Greater collaboration across the disciplines: challenges and opportunities.

This paper reports a panel discussion--Opportunities for and Limitations to Greater Collaboration Across the Disciplines--held at the conference. It highlights the need for greater collaboration between demographers and epidemiologists and notes the institutional and disciplinary challenges to and opportunities for promoting greater cooperation.

Alpha-synuclein cortical Lewy bodies correlate with dementia in Parkinson's disease.

BACKGROUND: Dementia is a frequent complication of idiopathic parkinsonism or PD, usually occurring later in the protracted course of the illness. The primary site of neuropathologic change in PD is the substantia nigra, but the neuropathologic and molecular basis of dementia in PD is less clear. Although Alzheimer's pathology has been a frequent finding, recent advances in immunostaining of alpha-synuclein have suggested the possible importance of cortical Lewy bodies (CLBs) in the brains of demented patients with PD. METHODS: The brains of 22 demented and 20 nondemented patients with a clinical and neuropathologic diagnosis of PD were evaluated with standard neuropathologic techniques. In addition, CLBs and dystrophic neurites were identified immunohistochemically with antibodies specific for alpha-synuclein and ubiquitin; plaques and tangles were identified by staining with thioflavine S. Associations between dementia status and pathologic markers were tested with logistic regression. RESULTS: CLBs positive for alpha-synuclein are highly sensitive (91%) and specific (90%) neuropathologic markers of dementia in PD and slightly more sensitive than ubiquitin-positive CLBs. They are better indicators of dementia than neurofibrillary tangles, amyloid plaques, or dystrophic neurites. CONCLUSION: CLBs detected by alpha-synuclein antibodies in patients with PD are a more sensitive and specific correlate of dementia than the presence of Alzheimer's pathology, which was present in a minority of the cases in this series.

Deaths attributable to Alzheimer's disease in the United States.

OBJECTIVES: This study provided 2 estimates of the number of deaths attributable to Alzheimer's disease in the United States. METHODS: One estimate was based on data from the East Boston, Mass, study. The second was based on a simulation using population-based estimates of prevalence and separate estimates of excess death by duration of disease. RESULTS: Despite different methods and very different estimates of prevalence, these 2 methods led to very similar estimates of 173,000 and 163,000 excess deaths. CONCLUSIONS: These estimates suggest that 7.1% of all deaths in the United States in 1995 are attributable to Alzheimer's disease, placing it on a par with cerebrovascular diseases as the third leading cause of death.

Maternal diagnosis and treatment of children's fever in an endemic malaria zone of Uganda: implications for the malaria control programme.

A mother's ability to suspect malaria in the presence of fever has important consequences for child survival in malaria-endemic areas. This paper presents results of a clinic-based study of mothers' abilities to suspect malaria in the event of recognizing fever and other physiological and behavioral changes associated with the disease. The study population consisted of all (439) women or mothers who had accompanied children 5 years and below to the Old Mulago Hospital, Kampala, Uganda over a 10 day period during the malaria season of 1992. The children were those who had fever as a major complaint at the time of the visit or those who had fever in the last 7 days and were visiting the clinic for the first time for the current illness. The children were physically examined and their blood tested for malaria parasites. Mothers' diagnosis was compared with clinical and laboratory diagnosis of malaria. Mothers associated the presence of fever with several types of illness and malaria was often not suspected. Only 40% of the mothers suspected malaria in their children. The mothers were poor at recognizing malaria when, in fact, it was present. The sensitivity of the mothers' diagnosis of malaria was found to be 37%; 63% of malaria cases were misclassified as other conditions. The doctors classified most (92%) of the cases presenting with fever as having malaria, but laboratory tests indicated that only 64% of the children really had malaria. The sensitivity of clinical diagnosis was 98%, but the specificity was only 18%. Ninety percent of the mothers gave some medicines before visiting the health centre; and, of these, 76% gave modern drugs exclusively, including antimalarials, antipyretics, antibiotics and other drugs. Among the modern drugs given to children suspected of having malaria, 50% were antimalarials. The most commonly used antimalarial was chloroquine tablets. Mothers indiscriminately administered antimalarials to children irrespective of the perceived cause of the fever. There is need to educate mothers to suspect malaria first in every case of febrile illness, just like the doctors do, and about the first line drugs for the treatment of malaria.

PIP: Maternal ability to suspect malaria in the presence of fever and behavioral changes was investigated in a study of all 439 mothers who had brought febrile children 5 years of age and under to Old Mulago Hospital in Kampala, Uganda, during a 10-day period in the 1992 malaria season. The mothers' diagnosis of malaria was compared with clinical and laboratory diagnoses. Laboratory tests indicated that 64% of these children actually had malaria. Only 40% of mothers suspected malaria in their children. The sensitivity of mothers' diagnosis of malaria was 37%; 63% of malaria cases were misclassified as other conditions. Physicians diagnosed 92% of cases presenting with fever as malaria. The sensitivity of clinical diagnosis was 98%, but the specificity was only 18%. 90% of mothers indiscriminately administered some medication--primarily antimalarials such as chloroquine--before bringing their child to the clinic. In malaria-endemic areas, mothers' inability or delay in relating fever to malaria may have adverse effects on child survival. These findings indicate a need to educate mothers to suspect malaria first when fever is present and to administer appropriate treatment.

The relationship between extrapyramidal signs and cognitive performance in patients with Alzheimer's disease enrolled in the CERAD Study. Consortium to Establish a Registry for Alzheimer's Disease.

The objective of this study was to determine the relationship between the presence of extrapyramidal signs and the severity of cognitive and functional impairment in patients with Alzheimer's disease (AD). Eleven university medical centers in the United States and France participated in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) study of extrapyramidal signs in AD. Forty-seven patients with probable AD who had extrapyramidal signs were matched by sex, race, education, and age with 132 probable AD patients without extrapyramidal signs. The main outcome measures were the Clinical Dementia Rating, Blessed Dementia Scale, and the CERAD Neuropsychology Battery (verbal fluency, naming, Mini-Mental State Examination, word list learning, word list recall, savings ratio, word list recognition, and constructional praxis). AD patients with extrapyramidal signs performed more poorly than AD patients without parkinsonism on various neuropsychological tests, even after controlling for the Clinical Dementia Rating and reported duration of cognitive impairment. The severity of the extrapyramidal manifestations was related to the degree of cognitive and functional impairment. Muscular rigidity and bradykinesia were the most frequent extrapyramidal signs associated with AD. Patients with AD associated with extrapyramidal signs have greater cognitive and functional impairment than AD patients without clinical evidence of parkinsonism.

Quantitative anatomic measures and comorbid medical illness in late-life major depression.

The authors examined the individual and relative roles of atrophy, comorbid medical illness, and cerebrovascular risk factors in the pathogenesis of late-life major depressive disorder (MDD). They used magnetic resonance imaging techniques to study 28 subjects with late-life MDD, 29 healthy control subjects, and 34 subjects with probable dementia of the Alzheimer type (DAT). Depressed subjects showed increases in cerebrospinal fluid volumes comparable to the DAT group but significantly different from control subjects. High-intensity signals, but not measures of atrophy correlated significantly with cerebrovascular risk factor scores. A logistic regression revealed that both brain atrophy and medical illness are associated with an increased risk of developing MDD. Data suggest that both atrophy and comorbid medical illness increase the likelihood of developing MDD in late life.

Performance of the dementia severity rating scale: a caregiver questionnaire for rating severity in Alzheimer disease.

The Dementia Severity Rating Scale (DSRS) is an informant-based, multiple-choice questionnaire that assesses severity from the mildest to the most severe stages in the major functional and cognitive domains affected in Alzheimer disease (AD). The DSRS has good reliability as measured by making repeated observations over short time periods and by comparing caregiver responses to information collected by a physician or an experienced nonphysician research associate. The measure correlates favorably with the Washington University Clinical Dementia Rating scale and with standard cognitive testing measures. The DSRS provides a simple, valid, and sensitive measure of impairment associated with AD. It is ideally suited for multisite collaborative studies and can be implemented with a minimum of staff time and training.

The focus group as a tool for health research: issues in design and analysis.

The focus group is a technique for eliciting information from specific population subgroups. Issues addressed may be little known or relatively well known to the researcher. The method is most effectively used when the objective of the investigation is to elicit points of view of client or consumer groups which may differ from those of providers. Despite the frequency with which focus groups are used, few published materials describe the practical application of the method. This paper presents a detailed methodology for the conduct of focus groups and analysis of focus-group data with the intention of improving its use among researchers and health-care professionals. Data from two studies, immunization compliance in West Africa, and barriers to use of prenatal-care services in Bolivia, are used as illustrative examples.

Child feeding practices in a rural area of Zimbabwe.

This paper reports preliminary results from a study of child feeding practices in a rural area of Zimbabwe. Although Zimbabwe has relatively low infant mortality rates, it still has high child malnutrition rates. Several factors, including sex roles and relations between the sexes, access to resources, food costs and availability, time and energy costs of food production and preparation, and illness beliefs and practices, especially those concerning diarrhea and malnutrition, are examined as possible determinants of feeding practices and nutritional and health status. Results are compared to reports made by the World Bank and the Zimbabwe national nutrition survey. Whereas the World Bank report suggests a problem of late introduction of breastmilk supplements or solids, we found the opposite tendency of early introduction (by 3 months) of supplements. We suggest that mothers' pragmatic attitudes, interacting with certain social, cultural, and economic variables, are important factors influencing their child feeding decisions, especially resisting the use of commercial infant formula, at least in this rural area, and promoting prolonged breastfeeding.

Impact of selective primary care on childhood mortality in a rural health zone of Zaire.

Following the introduction of intensified child survival activities, use of health services for children increased markedly: measles vaccination reached 74% of children aged 12-23 months, and the use of oral rehydration therapy for the treatment of diarrhoea had increased. During the same period, childhood mortality declined by 33% for children aged 1-4 years. Data on cases of measles in the local hospital reveals that the pattern of measles epidemics characteristic of the years preceding programme implementation was altered in the years following programme implementation. The mean annual number of inpatient measles cases declined from 108 before the programme to 36 after its start. The high correlation between the number of inpatient measles cases and mortality at ages 6-35 months suggests that the programme reduced mortality largely by reducing the incidence of measles. Primary health care activities, supported in part by the Combatting Childhood Communicable Diseases Project, is estimated to have reduced mortality at ages 6-35 months by at least the 18-23% associated with the change in the incidence of measles and may have been responsible for the full 28% reduction recorded between 1980-1984 and 1985-1989.

Impact of health programmes on child mortality in Africa: evidence from Zaire and Liberia.

The Mortality and Use of Health Services studies were designed to measure changes in the coverage of health services and in infant and child mortality rates associated with the implementation of the Combatting Childhood Communicable Diseases programme. The papers in this supplement provide the results of research carried out in areas of Zaire and Liberia. Data from these studies provide credible evidence that these programmes actually reduced mortality. The proportion of children dying by their fifth birthday declined by 17% in Zaire and by 32% in Liberia. These estimates of programme impact are consistent with the increases in the use of health services and with data from similar studies in other countries. Results of these surveys suggest that child survival programmes in Africa can reduce mortality substantially in populations living in different environments at very different initial levels of child mortality.

A strategy for evaluating the mortality impact of child survival programmes in Africa: Combatting Childhood Communicable Diseases Project.

The Mortality and Use of Health Services surveys were designed to measure the mortality impact of the Combatting Childhood Communicable Diseases programmes which are based on childhood vaccinations, prenatal immunization against tetanus, home-based use of oral rehydration therapy, and presumptive treatment of malaria. The survey design includes pretest and post-test surveys in programme and non-programme areas. The questionnaires are designed to collect information on use of health services and on pregnancy histories to provide retrospective reporting of child mortality. When combined with data from surveillance systems (particularly information on cases of measles cases seen at clinics and health centres), these data should provide reasonable estimates of programme impact.

Estimating birth stopping and spacing behavior.

A decomposition of age-specific marital fertility rates into indices related to spacing and stopping is developed by using Coale and Trussell's indices and the first few parity progression ratios. This approach leads to estimates of the mean birth interval among low-parity births that can be used to address the issue of fertility control early in marriage. In this way the model addresses several of the most serious limitations of Coale and Trussell's approach. The usefulness of the proposed indices is demonstrated by applications to historical data from the United States and Europe.

The effect of child fostering on feeding practices and access to health services in rural Sierra Leone.

In Sierra Leone, where infant and child mortality rates are quite high, a large proportion of small children from 1 to 5 yr are fostered: living away from their mothers. This paper examines the relationships between fosterage and child feeding practices and children's access to Western medical care. Ethnographic data from field studies in Sierra Leone are combined with quantitative data from Serabu Hospital, which show that fostered children are underrepresented in hospital admissions and that young fosters present more problems of malnutrition. (Fostered girls appear to be at more risk in both these categories than boys.) Unlike young fosters, however, older ones do not appear to be at more risk than children with mothers. We draw connections between these results and patterns of intra-household discrimination in food allocation and access to medical treatment for young fostered children: especially those sent to elderly rural caretakers. Finally, we examine the implications of the findings for applied issues, arguing that fostered children may slip through the cracks of maternal-child health care programs.

Demographic heterogeneity and uncertainty in population projections.

Recent developments in a class of stochastic population processes were used to study the impact of demographic heterogeneity on the uncertainty of population projections. Selected for study by computer simulation were population projections for East Africa designed to quantify opinions regarding expected fertility and mortality declines. Since both fertility and mortality declined in these projections, their laws of evolution may be described as time inhomogeneous. The computer simulation studies reported in this paper strongly suggest that randomized laws of evolution should be taken into account in further developments of population projection methodologies designed formally and computationally to accommodate uncertainty. Variability in fecundability, the kind of demographic heterogeneity studied in this paper, is only one aspect of these randomized laws.

History of black mortality and health before 1940.

This article documents the history of black mortality between 1850 and 1940 and begins the process of placing that history into the context of the more general history of mortality decline in the United States. One aspect of this process has been to discuss the trends in mortality among blacks and whites living in the same general geographic areas--for example, comparing southern rural blacks with southern rural whites. A second part has been to relate black mortality to many of the factors that have been discussed as determinants of general mortality trends--such as water and sanitation, the urban disadvantage in mortality, and child care and feeding practices. During the second half of the nineteenth century, black mortality declined only slightly or not at all. Between 1850 and 1880 there may have been some decline in child mortality, but the trends in adult mortality are indeterminate. Between 1880 and 1900 both child and adult mortality rates were constant. Sometime between 1900 and 1910 mortality rates among blacks began to decline at all ages, especially in urban areas. During the first four decades of this century mortality rates among American blacks declined substantially. Expectation of life at birth increased from about 35 years to about 54 years, which represents a significant improvement in health and living standards. The life expectancy among blacks in 1940, however, was still two years below the value for whites in the death registration area in 1920. (This may exaggerate the difference slightly since the mortality rates for 1919 and 1920 were artificially low following the pandemic of influenza in 1918. In addition, the mortality rates in the DRA may not have been representative of the whole white population.) Throughout the period studied, blacks had substantially higher mortality rates than whites living in the same area. Although the amount of excessive mortality among blacks differed from place to place and period to period, we did not find a single area or time when black mortality rates were close to those of whites. The examination of causes of death among whites and blacks in 1920 showed that racial differences in the amount of tuberculosis explained a substantial part of the mortality differences in New York and North Carolina, but blacks probably had excessive mortality due to all causes.(ABSTRACT TRUNCATED AT 400 WORDS)