John Bankart

Epidemiology of Autism Spectrum Disorders in Adults in the Community in England

CONTEXT To our knowledge, there is no published information on the epidemiology of autism spectrum disorders (ASDs) in adults. If the prevalence of autism is increasing, rates in older adults would be expected to be lower than rates among younger adults. OBJECTIVE To estimate the prevalence and characteristics of adults with ASD living in the community in England. DESIGN A stratified, multiphase random sample was used in the third national survey of psychiatric morbidity in adults in England in 2007. Survey data were weighted to take account of study design and nonresponse so that the results were representative of the household population. SETTING General community (ie, private households) in England. PARTICIPANTS Adults (people 16 years or older). MAIN OUTCOME MEASURES Autism Diagnostic Observation Schedule, Module 4 in phase 2 validated against the Autism Diagnostic Interview-Revised and Diagnostic Interview for Social and Communication Disorders in phase 3. A 20-item subset of the Autism-Spectrum Quotient self-completion questionnaire was used in phase 1 to select respondents for phase 2. Respondents also provided information on sociodemographics and their use of mental health services. RESULTS Of 7461 adult participants who provided a complete phase 1 interview, 618 completed phase 2 diagnostic assessments. The weighted prevalence of ASD in adults was estimated to be 9.8 per 1000 (95% confidence interval, 3.0-16.5). Prevalence was not related to the respondents age. Rates were higher in men, those without educational qualifications, and those living in rented social (government-financed) housing. There was no evidence of increased use of services for mental health problems. CONCLUSIONS Conducting epidemiologic research on ASD in adults is feasible. The prevalence of ASD in this population is similar to that found in children. The lack of an association with age is consistent with there having been no increase in prevalence and with its causes being temporally constant. Adults with ASD living in the community are socially disadvantaged and tend to be unrecognized.

Diabetes and cardiovascular events in women with polycystic ovary syndrome: a 20‐year retrospective cohort study

Women with polycystic ovary syndrome (PCOS) are potentially at increased risk of cardiovascular (CV) diseases due to well‐established risk factors, including insulin resistance, obesity and type 2 diabetes mellitus (T2DM). However, data showing excess CV events in this population are still lacking. We investigated the incidence and prevalence of CV events in a cohort of women with PCOS.

Epidemiologic variability of chronic inflammatory demyelinating polyneuropathy with different diagnostic criteria: study of a UK population.

Epidemiologic data on chronic inflammatory demyelinating polyneuropathy (CIDP) is limited, and previous studies have shown variable results. The frequencies of CIDP subtypes remain unknown. Variations due to use of different diagnostic criteria have not been studied. We examined the prevalence and incidence of CIDP in Leicestershire and Rutland, UK (population 963,600). Prevalence day was 1 May 2008. The prevalence of CIDP fulfilling the 2006 clinical and electrophysiologic European Federation of Neurological Societies/Peripheral Nerve Society (EFNS/PNS) criteria was 4.77 per 100,000 (95% confidence interval [CI] 3.49–6.37). Using the 1991 American Academy of Neurology (AAN) criteria, the prevalence was 1.97 per 100,000 in this population (95% CI 1.19–3.08). Lewis–Sumner syndrome was diagnosed in 15.2% of patients, and 23.9% had pure sensory onset. Over 40% required no immunotherapy, and 84.6% of those treated responded. More than 80% of the AAN criteria–negative but EFNS/PNS criteria–positive patients were responsive to treatment. Both sets of criteria were equally likely to identify patients who required therapy. The mean annual incidence rate over the 3 years preceding the prevalence day was 0.70 per 100,000/year using EFNS/PNS criteria (95% CI 0.43–1.08), and 0.35 per 100,000/year using AAN criteria (95% CI 0.17–0.64). We conclude that the AAN criteria may underestimate prevalence and incidence of the disease. The EFNS/PNS criteria provide higher diagnostic sensitivity and are of greater clinical relevance, and they also offer a useful breakdown of the epidemiologic data for CIDP subtypes. Muscle Nerve, 2008

Validating two survey methods for identifying cases of autism spectrum disorder among adults in the community.

BACKGROUND There are no tested methods for conducting epidemiological studies of autism spectrum disorders (ASDs) in adult general population samples. We tested the validity of the Autism Diagnostic Observation Schedule module-4 (ADOS-4) and the 20-item Autism-Spectrum Quotient (AQ-20). METHOD Randomly sampled adults aged ≥16 years were interviewed throughout England in a general population multi-phase survey. The AQ-20 was self-completed by 7353 adults in phase 1. A random subset completed phase 2, ADOS-4 assessments (n=618); the probability of selection increased with AQ-20 score. In phase 3, informant-based Diagnostic Interview Schedule for Social and Communication Disorders (DISCO) and Autism Diagnostic Interview-Revised (ADI-R) developmental assessments were completed (n=56). Phase 1 and 2 data were presented as vignettes to six experienced clinicians (working in pairs). The probability of respondents having an ASD was compared across the three survey phases. RESULTS There was moderate agreement between clinical consensus diagnoses and ADOS-4. A range of ADOS-4 caseness thresholds was identified by clinicians: 5+ to 13+ with greatest area under the curve (AUC) at 5+ (0.88). Modelling of the presence of ASD using 56 DISCO assessments suggested an ADOS-4 threshold in the range of 10+ to 13+ with the highest AUC at ADOS 10+ to 11+ (0.93-0.94). At ADOS 10+, the sensitivity was 1 [95% confidence interval (CI) 0.59-1.0] and the specificity 0.86 (95% CI 0.72-0.94). The AQ-20 was only a weak predictor of ADOS-4 cases. CONCLUSIONS Clinically recommended ADOS-4 thresholds are also recommended for community cases: 7+ for subthreshold and 10+ for definite cases. Further work on adult population screening methods is needed.

A self-management programme for COPD: a randomised controlled trial

Studies of programmes of self-management support for chronic obstructive pulmonary disease (COPD) have been inconclusive. The Self-Management Programme of Activity, Coping and Education (SPACE) FOR COPD is a 6-week self-management intervention for COPD, and this study aimed to evaluate the effectiveness of this intervention in primary care. A single-blind randomised controlled trial recruited people with COPD from primary care and randomised participants to receive usual care or SPACE FOR COPD. Outcome measures were performed at baseline, 6 weeks and 6 months. The primary outcome was symptom burden, measured by the self-reported Chronic Respiratory Questionnaire (CRQ-SR) dyspnoea domain. Secondary outcomes included other domains of the CRQ-SR, shuttle walking tests, disease knowledge, anxiety, depression, self-efficacy, smoking status and healthcare utilisation. 184 people with COPD were recruited and randomised. At 6 weeks, there were significant differences between groups in CRQ-SR dyspnoea, fatigue and emotion scores, exercise performance, anxiety, and disease knowledge. At 6 months, there was no between-group difference in change in CRQ-SR dyspnoea. Exercise performance, anxiety and smoking status were significantly different between groups at 6 months, in favour of the intervention. This brief self-management intervention did not improve dyspnoea over and above usual care at 6 months; however, there were gains in anxiety, exercise performance, and disease knowledge. A brief self-management programme for COPD improves some patient outcomes; however, more support may be required http://ow.ly/AbCpm

Impact of a tailored patient preference intervention in adherence to 5‐aminosalicylic acid medication in ulcerative colitis: Results from an exploratory randomized controlled trial

Background: Up to 40% of patients with ulcerative colitis (UC) fail to comply with 5‐aminosalicylic acid (5‐ASA) therapy. This study aimed to evaluate multifaceted adherence‐enhancing interventions for oral 5‐ASA therapy in UC and consider changes in health beliefs and satisfaction with information. Methods: Adults attending a UK gastroenterology outpatient clinic were recruited to an exploratory randomized controlled trial. The tailored intervention included educational and motivational components, plus options including simplified dosing regimes and practical reminders such as pill dispensers. Adherence was assessed objectively at baseline and after 1 year based on levels of urinary 5‐ASA and N‐acetly‐5‐ASA concentration. Changes in relevant beliefs and satisfaction with information were measured using validated questionnaires. Results: Seventy‐one people completed the study. Adherence levels in the study population were relatively high at baseline (76%) but a decline in adherence levels over the study period was noted. However, at follow‐up adherence in the intervention group was 44% greater than in the control group. Intervention group status had a significant positive impact on maintaining adherence levels after adjusting for potential confounders including baseline adherence (P = 0.001). This finding was supported by the results of a sensitivity analysis including patients who withdrew from the study. Changes in questionnaire scores suggested a positive effect of the intervention on satisfaction with information (P < 0.001). Conclusions: The multifaceted approach studied has potential for implementation in routine care for enhancing persistence with 5‐ASA and thus improving patient outcomes. (Inflamm Bowel Dis 2011;)

An investigation of medication adherence to 5‐aminosalicylic acid therapy in patients with ulcerative colitis, using self‐report and urinary drug excretion measurements

Background  Non‐adherence to 5‐aminosalicylic acid (5‐ASA) medication can limit the established benefits of this therapy in ulcerative colitis (UC).

Dichloroacetate Enhances Performance and Reduces Blood Lactate during Maximal Cycle Exercise in Chronic Obstructive Pulmonary Disease

RATIONALE Impaired skeletal muscle function contributes to exercise limitation in patients with chronic obstructive pulmonary disease (COPD). This is characterized by reduced mitochondrial adenosine triphosphate generation, and greater reliance on nonmitochondrial energy production. Dichloroacetate (DCA) infusion activates muscle pyruvate dehydrogenase complex (PDC) at rest, reducing inertia in mitochondrial energy delivery at the onset of exercise and diminishing anaerobic energy production. OBJECTIVES This study aimed to determine whether DCA infusion enhanced mitochondrial energy delivery during symptom-limited maximal exercise, thereby reducing exercise-induced lactate and ammonia accumulation and, consequently, improving exercise performance in patients with COPD. METHODS A randomized, double-blind crossover design was used. Eighteen subjects with COPD performed maximal cycle exercise after an intravenous infusion of DCA (50 mg/kg body mass) or saline (control). Exercise work output was determined, and blood lactate and ammonia concentrations were measured at rest, 1 and 2 minutes of exercise, peak exercise, and 2 minutes postexercise. MEASUREMENTS AND MAIN RESULTS DCA infusion reduced peak blood lactate concentration by 20% (mean [SE]; difference, 0.48 [0.11] mmol/L, P < 0.001) and peak blood ammonia concentration by 15% (mean [SE]; difference, 14.2 [2.9] mumol/L, P < 0.001] compared with control. After DCA, peak exercise workload improved significantly by a mean (SE) of 8 (1) W (P < 0.001) and peak oxygen consumption by 1.2 (0.5) ml/kg/minute (P = 0.03) compared with control. CONCLUSIONS We have shown that a pharmacologic intervention known to activate muscle PDC can reduce blood lactate and ammonia accumulation during exercise and improve maximal exercise performance in subjects with COPD. Skeletal muscle PDC activation may be a target for pharmacologic intervention in the management of exercise intolerance in COPD.

Age-specific normal values for the incremental shuttle walk test in a healthy British population.

PURPOSE: The Incremental Shuttle Walk Test (ISWT) is an important functional and prognostic marker in chronic disease. Aging has a detrimental effect on exercise performance. The objective of this study was to produce normal age-specific values for the ISWT in a healthy British population and to explore whether additional variables improve the accuracy of a predictive equation. METHODS: Healthy subjects (N = 152), aged 40 to 90 years, were recruited. Data collection occurred over 2 study visits. Anthropometric and demographic data were collected, and lung function and quadriceps maximal voluntary contraction were measured. An accelerometer was worn for 2 consecutive days at home. The Duke Activity Status Index was completed, and the greatest distance from 2 ISWTs was recorded. RESULTS: One hundred forty subjects (56 men) with mean age (SD) of 59.4 (11.0) years completed 2 ISWTs. Forced expiratory volume in 1 second (FEV1) was 109.1% (14.56%) predicted and ISWT distance was 737 m (183 m). Age-specific normal values for the ISWT were observed: mean (lower limit of normal)—40 to 49 years, 824 m (765 m); 50 to 59 years, 788 m (730 m); 60 to 69 years, 699 m (649 m); and 70 years and older, 633 m (562 m). A predictive equation was developed from 114 subjects. Age, body mass index, FEV1, quadriceps maximal voluntary contraction, and Duke Activity Status Index contributed to ISWT distance predicting 50.4% of the variation in performance. CONCLUSION: We have developed age-specific normal values for performance on the ISWT in a healthy British population. However, even using practical, clinically relevant variables, it is not possible to accurately predict exercise capacity from a regression equation.

Association of primary care characteristics with variations in mortality rates in England: an observational study.

Background Wide variations in mortality rates persist between different areas in England, despite an overall steady decline. To evaluate a conceptual model that might explain how population and service characteristics influence population mortality variations, an overall null hypothesis was tested: variations in primary healthcare service do not predict variations in mortality at population level, after adjusting for population characteristics. Methodology/Principal Findings In an observational study of all 152 English primary care trusts (geographical groupings of population and primary care services, total population 52 million), routinely available published data from 2008 and 2009 were modelled using negative binomial regression. Counts for all-cause, coronary heart disease, all cancers, stroke, and chronic obstructive pulmonary disease mortality were analyzed using explanatory variables of relevant population and service-related characteristics, including an age-correction factor. The main predictors of mortality variations were population characteristics, especially age and socio-economic deprivation. For the service characteristics, a 1% increase in the percentage of patients on a primary care hypertension register was associated with decreases in coronary heart disease mortality of 3% (95% CI 1–4%, p = 0.006) and in stroke mortality of 6% (CI 3–9%, p<0.0001); a 1% increase in the percentage of patients recalling being better able to see their preferred doctor was associated with decreases in chronic obstructive pulmonary disease mortality of 0.7% (CI 0.2–2.0%, p = 0.02) and in all cancer mortality of 0.3% (CI 0.1–0.5%, p = 0.009) (continuity of care). The study found no evidence of an association at primary care trust population level between variations in achievement of pay for performance and mortality. Conclusions/Significance Some primary healthcare service characteristics were also associated with variations in mortality at population level, supporting the conceptual model. Health care system reforms should strengthen these characteristics by delivering cost-effective evidence-based interventions to whole populations, and fostering sustained patient-provider partnerships.