A study protocol for a pilot randomised trial of a structured education programme for the self-management of type 2 diabetes for adults with intellectual disabilities

BACKGROUND: The need for structured education programmes for type 2 diabetes is a high priority for many governments around the world. One such national education programme in the United Kingdom is the DESMOND Programme, which has been shown to be robust and effective for patients in general. However, these programmes are not generally targeted to people with intellectual disabilities (ID), and robust evidence on their effects for this population is lacking. We have adapted the DESMOND Programme for people with ID and type 2 diabetes to produce an amended programme known as DESMOND-ID. This protocol is for a pilot trial to determine whether a large-scale randomised trial is feasible, to test if DESMOND-ID is more effective than usual care in adults with ID for self-management of their type 2 diabetes, in particular as a means to reduce glycated haemoglobin (Hb1Ac), improve psychological wellbeing and quality of life and promote a healthier lifestyle. This protocol describes the rationale, methods, proposed analysis plan and organisational and administrative details.

METHODS/DESIGN: This trial is a two arm, individually randomised, pilot trial for adults with ID and type 2 diabetes, and their family and/or paid carers. It compares the DESMOND-ID programme with usual care. Approximately 36 adults with mild to moderate ID will be recruited from three countries in the United Kingdom. Family and/or paid carers may also participate in the study. Participants will be randomly assigned to one of two conditions using a secure computerised system with robust allocation concealment. A range of data will be collected from the adults with ID (biomedical, psychosocial and self-management strategies) and from their carers. Focus groups with all the participants will assess the acceptability of the intervention and the trial.

DISCUSSION: The lack of appropriate structured education programmes and educational materials for this population leads to secondary health conditions and may lead to premature deaths. There are significant benefits to be gained globally, if structured education programmes are adapted and shown to be successful for people with ID and other cognitive impairments.

TRIAL REGISTRATION: Registered with International Standard Randomised Controlled Trial (identifier: ISRCTN93185560 ) on 10 November 2014.

Individual factors and perceived community characteristics in relation to mental health and mental well-being

Background
It has been argued that though correlated with mental health, mental well-being is a distinct entity. Despite the wealth of literature on mental health, less is known about mental well-being. Mental health is something experienced by individuals, whereas mental well-being can be assessed at the population level. Accordingly it is important to differentiate the individual and population level factors (environmental and social) that could be associated with mental health and well-being, and as people living in deprived areas have a higher prevalence of poor mental health, these relationships should be compared across different levels of neighbourhood deprivation.

Methods
A cross-sectional representative random sample of 1,209 adults from 62 Super Output Areas (SOAs) in Belfast, Northern Ireland (Feb 2010 – Jan 2011) were recruited in the PARC Study. Interview-administered questionnaires recorded data on socio-demographic characteristics, health-related behaviours, individual social capital, self-rated health, mental health (SF-8) and mental well-being (WEMWBS). Multi-variable linear regression analyses, with inclusion of clustering by SOAs, were used to explore the associations between individual and perceived community characteristics and mental health and mental well-being, and to investigate how these associations differed by the level of neighbourhood deprivation.

Results
Thirty-eight and 30 % of variability in the measures of mental well-being and mental health, respectively, could be explained by individual factors and the perceived community characteristics. In the total sample and stratified by neighbourhood deprivation, age, marital status and self-rated health were associated with both mental health and well-being, with the ‘social connections’ and local area satisfaction elements of social capital also emerging as explanatory variables. An increase of +1 in EQ-5D-3 L was associated with +1SD of the population mean in both mental health and well-being. Similarly, a change from ‘very dissatisfied’ to ‘very satisfied’ for local area satisfaction would result in +8.75 for mental well-being, but only in the more affluent of areas.

Conclusions
Self-rated health was associated with both mental health and mental well-being. Of the individual social capital explanatory variables, ‘social connections’ was more important for mental well-being. Although similarities in the explanatory variables of mental health and mental well-being exist, socio-ecological interventions designed to improve them may not have equivalent impacts in rich and poor neighbourhoods.

Using particle dispersal models to assist in the conservation and recovery of the overexploited native oyster (Ostrea edulis) in an enclosed sea lough

Oyster populations around the world have seen catastrophic decline which has been largely attributed to overexploitation, disease and pollution. While considerable effort and resources have been implemented into restoring these important environmental engineers, the success of oyster populations is often limited by poor understanding of site-specific dispersal patterns of propagules. Water-borne transport is a key factor controlling or regulating the dispersal of the larval stage of benthic marine invertebrates which have limited mobility. The distribution of the native oyster Ostrea edulis in Strangford Lough, Northern Ireland, together with their densities and population structure at subtidal and intertidal sites has been documented at irregular intervals between 1997 and 2013. This paper revisits this historical data and considers whether different prevailing environmental conditions can be used to explain the distribution, densities and population structure of O. edulis in Strangford Lough. The approach adopted involved comparing predictive 2D hydrodynamic models coupled with particle tracking to simulate the dispersal of oyster larvae with historical and recent field records of the distribution of both subtidal and intertidal, populations since 1995. Results from the models support the hypothesis that commercial stocks of O. edulis introduced into Strangford Lough in the 1990s resulted in the re-establishment of wild populations of oysters in the Northern Basin which in turn provided a potential source of propagules for subtidal populations. These results highlight that strategic site selection (while inadvertent in the case of the introduced population in 1995) for the re-introduction of important shellfish species can significantly accelerate their recovery and restoration.

Antifungal Activity of LL-37 and Truncated Mimetics

Background: Candida albicans is a commensal organism and a constituent of the normal oral flora. Cell concentrations of 1x102 cells/ml and below are indicative of commensal colonisation in the oral cavity, above this level C. albicans can become an opportunistic pathogen; it is the most prevalent human fungal pathogen and a causal agent of the oral infection, candidiasis. The capacity of C. albicans to cause infection arises from its ability to exist in a biofilm ecosystem. Mature C. albicans biofilms display a high level of resistance to antifungals and the need for other therapeutic options has become paramount. Objectives: The objectives of the current study were to determine the antifungal activity of LL-37 (a member of the human cathelicidin family) and two truncated peptide mimetics against C. albicans in both planktonic and biofilm form. Methods: Radial diffusion assays were used to obtain the minimum inhibitory concentration (MIC) of LL-37 and the truncated mimetics KE-18 and KR-12 against planktonic C. albicans. A 96 well microtitre plate assay was employed to study the effects of the peptides on early candida biofilm formation (up to 24 hours) compared with the antifungal drug fluconazole. Biofilm quantification was achieved using the crystal violet assay. Results: MIC values obtained: LL-37 >250µg/ml; KE-18 51µg/ml; and KR-12 11µg/ml. LL-37 significantly reduced the quantity of biofilm formed by C.albicans at both the 4 h and 24 h timepoints (p <0.0001). KE-18 showed significant biofilm reduction over 4 h and 24 h (p=0.0002, p=0.013 respectively), KR-12 showed significant reduction at the 24 h time point only (p=0.0256). Conclusions: Results suggest that LL-37 has the ability to disrupt early biofilm formation of C. albicans with its potency of action similar with that of fluconazole.

The value of tests in the diagnosis and management of glaucoma.

PURPOSE:

To assess the noneconomic value of tests used in the diagnosis and management of glaucoma, and explore the contexts and factors that determine such value.

DESIGN:

Perspective.

METHODS:

Selected articles from primary and secondary sources were reviewed and interpreted in the context of the authors' clinical and research experience, influenced by our perspectives on the tasks of reducing the global problem of irreversible blindness caused by glaucoma. The value of any test used in glaucoma is addressed by 3 questions regarding: its contexts, its kind of value, and its implicit or explicit benefits.

RESULTS:

Tonometry, slit-lamp gonioscopy, and optic disc evaluation remain the foundation of clinic-based case finding, whether in areas of more or less abundant resources. In resource-poor areas, there is urgency in identifying patients at risk for severe functional loss of vision; screening strategies have proven ineffective, and efforts are hindered by the inadequate allocation of support. In resource-abundant areas, the wider spectrum of glaucoma is addressed, with emphasis on early detection of structural changes of little functional consequence; these are increasingly the focus of new and expensive technologies whose clinical value has not been established in longitudinal and population-based studies. These contrasting realities in part reflect differences among the value ascribed, often implicitly, to the tests used in glaucoma.

CONCLUSIONS:

The value of any test is determined by 3 aspects: its context of usage; its comparative worth and to whom its benefit accrues; and how we define historically what we are testing. These multiple factors

Parenthood and Open Adoption: an Interpretative Phenomenological Analysis

This book explores what it is like to be involved in contemporary open adoption, characterised by varying forms of contact with birth relatives, from an adoptive parent point of view.

The author’s fine-grained interpretative phenomenological analysis of adopters’ accounts reveals the complexity of kinship for those whose most significant relationships are made, unmade and permanently altered through adoption. MacDonald distinctively connects adoption to wider sociological theories of relatedness and personal life, and focuses on domestic non-kin adoption of children from state care, including compulsory adoption. The book also addresses current child welfare concerns, and suggestions are made for adoption practice. The book will be of interest to scholars and students with an interest in adoption, social work, child welfare, foster care, family and sociology.

Do Gifts Increase Consent to Home-based HIV Testing? A Difference-in-differences Study in Rural KwaZulu-Natal, South Africa

Background Despite the importance of HIV testing for controlling the HIV epidemic, testing rates remain low. Efforts to scale-up testing coverage and frequency in hard-to-reach and at-risk populations commonly focus on home-based HIV testing. This study evaluates the effect of a gift (a food voucher for families, worth US$ 5) on consent rates for home-based HIV testing.
Methods We use data on 18,478 men and women who participated in the 2009 and 2010 population-based HIV surveillance carried out by the Wellcome Trust Africa Centre for Health and Population Studies in rural KwaZulu-Natal, South Africa. Our quasi-experimental difference-in-differences approach controls for unobserved confounding in estimating the causal effect of the intervention on HIV testing consent rates.
Results Allocation of the gift to a family in 2010 increased the probability of family members consenting to test in 2010 by 25 percentage points (95% CI 21-30; p<0.001). The intervention effect persisted, slightly attenuated, in the year following the intervention (2011), further increasing intervention value for money.
Conclusions In HIV hyperendemic settings a gift can be highly effective at increasing consent rates for home-based HIV testing. Given the importance of HIV testing for treatment uptake and individual health, as well as for HIV treatment-and-prevention strategies and for monitoring the population impact of the HIV response, gifts should be considered as a supportive intervention for HIV testing initiatives where consent rates have been low.

Mismatches and matches in address information from the Census and the BSO: A longitudinal perspective 2001-2011

Accurate address information from health service providers is fundamental for the effective delivery of health care and population monitoring and screening. While it is currently used in the production of key statistics such as internal migration estimates, it will become even more important over time with the 2021 Census of UK constituent countries integrating administrative data to enhance the quality of statistical outputs. Therefore, it is beneficial to improve understanding of the accuracy of address information held by health service providers and factors that influence this. This paper builds upon previous research on the social geography of address mismatch between census and health service records in Northern Ireland. It is based on the Northern Ireland Longitudinal Study; this is a large data linkage study including about 28 per cent of the Northern Ireland population, which is matched between the census (2001, 2011) and Health Card Registration System maintained by the Health and Social Care Business Service Organisation (BSO). This research compares address information from the Spring 2011 BSO download (Unique Property Reference Number, Super Output Area) with comparable geographic information from the 2011 Census. Multivariate and multilevel analyses are used to assess the individual and ecological determinants of match/mismatch between geographical information in both data sources to determine if the characteristics of the associated people and places are the same as the position observed in 2001. It is important to understand if the same people are being inaccurately geographically referenced in both Census years or if the situation is more variable.

Genetic structure, relationships and admixture with wild relatives in native pig breeds from Iberia and its islands

Background: Native pig breeds in the Iberian Peninsula are broadly classified as belonging to either the Celtic or the Mediterranean breed groups, but there are other local populations that do not fit into any of these groups. Most of the native pig breeds in Iberia are in danger of extinction, and the assessment of their genetic diversity and population structure, relationships and possible admixture between breeds, and the appraisal of conservation alternatives are crucial to adopt appropriate management strategies. Methods: A panel of 24 microsatellite markers was used to genotype 844 animals representing the 17 most important native swine breeds and wild populations existing in Portugal and Spain and various statistical tools were applied to analyze the results. Results: Genetic diversity was high in the breeds studied, with an overall mean of 13.6 alleles per locus and an average expected heterozygosity of 0.80. Signs of genetic bottlenecks were observed in breeds with a small census size, and population substructure was present in some of the breeds with larger census sizes. Variability among breeds accounted for about 20% of the total genetic diversity, and was explained mostly by differences among the Celtic, Mediterranean and Basque breed groups, rather than by differences between domestic and wild pigs. Breeds clustered closely according to group, and proximity was detected between wild pigs and the Mediterranean cluster of breeds. Most breeds had their own structure and identity, with very little evidence of admixture, except for the Retinto and Entrepelado varieties of the Mediterranean group, which are very similar. Genetic influence of the identified breed clusters extends beyond the specific geographical areas across borders throughout the Iberian Peninsula, with a very sharp transition from one breed group to another. Analysis of conservation priorities confirms that the ranking of a breed for conservation depends on the emphasis placed on its contribution to the betweenand within-breed components of genetic diversity. Conclusions: Native pig breeds in Iberia reveal high levels of genetic diversity, a solid breed structure and a clear organization in well-defined clusters.

Exploring the links between urban stucture and air quality

A poluição atmosférica constitui actualmente um grave problema ambiental cujos efeitos se fazem sentir a diversas escalas, desde os efeitos imediatos e de longo termo na saúde humana e nos materiais, até fenómenos regionais, como a acificação, e fenómenos globais que durante este século poderão alterar as condições de vida no globo. Apesar da redução das emissões de poluentes atmosféricos, conseguida através do uso de combustíveis mais limpos e tecnologias mais eficientes, as áreas urbanas continuam a evidenciar sinais de degradação ambiental. Para ser bem sucedida a cidade deve enfrentar as três dimensões da sustentabilidade: social, económica e ambiental. O modo de utilização do solo numa zona urbana é uma característica fundamental da cidade, com influência directa no seu desempenho ambiental e na qualidade de vida que proporciona à população. O presente trabalho explora a ligação entre a estrutura urbana e a qualidade do ar, um dos muitos aspectos do desenvolvimento urbano sustentável. A perspectiva histórica sobre o desenvolvimento urbano, a poluição atmosférica e a sua interligação é abordada, bem como o trabalho de investigação que tem vindo a ser conduzido na área. A aplicação de um sistema de modelação atmosférico a um caso de estudo idealizado demonstra a importância da estrutura espacial da cidade na sustentabilidade urbana, mostrando que cidades compactas com usos do solo misturados promovem uma melhor qualidade do ar quando comparadas com cidades dispersas, com baixa densidade populacional. De modo a explorar a relação entre a estrutura urbana e a qualidade do ar numa zona urbana real, a região urbana do Porto é identificada como um caso de estudo adequado, e o processo de crescimento urbano nas últimas décadas é analisado, assim como os níveis de qualidade do ar da região. De modo a definir a configuração do sistema de modelação mais adequada para a região de estudo, são efectuados diversos testes de sensibilidade com o modelo meteorológico. Relativamente ao modelo de qualidade do ar, é descrito e implementado um conjunto de acções de modo a melhorar o desempenho do modelo para a simulação das concentrações de poluentes na atmosfera urbana, no contexto de alterações do uso do solo. Finalmente, são desenvolvidos e testados, através da aplicação do sistema de modelação, dois cenários alternativos de desenvolvimento urbano para a área de estudo. Estes cenários alternativos implicam diferentes emissões de poluentes e diferentes distribuições espaciais dessas emissões, e como consequência, diferentes níveis de qualidade do ar. O estudo permite concluir que alterações nos padrões de uso do solo em áreas urbanas conduzem a alterações na meteorologia, emissões e qualidade do ar. As áreas urbanas dispersas, quando comparadas com estruturas urbanas compactas são responsáveis por temperaturas mais elevadas, emissões de poluentes para a atmosfera mais elevadas e maiores concentrações de poluentes.