Tackling increased risks in older adults with intellectual disability and epilepsy: Data from a national multicentre cohort study.

PURPOSE: People with intellectual disabilities (ID) suffer multimorbidity, polypharmacy and excess mortality at a younger age than general population. Those with ID and epilepsy are at higher risk of worse clinical outcomes than their peers without epilepsy. In the ID population the health profile of those aged ≥40 years can be compared to those aged over 65 in the general population. To date there is limited data available to identify clinical characteristics and risk factors in older adults (≥40 years) with ID and epilepsy. METHODS: The Epilepsy in ID National Audit (Epi-IDNA) identified 904 patients with ID and epilepsy from 10 sites in England and Wales. This subsequent analysis of the Epi-IDNA cohort compared the 405 adults over 40 years with 499 adults ≥18 years aged under 40 years. Comparison was made between clinical characteristics and established risk factors using the Sudden Unexpected Death in Epilepsy (SUDEP) and Seizure Safety Checklist. RESULTS: The older adults' cohort had significantly higher levels of co-morbid physical health conditions, mental health conditions, anti-seizure medications (median 5), and antipsychotics compared to the younger cohort. The older group were significantly less likely to be diagnosed with a co-morbid neurodevelopmental disorder, and to have an epilepsy care plan. CONCLUSION: This is the largest study to date focused on adults with ID and epilepsy over 40 years. The ≥40 years cohort compared to the younger group has higher levels of clinical risk factors associated with multi-morbidity, potential iatrogenic harm and premature mortality with worse clinical oversight mechanisms.

Multivalent weak interactions enhance selectivity of interparticle binding.

Targeted drug delivery critically depends on the binding selectivity of cargo-transporting colloidal particles. Extensive theoretical work has shown that two factors are necessary to achieve high selectivity for a threshold receptor density: multivalency and weak interactions. Here, we study a model system of DNA-coated particles with multivalent and weak interactions that mimics ligand-receptor interactions between particles and cells. Using an optomagnetic cluster experiment, particle aggregation rates are measured as a function of ligand and receptor densities. The measured aggregation rates show that the binding becomes more selective for shorter DNA ligand-receptor pairs, proving that multivalent weak interactions lead to enhanced selectivity in interparticle binding. Simulations confirm the experimental findings and show the role of ligand-receptor dissociation in the selectivity of the weak multivalent binding.

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.

Inter-particle biomolecular reactivity tuned by surface crowders.

The rate at which colloidal particles can form biomolecular bonds controls the kinetics of applications such as particle-based biosensing, targeted drug delivery and directed colloidal assembly. Here we study how the reactivity of the particle surface depends on its molecular composition, quantified by the inter-particle rate of aggregation in an optomagnetic cluster experiment. Particles were functionalized with DNA or with proteins for specific binding, and with polyethylene glycol as a passive surface crowder. The data show that the inter-particle binding kinetics are dominated by specific interactions, which surprisingly can be tuned by the passive crowder molecules for both the DNA and the protein system. The experimental results are interpreted using model simulations, which show that the crowder-induced decrease of the particle surface reactivity can be described as a reduced reactivity of the specific binder molecules on the particle surface.

Single-Dimer Formation Rate Reveals Heterogeneous Particle Surface Reactivity.

Biofunctionalized micro- and nanoparticles are important for a wide range of applications, but methodologies to measure, modulate, and model interactions between individual particles are scarce. Here, we describe a technique to measure the aggregation rate of two particles to a single dimer, by recording the trajectory that a particle follows on the surface of another particle as a function of time. The trajectory and the interparticle potential are controlled by a magnetic field. Particles were studied with and without conjugated antibodies in a wide range of pH conditions. The data shows that the aggregation process strongly depends on the particle surface charge density and hardly on the antibody surface coverage. Furthermore, microscopy videos of single particle dimers reveal the presence of reactive patches and thus heterogeneity in the particle surface reactivity. The aggregation rates measured with the single-dimer experiment are compared to data from an ensemble aggregation experiment. Quantitative agreement is obtained using a model that includes the influence of surface heterogeneity on particle aggregation. This single-dimer experiment clarifies how heterogeneities in particle reactivity play a role in colloidal stability.

Rate of Dimer Formation in Stable Colloidal Solutions Quantified Using an Attractive Interparticle Force.

We describe an optomagnetic cluster experiment to understand and control the interactions between particles over a wide range of time scales. Aggregation is studied by magnetically attracting particles into dimers and by quantifying the number of dimers that become chemically bound within a certain time interval. An optomagnetic readout based on light scattering of rotating clusters is used to measure dimer formation rates. Magnetic field settings, that is, field rotation frequency, field amplitude, and on- and off-times, have been optimized to independently measure both the magnetically induced dimers and chemically bound dimers. The chemical aggregation rate is quantified in solutions with different pH and ionic strengths. The measured rates are extrapolated to effective dimer formation rates in the absence of force, showing that aggregation rates can be quantified over several orders of magnitude, including conditions of very low chemical reactivity.

Consensus guidelines into the management of epilepsy in adults with an intellectual disability.

BACKGROUND: Epilepsy has a pervasive impact on the lives of people with intellectual disability and their carers. The delivery of high-quality care is impacted on by the complexity and diversity of epilepsy in this population. This article presents the results of a consensus clinical guideline process. RESULTS: A Delphi process identified a list of priority areas for the development of evidence-based guidelines. All guidelines were graded and consensus on scoring was achieved across the guideline group. CONCLUSION: There is a dearth of high-quality evidence from well-constructed studies on which to base guidance. However, the development of internationally derived consensus guidelines may further support the management of epilepsy in adults with an intellectual disability.

[Bluetongue in The Netherlands; description of the first clinical cases and differential diagnosis. Common symptoms just a little different and in too many herds]. / Bluetongue voor het eerst in Nederland: beschrijving van de klinische verschijnselen en differentiaaldiagnose.

For the first time Bluetongue (BT) has been diagnosed in the Netherlands. The clinical symptoms of BT on five farms during the first outbreak ever in the Netherlands are described. Fever and swollen sensitive coronets leading to reluctance to stand and walk were sometimes the first symptoms. Later lesions in the mouth occurred with foamy salivation and respiratory problems. In other cases a swollen head with swollen lips and foamy salivation were the first clinical signs. Also sudden death occurred. In the first sixteen confirmed cases morbidity and mortality were lower than described in outbreaks in other countries. Good collaboration between practitioners, specialists of the Animal Health Service (GD-Deventer), and specialists of the Food and Consumer Product Safety Authority (VWA) and CIDC-Lelystad (Wageningen UR) led to a rapid notification and ultimately confirmation of the suspected diagnosis BT.

Helicobacter pylori: has the killer escaped from the institution? A possible cause of increased stomach cancer in a population with intellectual disability.

Advancing knowledge of the existence of Helicobacter pylori and its association with gastrointestinal tract malignancy, and previous research showing higher-than-expected gastrointestinal tract malignancy in institutionalized adults with intellectual disability (ID) prompted a review of all deaths as a result of cancer in the Stoke Park group of hospitals for people with ID between 1946 and 1996. A 50-year, retrospective case note analysis of all deaths from cancer in an institution for people with ID was undertaken. Death from stomach cancer accounted for up to 48% of all cancer deaths. A further 25 residents had died of perforated stomach ulcers. The higher proportion of deaths specifically caused by stomach cancer in a population with ID has not been noted previously. It is postulated that the high levels of H. pylori infection found in institutionalized populations may be instrumental in this higher mortality rate and that the closure of the institutions without evaluation of H. pylori status transfers the problem unresolved to the community. Existing guidelines for the screening and eradication of H. pylori developed for the general population are inadequate when applied to people with ID, and therefore, the value of population screening and mass eradication programmes is explored.

Helicobacter pylori and the learning disabled.

Those with a learning disability previously cared for in institutions have now been discharged into smaller community homes. This has meant that an increased burden has been placed on general practitioners (GPs) to evaluate and treat those who have symptoms that may be difficult to interpret. This report presents the prevalence of Helicobacter pylori in those still awaiting discharge and discusses the possible symptoms that GPs may encounter.

Is intranasal midazolam an effective rescue medication in adolescents and adults with severe epilepsy?

The aim of this study was to determine whether intranasal midazolam is a safe and effective rescue medication in adolescent and adult patients with severe epilepsy. This field trial was designed to test the feasibility of the use of intranasal midazolam as an alternative to rectal diazepam in a cohort of patients with severe epilepsy who require rescue medication as part of their treatment. A dose of intranasal midazolam (5 mg if the patient weighed less than 50 kg and 10 mg if the patient weighed over 50 kilograms) was prescribed for those who had previously responded to other rescue medication. Midazolam was prescribed buccally if excessive head movement accompanied seizures. The protocol reverted to the usual rescue medication if there was no response to midazolam within 10 minutes. Vital signs were monitored for half an hour following the administration of the treatment. Twenty-two patients received 84 treatment episodes and 79 of these were considered clinically effective. Five treatment failures were recorded, three due to poor technique in delivering the midazolam. Two patients were successfully retried on midazolam and a third is awaiting a retrial of this drug. The two other treatment failures received the drug buccally. In the first patient the clinical opinion was that this was possibly a psychogenic non-epileptic seizure. The other patient responded initially, but within an hour had another seizure requiring further rescue treatment. No significant adverse effects were reported. Our study shows that intranasal midazolam, when used appropriately, is an effective treatment in those who require rescue treatment. There are clear advantages in the use of midazolam over diazepam in the treatment of acute seizures. These include the favourable pharmacokinetic and pharmacodynamic properties of midazolam as well as the potential of a more acceptable and dignified administration route.

Midazolam via the intranasal route: an effective rescue medication for severe epilepsy in adults with learning disability.

People with a learning disability are often disadvantaged due to the nature of their disability. Up to a third are likely to have concomitant epilepsy which adds to the health loss experienced by this group. It is important to manage their epilepsy in such a way as to limit the debilitating effects of both the illness and the medication. Rectal diazepam remains the gold standard rescue medication for prolonged, recurrent seizures or seizures associated with hypoxia. Some of the drawbacks are highlighted in this paper and we go on to explore a novel means of treating these seizures. Midazolam, via the intranasal route, has been used extensively in children, mostly as a sedative but also in the treatment of epilepsy. We present two cases, both are adults with a learning disability, who have benefited significantly from the use of intranasal midazolam. Ongoing research into the safe use of this form of treatment, training of staff and carers and the impact on the individual is being conducted.

Comparison of clinical examination, current and vibratory perception threshold in diabetic polyneuropathy.

The study of diabetic polyneuropathy is complicated by a lack of clear definitions and the absence of a simple reliable test procedure. Recently, a new sensory perception testing device has been introduced for detection of thresholds for electrical stimuli (current perception: CPT) at different frequencies (Neurometer). We compared standardized clinical examination scores with measurements of vibratory perception threshold (VPT) and CPT (foot) and obtained reproducibility figures. Participants in the study were healthy controls (H, n = 33), diabetic patients without clinical signs of neuropathy (DN-, n = 23), diabetics with overt diabetic neuropathy (DN+, n = 22), and patients with a diabetes duration of over 20 years (D20, n = 38). As expected, there were highly significant differences (Wilcoxon) in CPT, VPT and neurological scores between H/DN- and DN+ (p < 0.001), but not between H and DN-. Correlation between CPT and total as well as partial (reflecting small and large fibre functions) neurological examination score were highest at 2000 Hz (r = 0.88); no advantage of lower frequency CPT could be identified. CPT seemed rather insensitive in detecting neuropathy. Correlations between CPT and VPT were only moderate and maximal at 2000 Hz (r = 0.61). Reproducibility of CPT was good at 2000 Hz (coefficient of variation 13.3-20.2%), but moderate to poor at lower frequencies (ranging to 62%). We conclude that CPT and VPT quantitative sensory testing is only of limited value, mainly because of high variability and poor reproducibility.