral malformations; 100% (83.9 to 100), and 99.1% (97.2 to 99.7) for major intracranial bleeds; and 87.5% (80.1 to 92.4) and 74.1% (68 to 79.4) for overall brain pathology. Formal neuropathological examination was non-diagnostic due to maceration/autolysis in 43/277 (16%) fetuses; of these, cerebral PMMRI imaging provided clinically important information in 23 (53%). The sensitivity of PMMRI for detecting significant ante-mortem ischaemic injury was only 68% (48.4 to 82.8) overall. CONCLUSIONS: PMMRI is an accurate investigational technique for identifying significant neuropathology in fetuses and children, and may provide important information even in cases where autolysis prevents formal neuropathological examination; however, PMMRI is less sensitive at detecting hypoxic-ischaemic brain injury, and may not detect rarer disorders not encountered in this study.

Does a higher frequency of difficult patient encounters lead to lower quality care?

BACKGROUND: Difficult patient encounters in the primary care office are frequent and are associated with physician burnout. However, their relationship to patient care outcomes is not known. OBJECTIVE: To determine the effect of difficult encounters on patient health outcomes and the role of physician dissatisfaction and burnout as mediators of this effect. DESIGN: A total of 422 physicians were sorted into 3 clusters based on perceived frequency of difficult patient encounters in their practices. Patient charts were audited to assess the quality of hypertension and diabetes management and preventive care based on national guidelines. Summary measures of quality and errors were compared among the 3 physician clusters. RESULTS: Of the 1384 patients, 359 were cared for by high-cluster physicians (those who had a high frequency of difficult encounters), 871 by medium-cluster physicians, and 154 by low-cluster physicians. Dissatisfaction and burnout were higher among physicians reporting higher frequencies of difficult encounters. However, quality of patient care and management errors were similar across all 3 groups. CONCLUSIONS: Physician perception of frequent difficult encounters was not associated with worse patient care quality or more medical errors. Future studies should investigate whether other patient outcomes, including acute care and patient satisfaction, are affected by difficult encounters.

Does a highest pre-ductal O(2) saturation <85% predict non-survival for congenital diaphragmatic hernia?

OBJECTIVE: To analyze operative repair, extracorporeal membrane oxygenation (ECMO) and survival rates based on highest pre-ductal oxygen saturation (Pre-O(2)SAT) in a large infant cohort reported to Congenital Diaphragmatic Hernia Study Group Registry between 2000 and 2010. STUDY DESIGN: Analyzed data included gestational age, birth weight, defect side and size, repair, ECMO use, survival and highest reported PaO(2) and Pre-O(2)SAT in first 24 h of life. We excluded 614 infants due to severe anomaly. Pre-O(2)SAT data were available for 1672 infants. RESULT: Among infants with highest Pre-O(2)SAT value <85%, survival (24/105=23%) and repair (55/105=52%) rates were significantly decreased compared with infants with higher values. Survival increased to 44% for infants with highest Pre-O(2)SAT<85% who underwent operative repair. Of these, 83% (20/24) required ECMO support compared with 15% (144/961) of survivors with Pre-O(2)SAT>99% (P<0.001). The lowest reported Pre-O(2)SAT with survival was 32% and for survival without ECMO was 52%. CONCLUSION: A reported highest Pre-O(2)SAT<85% in the first 24 h of life was not uniformly fatal; but survival of infants with Pre-O(2)SAT<85% was associated with high ECMO use and prolonged hospitalization.

Healthy habits: efficacy of simple advice on weight control based on a habit-formation model.

OBJECTIVE: To evaluate the efficacy of a simple weight loss intervention, based on principles of habit formation. DESIGN: An exploratory trial in which overweight and obese adults were randomized either to a habit-based intervention condition (with two subgroups given weekly vs monthly weighing; n=33, n=36) or to a waiting-list control condition (n=35) over 8 weeks. Intervention participants were followed up for 8 months. PARTICIPANTS: A total of 104 adults (35 men, 69 women) with an average BMI of 30.9 kg m(-2). INTERVENTION: Intervention participants were given a leaflet containing advice on habit formation and simple recommendations for eating and activity behaviours promoting negative energy balance, together with a self-monitoring checklist. MAIN OUTCOME MEASURES: Weight change over 8 weeks in the intervention condition compared with the control condition and weight loss maintenance over 32 weeks in the intervention condition. RESULTS: At 8 weeks, people in the intervention condition had lost significantly more weight (mean=2.0 kg) than those in the control condition (0.4 kg), with no difference between weekly and monthly weighing subgroups. At 32 weeks, those who remained in the study had lost an average of 3.8 kg, with 54% losing 5% or more of their body weight. An intention-to-treat analysis (based on last-observation-carried-forward) reduced this to 2.6 kg, with 26% achieving a 5% weight loss. CONCLUSIONS: This easily disseminable, low-cost, simple intervention produced clinically significant weight loss. In limited resource settings it has potential as a tool for obesity management.

Evaluation of a lead screening program in Houston, Tex.

Universal screening for childhood lead poisoning is widely debated. Our purpose was to compare screening results at three pediatric clinics within Houston and to evaluate the effectiveness of screening according to published criteria. The clinics were chosen for their geographic and socioeconomic diversity. Children between 6 months and 6 years of age were tested, and the results were classified according to current guidelines. We screened 864 children. Results between sites were significantly different, P = 0.002. No children with blood lead levels greater than 0.45 mumol/L (9 micrograms/dL) were identified at Clinic C compared to 76 (8.8%) from Clinics A and B, but no site had children with levels greater than or equal to 2.20 mumol/L (45 micrograms/dL). The prevalence of childhood lead poisoning can vary even within the city. If regional screening is to replace universal screening, statewide as well as citywide data are needed to identify high-risk areas. This could be done by clinic site, zip code, or census track data with a minimum of 3000 children.

Neonatal pain management.

Neonatal pain management is a challenge for the clinician. Research is just beginning to uncover the neonates' capability of expression of pain, explore pharmacologic management strategies, and identify the spectrum of intrusions that may precipitate pain or distress in the critically ill neonate. This article reviews the neonatal biologic, behavioral, and physiologic responses to pain and describes recommendations for clinical management and decision-making.

The new challenges of physical therapy for external fixation treatment of fractures*.

External fixation, the restoration of skeletal integrity using pins connected by an external support, had its birth in the mid- 1800's. Recent improvements have caused a resurgence of interest in this art when dealing with complicated fractures. The health team is involved in enhancing the benefits gained from this method of fracture management. The physical therapist works in conjunction with the orthopaedic surgeon to achieve maximal rehabilitation of the injured limb. Rehabilitation includes functional training and education concerning limitations and daily care of the patient apparatus. J Orthop Sports Phys Ther 1981;2(4):171-176.