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Prostate cancer is a common malignancy with rising incidence in Western countries such as the United Kingdom. In localised disease there are a variety of curative treatment modalities. Patients can be referred for surgery, or for a combination of hormonal therapies and radiotherapy (external beam radiotherapy or brachytherapy). Each treatment option comes with side effects and in the case of radiotherapy one potential complication is bowel toxicity from radiation exposure. New technologies are being developed to try and mitigate the side effects and long term morbidity of this treatment, and to expand access to radiotherapy for patients who may previously have been excluded (i.e those with inflammatory bowel disease). Rectal Spacers are absorbable polyethylene glycol hydrogels injected into the perirectal space. These position the anterior rectal wall away from the prostate, subsequently minimising radiation dose to the rectum. Rectal Spacers have been introduced to National Healthcare Service (NHS) practice as part of the Innovation and Technology Payment (ITP) programme, however, their use is now under review.
Methodology and Results:
In this editorial we conduct a narrative review of some of the available evidence for Rectal Spacers, discuss their utilization within the NHS and the barriers to their wider use. We also explore preliminary dosimetry and quality of life data for use of Rectal Spacers in our centre where we have been part of the NHS ITP programme. Dosimetry data and Quality of life questionnaires were gathered from 22 treated patients and 11 matched controls. This indicated lower radiation doses to the prostate in those treated with Rectal Spacers.
Rectal Spacers are an effective method to reduce radiation dose to the prostate in men treated for localised prostate cancer, however, their use remains under review in the NHS and there are a variety of barriers to upscaling their use.
An area of interest presently is the lingering symptoms after COVID-19, i.e. post-COVID-19 syndrome (PCS). Specifics of diagnosis and management of PCS are emerging. However, vulnerable populations such as those with intellectual disabilities, who were disproportionately affected by the pandemic, risk being ‘left behind’ from these considerations.
Despite the widespread use of psychotropic medications in people with autism spectrum disorder (ASD), there is limited evidence to suggest that psychotropic medications including mood stabilisers are effective in individuals with ASD.
To carry out a systematic review and meta-analysis of randomised controlled trials (RCTs) that assessed the effectiveness of mood stabilisers in people with ASD.
We searched the following databases: Cochrane Library, MEDLINE, Embase, CINAHL, PsycINFO, ERIC, DARE, and ClinicalTrials.gov. In addition, we hand-searched 12 relevant journals. We used the Cochrane Risk of Bias and Jadad scores to assess the quality of included RCTs. We carried out a meta-analysis using a random-effects model.
We included eight RCTs (four on valproate, two on levetiracetam, and one each on lamotrigine and topiramate) that included a total of 310 people with ASD, primarily children. Outcomes were based on core and associated ASD symptoms including irritability and aggression but not bipolar disorder. Only two small studies (25%) from the same group showed definite superiority over placebo and one over psychoeducation alone. Meta-analysis of pooled data on the Aberrant Behaviour Checklist-irritability, Clinical Global Impression Scale-improvement, and Overt Aggression Scale (OAS)/OAS-modified did not show any significant inter-group difference. The rates of adverse effects did not show any significant inter-group difference.
Given the methodological flaws in the included studies and the contradictory findings, it is difficult to draw any definitive conclusion about the effectiveness of mood stabilisers to treat either ASD core symptoms or associated behaviours. Robust large-scale RCTs are needed in the future to address this issue.
PROSPERO registration: CRD42021255467 on 18 May 2021.
Unrecognised psychiatric and medical conditions can lead poorer health outcomes, lower health-related quality of life and increased mortality in people with autism, compared with the general population. A reasonable adjustment required in mainstream services is patient prioritisation by clinicians with knowledge and understanding of autism. Developed as part of the revised autism strategy, the recently developed autism competency framework lists the range of capabilities that psychiatrists who treat people with autism should have. Psychiatrists could lead the workforce transformation required to make the reasonable adjustments to mainstream mental health services needed to improve outcomes for people with autism.
Although widely used, the current evidence for the efficacy of antidepressant and anti-anxiety medications for people with autism spectrum disorder (ASD) is limited and conflicting.
We carried out a systematic review and meta-analysis of randomised controlled trials that assessed the effectiveness of these medications in people with ASD.
We searched the following databases: Cochrane Library, Medline, EMBASE, CINAHL, PsycINFO, ERIC, DARE and ClinicalTrials.gov. Additionally, we hand-searched 11 relevant journals. We used the Cochrane risk-of-bias tool and Jadad score to assess the quality of each included study. We carried out a meta-analysis using a random effects model.
We included 15 randomised controlled trials (13 on antidepressants and two on anti-anxiety medications) for 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 groups. 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 inter-group difference on either of the outcome measures. The adverse effects reported were mild and, in most studies, their rates did not show any significant inter-group difference.
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 anti-anxiety medications to treat either ASD core symptoms or associated behaviours. Robust, large-scale, randomised controlled trials are needed to address this issue.
We conducted a secondary analysis of data from a Prescribing Observatory for Mental Health audit to assess the quality of requests from intellectual disability services to primary care for repeat prescriptions of antipsychotic medication.
Forty-six National Health Service Trusts submitted treatment data on 977 adults with intellectual disability, receiving antipsychotic medication for more than a year, for whom prescribing responsibility had been transferred to primary care. Therapeutic effects had been monitored in the past 6 months in 80% of cases with a documented communication indicating which service was responsible for this and 72% of those with no such communication. The respective proportions were 69% and 42% for side-effect monitoring, and 79% and 30% for considering reducing/stopping antipsychotic medication.
Where continuing antipsychotic medication is prescribed in primary care for people with intellectual disability, lack of guidance from secondary care regarding responsibilities for monitoring its effectiveness may be associated with inadequate review.
The COVID-19 pandemic and associated restrictions are expected to affect the mental health of the population, especially people with intellectual disability and/or autism spectrum disorder, because of a variety of biological and psychosocial reasons.
This study aimed to estimate if COVID-19 restrictions are associated with a change in number of total consultations carried out by psychiatrists and prescription of psychotropic medication in people with intellectual disability and/or autism spectrum disorder, within a community intellectual disability service.
A quantitative observational study was conducted, involving retrospective and prospective data collection before and during lockdown. Data was collected on a spreadsheet and emailed to all psychiatrists working within the Coventry and Warwickshire Partnership NHS Trust-wide community intellectual disability service. Variables included total consultations, medication interventions, types of medications used, multidisciplinary team input and clinical reasons for medication interventions. Data was analysed separately for child and adolescent mental health services (CAMHS) and adult intellectual disability teams, and for the whole service.
During the lockdown period, total consultations in the community intellectual disability service increased by 19 per week and medication interventions increased by two per week. Multidisciplinary team input increased in CAMHS from 0.17 to 0.71 per week and in adult intellectual disability from 5.7 to 6.5 per week. Hypnotics and benzodiazepines were the most commonly prescribed psychotropic medications during the lockdown period.
COVID-19-related lockdown resulted in an increase in medication interventions, total consultations and involvement of multidisciplinary teams to manage mental health and behavioural issues in people with intellectual disability and/or autism spectrum disorder.
People with DSM-5 intellectual disability/intellectual developmental disorder (ID/IDD) or ICD-11 disorders of intellectual development (DID) have multiple healthcare needs, but in many countries these needs are neither recognised nor managed effectively. This paper discusses the negative impact that stigma, discrimination and social exclusion have on the identification and care of persons with ID/IDD in low- and middle-income countries (LMICs). It also reviews different models of care for children, adolescents and adults. In discussing some initiatives in LMICs the emphasis is on early diagnosis, with success in providing locally sourced care for affected people and their families. This is where the medical, social and rights-based models of care intersect and is a premise of the person-centred biopsychosocial framework of the World Psychiatric Association's Presidential Action Plan 2020–2023. The plan invites psychiatrists to take a lead in changing the culture of care, as well as medical education, clinical training and research, with a renewed emphasis on workforce integration and service development in terms of community-based rehabilitation strategies.
The approach taken to support individuals during the coronavirus disease 2019 (COVID-19) pandemic needs to take into account the requirements of people with intellectual disabilities and/or autism, who represent a major vulnerable group, with higher rates of co-occurring health conditions and a greater risk of dying prematurely. To date, little evidence on COVID-related concerns have been produced and no report has provided structured feedback from the point of view of people with intellectual disabilities and/or autism or of their family/carers.
To provide systemised evidence-based information of the priority concerns for people with intellectual disabilities and/or autism regarding the COVID-19 pandemic.
Senior representatives of major UK-based professional and service-user representative organisations with a stake in the care of people with intellectual disabilities and/or autism were contacted to provide a list of concerns across three domains: ‘mental health and challenging behaviour’, ‘physical health and epilepsy’ and ‘social circumstances and support’. The feedback was developed into statements on frequently reported priorities. These statements were then rated independently by expert clinicians. A video-conference meeting to reconcile outliers and to generate a consensus statement list was held.
Thirty-two organisations were contacted, of which 26 (81%) replied. From the respondent's data, 30 draft consensus statements were generated. Following expert clinician review, there was initially strong consensus for seven statements (23%), increasing to 27 statements (90%) following video conferencing.
These recommendations highlight the expectations of people with intellectual disabilities and/or autism in the current pandemic. This could support policymakers and professionals’ deliver and evidence person-centred care.
Payment by results (PbR) for mental health services is currently being piloted with the aim of arriving at a national tariff for mental health by 2013/2014. The Department of Health has also established two pilot sites to consider applicability of PbR for learning disability services. This article outlines the concept of PbR in learning disability services and describes the progress of the pilot work being undertaken in this area.
Interpreting how people walk is intuitive for humans. From birth, we observe physical motion in the world around us and create perceptual models to make sense of it. Neurobiologically, we invent a framework within which we understand and interpret human activities like walking (Kandel et al. 2000). Analogously, in this chapter we propose a computational model that seeks to understand human gait from its neural basis to its physical essence.
We thus started by examining the basis of all human activities: motion. The rigorous study of motion has been the cornerstone of physics for the last 450 years, over which physicists have unlocked a deep, underlying structure of motion. We employ ideas grounded firmly in fundamental physics that are true for the motion of the physical systems we consider in gait analysis.
Using this physics-based methodology, we compute Hamiltonian Energy Signatures (HES) for a person by considering all the points on their contour, thus leading to a multidimensional time series that represents the gait of a person. These HES time-series curves thus provide a model of the gait for each person's style of walking. It can also be shown, using basic physical principles, that the HES is invariant under a special affine transformation, as shown in Appendix 9.A.1.3. This allows us to use the HES to categorize the activities of different people across different domains (high resolution, low resolution, etc.) in a moderately view-invariant manner.
Long-term admission trends in a large specialist National Health Service (NHS) hospital were examined over a 3-year period. These were compared with three earlier 3-year periods. the medical records were examined for admission numbers, source of admissions, length of stay, legal status, reason for admission and readmission rate.
The percentage of patients admitted from home decreased over time, whereas the admissions from group homes increased threefold. Long-stay admissions decreased in the second and third periods followed by an increase in the fourth period. There was a progressive increase in formal admissions and a decrease in informal ones. There was an increase in admissions of people with psychiatric illness and a decrease in admissions because of social difficulties. the percentage of first admissions gradually increased and the percentages of readmissions gradually decreased.
People with intellectual disability are more likely to be admitted for psychiatric reasons and to be detained under the Mental Health Act than in the 1970s. There should be a much greater interaction between hospital and community services to facilitate shorter stays and early discharge. Out-of-area placements need to be taken account of while commissioning for the total need in a geographical area.
The Health of the Nation Outcomes Scales (HoNOS) have been developed to measure outcomes in people with mental health problems.
Frequent impaired social functioning, problems with communication and associated physical conditions meant that a bespoke instrument was needed for people with learning disabilities. We describe the development of the Health of the Nation Outcomes Scales for People with Learning Disabilities (HoNOS–LD).
HoNOS-LD was piloted at 26 sites. Two raters, at two points in time, rated 372 subjects. Analysis determined acceptability, ease of use, interrater reliability, sensitivity to change and reliability with the Aberrant Behavior Checklist (ABC).
The resulting 18-item instrument demonstrated good reliability and validity characteristics and is generally acceptable to clinicians.
HoNOS-LD is an appropriate instrument for measuring outcome in people with learning disabilities with additional mental health needs.
rating instructions: (a) Complete the front sheet including ICD–10 diagnoses and subjective rating. (b) Rate each in order from item 1 to 18. (c) Do not include information rated in an earlier item. (d) Rate the person over the previous 4 weeks. (e) Rate the most severe problem that has occurred during the period rated. (f) All items follow the five-point rating format similar to other HoNOS instruments: 0=no problem during the period rated; 1=mild problem; 2=moderate problem; 3=severe problem; 4=very severe problem.
Priapism is a rare urological emergency, which can be associated with the use of psychotropic medication. The authors were able to find only one brief report of this condition in people with an intellectual disability. A case is reported in a man with moderate intellectual disability, who was receiving antipsychotic medication to manage extreme challenging behaviour. We discuss the condition and its implications for pharmacological treatments of behavioural disturbance in susceptible individuals.
For nearly three decades, closure of large psychiatric and learning disability hospitals has continued and more people with mental health needs remain in the community. With this continuing decrease in hospital provision, there has been an increased focus on the development of systems of safe care and effective treatment for people with significant mental health problems living in the community. Attempts to make this a central plank of mental health care have been reflected in legislation and guidance produced by the Department of Health. The Care Programme Approach (CPA) was introduced in 1991 after the publication of HC (90) 23/LASSL (90) 11 and subsequent guidance from the White Paper Caring for People (Department of Health, 1990).
People with learning disability and behavioural disturbance can be difficult to treat in the community, frequently requiring specialist in-patient assessment. The impact which a new community-based ‘challenging behaviour service’ has had on a district's in-patient bed use is described.