Dementia among Older Persons in Jamaica: Prevalence and Policy Implications / La demencia entre las personas de edad en Jamaica: prevalencia e implicaciones para la implementación de políticas

ABSTRACT Objective: To determine the prevalence of dementia and dementia types in Jamaica. Methods: An embedded case-control design was used to investigate dementia within the ageing population. Cases (Mini-Mental State Examination [MMSE] scores of < 20) and controls (MMSE scores of > 20) were evaluated using DSM-IVprotocol and magnetic resonance imaging. Prevalences (crude and age-adjusted) were calculated and distribution of dementia by type described. Results: Dementia prevalence was 5.9%. Alzheimer's pattern dementia accounted for 61.8% and vascular dementia 32.4%. However, vascular disease was prominent in 45.5% of the Alzheimer's cases. Female gender and increasing age were associated with higher rates of dementia. Dementia was 38 times more likely in participants with MMSE scores below 20. Conclusion: This first nationally representative study indicated that dementia rates in Jamaica were comparable with regional and global estimates. Regardless of the dementia type, vascular change was pervasive and suggested that synergistic efforts should be made to address underlying contributory factors. Cardiovascular and cerebrovascular risk reduction should be deliberately pursued as integral adjuncts to dementia risk reduction.

RESUMEN Objetivo: Determinar la prevalencia de los tipos de demencia y demencia en Jamaica. Métodos: Se utilizó un diseño de caso-control incrustado para investigar la demencia dentro de la población en proceso de envejecimiento. Los casos (puntuación < 20 en el Mini Examen del Estado Mental [MEEM]) y los controles (puntuación > 20 en el MEEM) fueron evaluados usando el protocolo DSM-IVy la imagen por resonancia magnética. Se calcularon prevalencias (crudas y ajustadas por edad) y se describió la distribución de la demencia por tipo. Resultados: La prevalencia de demencia fue de 5.9%. El Alzheimer representó el 61.8% y la demencia vascular 32.4%. Sin embargo, la enfermedad vascular fue prominente en el 45.5% de los casos de Alzheimer. El género femenino y la edad creciente se asociaron con tasas más altas de demencia. La demencia fue 38 veces más probable en los participantes con puntuaciones de MEEM por debajo de 20. Conclusión: Este primer estudio nacionalmente representativo indicó que las tasas de demencia en Jamaica eran comparables con los estimados regionales y globales. Independientemente del tipo de demencia, el cambio vascular fue generalizado y sugirió que se hicieran esfuerzos sinérgicos para abordar los factores contribuyentes subyacentes. Debe buscarse deliberadamente la reducción del riesgo cardiovascular y cerebrovascular como adjuntos integrantes de la reducción del riesgo de demencia.

Response to first line HAART using CD4 cell counts: experience in a University Hospital in Kingston / Respuesta a la terapia TARGA de primera línea usando conteos CD4: experiencia en el Hospital Universitario en Kingston

OBJECTIVES: To assess the extent to which the current practice for first line therapy concurs with the recommended guidelines and to examine the response of treatment naïve patients to first line Highly Active Antiretroviral Therapy (HAART) at the University Hospital of the West Indies, using CD4 cell counts. METHODS: Over a three-month period, a cross-sectional study design was instituted and data were collected on all patients on HAART at the University Hospital ofthe West Indies (UHWI) outpatient HIV clinic. Information was collected by reviewing patient medical records using data collection sheets. The data obtained from the medical records included: age, gender, date of diagnosis of HIV, date at which HAART was commenced, CD4 cell counts prior to the commencement of antiretrovirals, the initial HAART regimes and subsequent CD4 cell counts. RESULTS: A total of 165 persons who met the criteria of being on HAART therapy were enrolled in the study. The average time span between diagnosis of HIV and commencement of antiretroviral therapy was 1.92 years and the range for this was 0 to 12.29 years. The average CD4 count prior to initiation of HAART was 186 cells/mm³. The most common regime used at the UHWI for first line therapy was combivir and efavirenz, n = 78 (47.3%), followed by combivir and nevirapine, n = 29 (17.6%). The average difference between the initial CD4 count prior to the initiation of HAART and first repeated CD4 count was 102 cells/mm³. The mean time between the first and repeated CD4 cell counts was 376 days. CONCLUSION: The recommended guidelines were adhered to for the majority of patients initiated on antiretrovirals at the UHWI. The treatment outcomes achieved at the UHWI were similar to those achieved in developed countries. This gives substantial evidence in support of international efforts to make antiretroviral therapy available in developing countries.

OBJETIVOS: Evaluar hasta que punto la práctica actual de la terapia de primera línea concuerda con las normas recomendadas y examinar la respuesta al tratamiento por parte de los pacientes nunca antes sometidos a la terapia antiretroviral altamente activa, (TARGA) en el Hospital Universitario, usando conteos de células CD4. MÉTODOS: Por un periodo de tres meses, se instituyó un diseno de estudio transversal, y se recogieron datos de todos los pacientes sometidos a TARGA en la clínica de VIH para pacientes externos en el Hospital Universitario de West Indies (UHWI). La información fue obtenida revisando las historias clínicas de todos pacientes, usando hojas de recogida de datos. Los datos obtenidos de las historias clínicas incluían: edad, género, fecha de diagnóstico de VIH, fecha de comienzo de TARGA, conteo de células CD4 antes del comienzo de los antiretrovirales, los regimenes iniciales de TARGA y los subsecuentes conteos de células CD4. RESULTADOS: Un total de 165 personas que satisfacían los criterios de la terapia TARGA fueron enroladas en el estudio. El tiempo promedio que medió entre el diagnóstico de VIHy el comienzo de la terapia antiretroviral fue 1.92 anos, en tanto el rango para esta fue de 0 a 12.29 anos. El conteo promedio de conteo de CD4 antes del comienzo de TARGA fue 186 células/mm3. El régimen más común usado en UHWIpara la terapia de primera línea fue combivir y efavirenz, n = 78 (47.3%), seguido por el combivir y nevirapine, n = 29 (17.6%). La diferencia promedio entre el conteo inicial de CD4 antes del comienzo de TARGA y elprimer conteo repetido de CD4 fue 102 células/mm3. El tiempo promedio entre los primeros conteos CD4 y los repetidos fue 376 días. CONCLUSIÓN: Se siguieron las normas recomendadas en relación con la mayoría de los pacientes iniciados en el tratamiento con antiretrovirales en UHWI. Los resultados del tratamiento logrados en UHWI fueron similares a los logrados en los países desarrollados. Esto ofrece sólidas evidencias en apoyo a los esfuerzos internacionales por poner la terapia antiretroviral a disposición de los países en vías de desarrollo.

Disclosure of HIV status among HIV Clinic attendees in Jamaica / Revelación del estado de VIH entre los pacientes que asisten a la Clínica de VIH en Jamaica

OBJECTIVE: This study aimed to examine factors related to disclosure of HIV serostatus among clinic attendees in an outpatient HIV clinic at the University Hospital of the West Indies (UHWI). METHODS: This was a cross-sectional survey of 107 attendees to a HIV clinic at the University Hospital of the West Indies. Participants were selected on a convenience basis. The instrument was developed for this study and covered socio-demographic data and self-report of disclosure and other variables related to HIV experience such as perceptions of family support. Data were analysed using non-parametric tests. RESULTS: Findings demonstrate a 49% disclosure rate among males and 60% among females. The results further indicate that age, sexual orientation, mode of transmission, and perception of family support were significantly associated with disclosure. Age and perception of family support were found to be significantly associated with consistent condom use. Age and perception of family support were the factors demonstrating the most significant correlations with age being significantly associated with disclosure to partner. Perception of family support was significantly associated with disclosure to family. CONCLUSION: Findings from this study demonstrate a low disclosure rate among HIV clinic attendees. Given that disclosure of HIV serostatus is critical in the control of the spread of HIV, this report highlights the need for the development of prevention interventions focussed on de-stigmatization for both infected and non-infected persons.

OBJETIVO: Este estudio tiene por objeto examinar factores relacionados con el dar a conocer el seroestado de VIH entre los pacientes externos que asisten a la clínica de VIH en el Hospital Universitario de West Indies (UHWI). MÉTODOS: Se realizó un estudio transversal de 107 asistentes a una clínica de VIH en el Hospital Universitario de West Indies. Se seleccionaron los participantes de acuerdo con las conveniencias. El instrumento fue desarrollado para este estudio y abarcó los datos sociodemográficos así como autoreportes de la revelación del estado y otras variables relacionados con la experiencia del VIH, tales como las percepciones de apoyo familiar. Los datos fueron analizados usando pruebas no paramétricas. RESULTADOS: Los resultados muestran una tasa de revelación de 49% entre los varones y 60% entre las hembras. Los resultados también indican que la edad, la orientación sexual, el modo de transmisión, y la percepción de apoyo familiar, estuvieron significativamente asociados con la revelación de esta condición. La edady la percepción del apoyo familiar estuvieron significativamente asociadas con el uso consistente del condón. La edad y la percepción del apoyo familiar fueron los factores que demostraron las correlaciones más significativas, hallándose la edad significativamente asociada con la revelación de la condición a las parejas. La percepción del apoyo familiar estuvo significativamente asociada con la revelación de la condición a la familia. CONCLUSIÓN: Los resultados de este estudio demuestran una baja tasa de revelación entre los asistentes a la clínica de VIH. Puesto que dar a conocer el seroestado de VIH es un aspecto crítico en el control de la diseminación del VIH, este informe resalta la necesidad de desarrollar intervenciones de prevención encaminadas a la desestigmatización tanto para los infectados como para los no infectados.

Multiple Micronutrient Defficiencies During Early Childhood / Монголын Анагаах Ухаан

Introduction. The high rate of malnutrition in young Mongolian children is a serious issue. Anemia, stunting and rickets have all been identified as significant problems. Low levels of serum folate have been reported among some young children in two previous surveys. Zinc is a growth-limiting micronutrient that may contribute to the persistent stunting in young Mongolian children. The traditional rice and wheat-based complementary foods used for young child feeding are likely to be inadequate in zinc. Certainly, the overall prevalence of stunting in Mongolia (i.e., 20%) is suggestive of substantial risk of zinc deficiency. It is possible that co-existing low selenium status may exacerbate zinc deficiency, because selenium compounds regulate the delivery of zinc from metallothioneine to zinc enzymes. To date, however, there have been no studies on the selenium and zinc status of the Mongolian population. Study objective. The objective of this study was to assess the biochemical indicators of micronutrient deficiency among 6-36 months old children. Subjects and methods. This cross-sectional study was conducted in four districts of Ulaanbaatar city and in centers of Bulgan, Bayanhongor, Dornod and Khovd aimags and included 243 (122 male and 121 female) apparently healthy children aged 6 to 36 months. Hemoglobin analysis was performed using a hemoglobinometer Hemocue AB, serum ferritin was analyzed by enzyme immunoassay technology, serum retinol by high-pressure liquid chromatography, serum zinc and selenium were analyzed by atomic absorption spectrophotometry and serum 25(OH)D analysis was performed using radioimmuno assay procedure. Results. Mean hemoglobin, serum ferritin, folate, 25(OH)D, retinol, zinc and selenium concentrations in children from Ulaanbaatar city and aimag centers were determined. Age-group differences for the means were significant for hemoglobin, serum ferritin, serum folate (p=0.001)and serum zinc(p=0.01). The differences between Ulaanbaatar and the aimag centers were also significant for hemoglobin, serum ferritin, serum zinc (p=0.05) and serum folate (p=0.001). 24.3% of the children were anemic. The prevalence of anemia was greater among the children in the aimag centers than in Ulaanbaatar city and in younger children than in the oldest age group. The prevalence of iron deficiency anemia was 15.3% and was independent of setting but was lowest in the oldest children aged 24 to 36 months. Of all the surveyed children, only 3.7% had low level of serum folate. The overall prevalence of low serum retinol levels indicative of vitamin A deficiency was 33.7%, with no differences by setting or age group. 74.7% of the children had low serum zinc concentrations. There was no significant difference in the prevalence between children living in Ulaanbaatar city and the aimag centers, or among the three age groups of children in either setting. The overall prevalence of low serum selenium concentrations was 57.7%, with no differences in the prevalence by setting or age-group. The prevalence of low serum levels of 25(OH)D was 61% and was highest among the children aged 6 to 12 months of Ulaanbaatar city. Conclusion: 1. Zinc deficiency had the highest prevalence (74.7%) among the surveyed children, followed by low serum selenium levels (57.7%). 2. 36% of the children were at risk of two and 64% of more than two coexisting micronutrient deficiencies. 3. There is a need for multi-micronutrient programs that take into account the potential interactions of micronutrients instead of the present single micronutrient based interventions on-going in Mongolia.

Changing the research culture at the section of psychiatry, the University of the West Indies, Mona / Cambiando la cultura de la investigación en el Departamento de Psiquiatría de la Universidad de West Indies, Mona

OBJECTIVE: To compare the medical research output of the Section of Psychiatry, The University of the West Indies (UWI), Mona, before and after the implementation of strategies aimed at stimulating research. METHOD: Specific strategies such as weekly research and journal club meetings, with an emphasis on team activities and the establishment of bi-annual targets for submission of research papers were instituted in 2000. All research outputs from the Section of Psychiatry over the period 1995 to 2005 were identified from the Departmental Reports of the University of the West Indies and the published abstracts of the UWI Faculty of Medical Sciences and the Caribbean Health Research Council annual research conferences. A number of variables were extracted from each paper and comparisons made between the five-year period before and the five-year period after the implementation of the research enhancing strategies. Statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS; version 11.5) and included chi-squared and Mann Whitney U tests. RESULTS: One-hundred and sixty-two items of research output were identified for the entire period under study. In the period after the implementation of the research enhancing strategies, there were significant increases in the total research output (p = 0.008) and refereed publications (p = 0.016). CONCLUSIONS: There were considerable increases in the overall research output of the department as well as in many sub-categories of output. These strategies are presented as a model to other departments seeking to augment their output of research.

OBJETIVO: Comparar la producción médico-investigativa del Departamento de Psiquiatría de la Universidad de West Indies (UWI), Mona, antes y después de la implementación de las estrategias encaminadas a estimular la investigación. MÉTODO: En el año 200, se instituyeron estrategias específicas, tales como reuniones semanales del club de investigación y publicaciones, con énfasis en las actividades en equipo y el establecimiento de objetivos semestrales para la presentación de trabajos de investigación. Todas las producciones investigativas del Departamento de Psiquiatría durante el periodo de 1995 al 2005, fueron identificadas a partir de los informes Departamentales de la Universidad de West Indies y los resúmenes publicados por las conferencias anuales de la Facultad de Ciencias Médicas de UWI y el Consejo Caribeño de Investigaciones de la Salud. Se extrajeron un número de variables de cada trabajo y se hicieron comparaciones entre el quinquenio anterior y el posterior a la implementación de las estrategias del perfeccionamiento de las investigaciones. Se realizaron análisis estadísticos con el Paquete Estadístico para las Ciencias Sociales (SPSS; versión 11.5) y se incluyeron pruebas U de Mann-Whitney y Chi-cuadrado. RESULTADOS: Se identificaron ciento sesenta y dos ítems de output investigativo para todo el periodo en estudio. En el periodo posterior a la implementación de las estrategias de perfeccionamiento de las investigaciones, hubo aumentos significativos en la producción investigativa total (p = 0.008) y en las publicaciones referenciadas (p = 0.016). CONCLUSIONES: Hubo aumentos considerables en la producción investigativa general del departamento, así como en muchas subcategorías de producción. Estas estrategias se presentan como un modelo para otros departamentos que buscan aumentar su producción investigativa.

Depression in adolescence: new developments / La depresión en la adolescencia: nuevos desarrollos

Depression in adolescence is under-recognized although its associated burden of illness is very high. Some frequent associations with depression in this age group are under-achievement, poor lifestyle choices including substance abuse, and a high risk of the persistence of the illness into adulthood There is also an increased risk of mortality related to suicide and harmful lifestyles. For depression in adolescents to be reduced, there needs to be strong collaboration among health professions, adolescents and their caregivers. Non-mental health clinicians must expand their role and become better prepared to recognize, prevent and treat depression in this age-group. Greater public awareness must also be achieved so that adolescents and their caregivers can seek help early.

La depresión en la adolescencia es subreconocida, a pesar de que la carga de padecimientos asociada con ella es muy alta. Algunas de las asociaciones frecuentes de la depresión en este grupo de edad son el bajo rendimiento académico, opciones de vida pobre – incluyendo el abuso de sustancias –, y un alto riesgo de que la enfermedad persista y continúe en la adultez. Existe también un riesgo elevado de mortalidad relacionado con el suicidio y los estilos de vida nocivos. A fin de reducir la depresión en los adolescentes, es necesaria una sólida cooperación entre los profesionales de la salud, los adolescentes y sus cuidadores. Inclusive los clínicos que no se ocupan directamente de la salud mental deben ampliar su función y prepararse mejor para reconocer, prevenir y tratar la depresión en este grupo de edad. También es necesaria una mayor concientización del público con el propósito de que los adolescentes y sus cuidadores puedan buscar ayuda temprano.

Rivastigmine in the treatment of alcohol-induced persisting dementia

A case of Alcohol-Induced Persisting Dementia (AIPD) in a 62-year-old man is presented. His progress on treatment with the acetylcholinesterase inhibitor, rivastigmine, is followed. The significant improvement observed suggests that AIPD may be a new indication for this class of drug

Seasonal variations in hair zinc concentrations in Canadian and African children

Proximal occipital scalp hair samples were collected during three survey periods from 30 omniverous Canadian boys aged 75.6 +/- 10.4 months (mean +/- SD) and 66 rural Malawian children (37 M; 29 F) aged 62 +/- 10 months (mean +/- SD) consuming predominantly plant-based diets. Hair samples were washed and then analyzed for zinc and copper using instrumental neutron activation analysis. Selected anthropometric measurements were also taken and dietary intakes calculated from weighed dietary records. A marked seasonal variation in hair zinc concentrations occurred in both groups; levels were highest in the season with shortest daylight hours (i.e. December /January in Canada vs July/August in Malawi). A similar trend was not observed for hair copper concentrations. Changes in hair zinc were not associated with changes in growth indices; age; socio-economic group; method of infant feeding; in either group; but were related to intakes of protein (per 1000 kcal) (p = 0.02; r = -0.36); zinc (mg day-1) (p = 0.01; r = -0.39); and dietary fiber (g day-1) (p = 0.04; r = 0.28); in the Malawian children during the second survey period. The seasonal effect on hair zinc concentrations must always be considered when interpreting hair zinc concentrations in children; its etiology remains unclear

Dietary calcium; phytate; and zinc intakes and the calcium; phytate; and zinc molar ratios of the diets of a selected group of East African children

Dietary zinc; calcium; and phytate intakes of 66 rural Malawian children aged 4-6 y were determined during three seasons on the basis of weighed food records and analyzed food composition data. Height and weight measurements were also recorded and hair samples were collected for zinc analysis. Seasonal daily zinc; calcium; and phytate intakes of females ranged from 6.2 +/- 1.7 to 6.8 +/- 2.1 mg (mean +/- SD); from 335 +/- 170 to 401 +/- 257 mg; and from 1621 +/- 660 to 1729 +/- 592 mg; respectively and; for males; 7.0 +/- 1.7 to 8.0 +/- 2.3 mg; 342 +/- 164 to 473 +/- 310 mg; and 1857 +/- 530 to 2161 +/- 684 mg; respectively. Cereals provided greater than 42 percent of dietary zinc. Seasonal mean molar ratios of phytate to Zn and Ca x phytate to Zn (per 1000 kcal (4.2 MJ)) and the median Ca to phytate molar ratio ranged from 24 to 27; 151 to 188 mmol/1000 kcal (4.2 MJ); and 3.1 to 3.4; respectively. Over 78 percent of the children consumed diets with phytate-to-Zn and Ca x phytate.Zn-1 . 1000 kcal-1 molar ratios above values suggested to jeopardize zinc status. Correlations between hair zinc; phytate-to-Zn; and Ca x phytate.Zn-1 . 1000 kcal-1 molar ratios suggest that high phytic acid intakes may compromise zinc status in these children