Chronic disease and ageing in the Caribbean: opportunities knock at the door / Enfermedades crónicas y envejecimiento en el Caribe: las oportunidades llaman a la puerta

Amidst rapid population ageing, the incidence and prevalence of chronic diseases and their sequelae demand reflective and critical looks at the issue and the subsequent development of informed age-sensitive responses. This paper reviews the burden of chronic diseases in the Caribbean, and its relationship to ageing and the demographic transition. Inter-linkages between the social determinants of health, poverty, ageing, and chronic disease are illustrated. Suggestions are made regarding directions to be pursued and the emerging initiative regarding chronic non-communicable diseases being spearheaded at the United Nations by CARICOM countries.

En medio del rápido envejecimiento de la población, la incidencia y prevalencia de las enfermedades crónicas y sus secuelas, requiere echar una ojeada reflexiva y crítica al problema y al desarrollo ulterior de las respuestas informadas sensibles a la edad. El presente trabajo examina la carga de las enfermedades crónicas en el Caribe, y su relación tanto con el envejecimiento como con la transición demográfica. Se ilustran los vínculos existentes entre las determinantes sociales de la salud, la pobreza, el envejecimiento, y las enfermedades crónicas. Se hacen sugerencias en cuanto a los caminos a seguir y la iniciativa emergente en relación con las enfermedades crónicas no comunicables, encabezada por los países del Caricom en las Naciones Unidas.

Paediatric and perinatal HIV/AIDS in Jamaica: an international leadership initiative, 2002-2007 / VIH/SIDA pediátrico y perinatal en Jamaica: iniciativa de liderazgo internacional, 2002-2007

BACKGROUND: Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa. METHOD: We describe a collaborative approach to the prevention, treatment and care of HIV in pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach. RESULTS: A core group of paediatric/perinatal HIV professionals were trained, including paediatricians, obstetricians, public health practitioners, nurses, microbiologists, data managers, information technology personnel and students to serve Greater Kingston (birth cohort 20 000). During September 2002 to August 2007, over 69 793 pregnant women presented for antenatal care. During these five years, significant improvements occurred in uptake of voluntary counselling (40% to 91%) and HIV-testing (53% to 102%). Eight hundred and eighty-three women tested HIV-positive with seroprevalence rates of 1-2% each year. The use of modified short course zidovudine or nevirapine in the first three years significantly reduced mother-to-child transmission (MTCT) of HIV from 29% to 6% (RR 0.27; 95% CI - 0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART, resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented. CONCLUSION: Working collaboratively, our mission of pMTCT of HIV and improving the quality of life for families living and affected by HIV/AIDS in Jamaica is being achieved.

ANTECEDENTES: El VIH/SIDA pediátrico y el perinatal continúan siendo retos significativos para la salud en el Caribe, donde la seroprevalencia de VIH ocupa el segundo lugar tras el África Subsahariana. MÉTODO: Se describe un enfoque colaborativo para tratamiento, prevención y cuidado de embarazadas, bebés y niños en Jamaica. Un equipo de personal académico y gubernamental vinculados a la salud, colaboraron para abordar la epidemia de VIH pediátrico y perinatal en Greater Kingston, como modelo para Jamaica (población de 2.6 millones, 1.5% seroprevalencia VIH). Se utilizó un plan de cinco puntos que incluyó liderazgo y entrenamiento, prevención de la transmisión madre a hijo (PTMAH), tratamiento y cuidado de mujeres, bebés y niños, investigaciones basadas en resultados, y outreach local, regional e internacional. RESULTADOS: Un grupo básico de profesionales del VIH pediátrico/perinatal, que incluía pediatras, obstetras, trabajadores de la salud, enfermeras, microbiólogos, administradores de datos, así como personal y estudiantes de la tecnología de la información, fue entrenado para servir en Greater Kingston (cohorte de nacimiento 20 000). De septiembre de 2002 hasta Agosto de 2007, más de 69 793 embarazadas se presentaron para recibir atención prenatal. Durante estos cinco años, tuvieron lugar mejoras significativos en cuanto a la recepción de asesoramiento (40% to 91%) y pruebas (53% to 102%) de VIH voluntarios. Ochocientos ochenta y tres mujeres resultaron VIH positivas en las pruebas, con tasas de seroprevalencia de 1-2% cada año. El uso de un ciclo corto modificado de zidovudina o nevirapina en los primeros tres años, redujo la transmisión madre a hijo (TMAH) de VIH significativamente de 29% a 6% (RR 0.27; 95% CI - 0.10, 0.68). Durante el 2005 hasta 2007, usando terapia antiretroviral altamente activa (TARAA) materna, con zidovudina y lamivudina con nevirapina, nelfinavir o lopinavir/ritonavir y nevirapina y zidovudina para niños, la TMAH se redujo a un estimado de 1.6 % en Greater Kingston y a .75% a lo largo de la isla. En cinco años, evaluamos 1570 niños en cuatro clínicas infecciosas pediátricas semanales en Kingston, Saint Andrew y Saint Catherine, así como en seis otros lugares destinados al servicio comunitario (outreach) por toda Jamaica; 24% (377) tenían VIH/SIDA y 76% (1193) estaba expuestos al VIH. Entre los niños infectados, 79% (299 de 377) iniciaron el TARAA, lo que trajo como resultado una reducción de la mortalidad y la morbilidad infantil atribuible al VIH, en todo el país. Se implementó exitosamente un programa de investigación basado en resultados. CONCLUSIÓN: Trabajando en colaboración, estamos logrando nuestra misión de prevenir la TMAH del VIH, y mejorar la calidad de vida de las familias que viven afectadas por el VIH/SIDA en Jamaica.

The Protege and the Sage : Students' Perceptions of Work-Based Mentoring Experiences

Mentoring is offered as a supportive learning strategy within an educational programme for mature multi-cultural South African nurses. This paper considers the literature; describes mentoring within a nursing management course; and uses the findings to illustrate students' mentoring experience through the following three themes: (1) Mentoring as a teaching strategy: Initial considerations; (2) Mentoring as a process; and (3) Consequences of mentoring as a teaching strategy. Self-reports; based on two questions; describe the perceptions 16 post-basic students have of mentoring as a means of scaffolded learning through the voicing of their 'authentic' experiences. This study forms a component of a larger qualitative case study of a management course using action research within the critical genre. A way forward is suggested that can promote both the mentor/mentee relationship and meaningful learning. Students paid particular attention to the difficulties of choosing mentors; engaging in and 'negotiating' the process and maintaining the relationship. They recognised the value of 'special people' (not necessarily in their discipline); in their professional development and noted the need for mutual commitment to the process to achieve mutual benefits

Massive gastrointestinal bleeding in a patient with AIDS.

Cytomegalovirus enteritis can lead to gastrointestinal bleeding in patients with the acquired immune deficiency syndrome. The commonest site of involvement is the colon, followed by the stomach and terminal ileum. Most of these lesions can be diagnosed by colonoscopy or gastroscopy. We present our experience of a patient with cytomegalovirus infection involving only the proximal jejunum causing massive lower gastrointestinal bleeding. Conventional endoscopy and imaging had failed to locate the source of bleeding. Enteroscopy performed at the time of laparotomy showed an ulcerated lesion in the jejunum. Resection followed by histological examination of the resected area confirmed the diagnosis of cytomegalovirus infection. In addition to highly active antiretroviral therapy, ganciclovir was given for 14 days in a dose of 5 mg/kg twice a day and tapered over a period of 3 months. There has been no further episode of gastrointestinal bleeding over a follow up of 9 months.

Is Journaling Empowering ? Students' Perceptions of their Reflective Writing Experience

South African health care organisations are faced by enormous challenges. Responsive measures must include employing nurse practitioners who can think critically and creatively and who can make appropriate decisions that do not necessarily fit into theory learned within a formal educational system. This study arose out of the need for a university of technology nursing department to respond to limitations imposed by traditionally-formed educational frames of reference of post-basic nurse practitioner students that historically rated proficiency in the tasks of nursing above that of knowing nursing. Reflective journals were introduced as an educational strategy within a model for critical reflective practice (Van Aswegen; 1998) to promote independent thinking for improved professional practice and support and sustain 'deep' learning. This four-year qualitative descriptive study; using content analysis of 110 student journal self-evaluations; seeks to determine the value part-time post-basic nursing students place on journaling as a means of enhancing critical reflective practice. The findings of the study suggest that open-ended reflective journals encouraged self-directed learning. Despite journaling being perceived as an arduous; time-consuming exercise particularly in the light of concomitant learning; occupational and social commitments; it was seen as a means of promoting self-insight and self-development and as a viable strategy for life-long learning

Oxygen free radicals in idiopathic facial pain.

Chronic idiopathic oro-facial pain has become a common complaint, resulting increasingly in referral to the pain clinics world-wide, about 90% of the psychologically stress-related patients of the psychiatric clinic of Eastman Dental Hospital, London have been found to have associated idiopathic oro-facial pain. Psychological stress may produce a situation where oxidative stress might enhance the production of free radicals, especially OH radicals, in human biological fluids. Furthermore, it has been suggested that. OH radicals are responsible for the production of many systemic and local tissue injury diseases which may initially manifest as pain syndrome. It has been suggested that the oxygen free radical production of sailcloth, 2,3-dihydroxybenzoic acid (DHB) is a biological marker for the detection and quantification of OH radicals. Analyses of plasma samples collected from patients with chronic idiopathic orofacial pain and an equal number of age and sex matched control subjects revealed that the patient group had significantly increased evidence for circulating levels of 2,3-DHB after aspirin ingestion than control subjects. There was no significant difference in 2,5-DHB levels between the two groups. The urine samples from the same individuals showed evidence of measurable amounts of 2,3 and 2,5-DHB in both pre- and post-aspirin samples. These results suggest that OFRs may be involved in the aetiology of pain in patients that present with facial pain.

Yaws infection in Tanna, Vanuatu 1989.

Yaws has been resurgent in the island of Tanna in southern Vanatu in the 1980's. Screening, conducted in 1988 and in 1989 during a mass treatment program identified a total of 464 clinical cases from the population of 20,200, a rate of 23 per thousand. Most of these (82%) were under 15 years of age. Serology was performed on 286 of which 23% were VDRL positive. Primary care services had been hampered in controlling yaws by difficulties with transport, isolation, community resistance and the lack of skilled personel to diagnose yaws and arrange prophylactic treatment. A mass screening and treatment program was implemented in 1989 with 91.8% coverage. This program was designed to work in the context of primary health care and thus has enhanced the relationship between the health services and local villagers. The program was successfully integrated with other health activities including health education, treatment of other diseases and vector control.

Síndrome hepatocutáneo / Hepato-cutaneous syndrome

El síndrome hepato-cutáneo comprende la asociación de hepatopatías autoinmunes, cirrosis biliar primaria o hepatitis crónica activa y lesiones cutáneas de tipo prurigoide debidas a vasculitis alérgicas. La coexistencia con otras entidades de idéntica patogenica le haría formar parte de una enfermedad autoinmune multisistémica