Help-seeking for 'memory loss' by older adults in India : patient, caregiver and health providers' perspectives

ABSTRACT: Background. In India, prevalence rates of dementia and prodromal amnestic Mild Cognitive Impairment (MCI) are 3.1% and 4.3% respectively. Most Indians refer to the full spectrum of cognitive disorders simply as ‘memory loss.’ Barring prevention or cure, these conditions will rise rapidly with population aging. Evidence-based policies and practices can improve the lives of affected individuals and their caregivers, but will require timely and sustained uptake. Objectives. Framed by social cognitive theories of health behavior, this study explores the knowledge, attitudes and practices concerning cognitive impairment and related service use by older adults who screen positive for MCI, their primary caregivers, and health providers. Methods. I used the Montreal Cognitive Assessment to screen for cognitive impairment in memory camps in Mumbai. To achieve sampling diversity, I used maximum variation sampling. Ten adults aged 60+ who had no significant functional impairment but screened positive for MCI and their caregivers participated in separate focus groups. Four other such dyads and six doctors/ traditional healers completed in-depth interviews. Data were translated from Hindi or Marathi to English and analyzed in Atlas.ti using Framework Analysis. Findings. Knowledge and awareness of cognitive impairment and available resources were very low. Physicians attributed the condition to disease-induced pathology while lay persons blamed brain malfunction due to normal aging. Main attitudes were that this condition is not a disease, is not serious and/or is not treatable, and that it evokes stigma toward and among impaired persons, their families and providers. Low knowledge and poor attitudes impeded help-seeking. Conclusions. Cognitive disorders of aging will take a heavy toll on private lives and public resources in developing countries. Early detection, accurate diagnosis, systematic monitoring and quality care are needed to compress the period of morbidity and promote quality of life. Key stakeholders provide essential insights into how scientific and indigenous knowledge and sociocultural attitudes affect use and provision of resources

Screening and Diagnosis of Dementia in the Hospital and the Community.

Introduction: Dementia (from the Latin de mens—from the mind) is not a specific disease itself, but Rather a group of psychological and behavioral symptoms associated with a variety of Diseases and conditions that affect the brain (Rabins, Lyketsos, and Steele 1999). Generally, dementia is characterized as the loss or impairment of mental abilities. With Dementia, these cognitive losses (e.g., in reasoning, memory, and thinking) are severe Enough to interfere with a person's daily life. Additionally, such losses are noticeable in A person who is awake and alert—the term dementia does not apply to cognitive Problems caused by drowsiness, intoxication or simple inattention (American Psychiatric Association 1994). Although often associated with later life, the symptoms of dementia can affect people Of any age. Before age sixty-five, however, the incidence of dementia is low—affecting One-half to 1 percent of the population (Rabins et al. 1999). As people get older, the Risk of dementia rises. It is estimated that dementia affects less than 10 percent of the Sixty-five-and-over population globally (Ikels 1998). The prevalence doubles every 5 Years among people in this age group. Despite its prevalence, up to three fourths of dementia goes unrecognized or Misdiagnosed in its early stages (Sternberg, et al., 2000). Many health care Professionals mistakenly view the early symptoms of dementia as inevitable Consequences of ageing or Minimal Cognitive Impairment (MCI). Dementia continues To be one of the most common causes of institutionalization, morbidity, and mortality Among the elderly. 1.1 DEMENTIA 1.1.1 DEFINITION Dementia is defined as global impairment of cognitive function that interferes with Normal activities (APA, 1994). Although impaired memory -both short term and long Term- are typical of dementia, deficits in other cognitive functions such as abstract Thinking, judgment, speech, coordination, planning and organization are required to Make a diagnosis. There are many definitions of dementia. The Royal College of Physicians (1982), Define dementia as the acquired global impairment of higher cortical functions Including memory, the capacity to solve problems of day-to-day living, the Performance of learned perceptual and motor skills, the correct use of social skills, all Aspects of language and communication and the control of emotional reaction, in the Absence of clouding of consciousness. The condition is often progressive though not Necessarily irreversible. 1.1.2 DIAGNOSTIC CRITERIA DSM IV DIAGNOSTIC CRITERIA The diagnosis of dementia can be made according to the DSM-IV classification as Stated below: A. The development of multiple cognitive deficits manifested by:- Memory impairment (impaired ability to learn new information or to Recall previously learned information) One (or more) of the following cognitive disturbances Aphasia Apraxia Agnosia Disturbance in executive functioning B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in Social and occupational functioning and represent a significant decline from a previous Level of functional (APA, 2000). INTERNATIONAL CLASSIFICATION OF DISEASES (ICD – 10) DIAGNOSTIC CRITERIA: Dementia is a syndrome due to disease of the brain, usually of a chronic or progressive Nature, in which there is disturbance of multiple higher functions, including memory, Thinking, orientation and comprehension, calculation, learning capacity, language and Judgment. Consciousness is not clouded. Impairments of cognitive function are Accompanied and occasionally preceded by deterioration in emotional control, social Behavior or motivation (WHO, 1992). 1.1.3 TYPES Dementing disorders can be classified in many different ways. These classification Schemes attempt to group disorders that have particular features in common, such as Whether they are progressive or what parts of the brain are affected. Examples of types Of dementia include the following: I. Cortical Dementia: Dementia caused due to damage to the cortex or outer layer is cortical dementia. Cortical dementias tend to cause problems with memory, language, thinking and Social behavior. Some example of cortical dementias are Alzheimer's disease, Vascular dementia (also known as multi-infarct dementia), Binswanger's Disease, Dementia with Lewy bodies (DLB), Alcohol-Induced Persisting Dementia, Frontotemporal lobar degenerations (FTLD), including Pick's Disease, Creutzfeldt-Jakob disease and Dementia pugilistica. II. Subcortical Dementia: Dementia affecting parts of the brain below cortex is subcortical dementia. This type Causes changes in emotions and movement in addition to problems with memory. Some Examples of sub-cortical dementias are Dementia due to Huntington's disease, Dementia due to Hypothyroidism, Dementia due to Parkinson's disease, Dementia due To Vitamin B1 deficiency, Dementia due to Vitamin B12 deficiency, Dementia due to Folate deficiency, Dementia due to Syphilis, Dementia due to Subdural hematoma, AIDS dementia complex III. Progressive Dementia: As the name indicates, the dementia that worsens over a period interfering with Cognitive abilities is called progressive dementia. IV. Primary Dementia: Primary dementia does not result from any other disease for example: Alzheimer’s Disease. V. Secondary Dementia: Dementia caused due to a physical disease or injury is called secondary dementia. (Karen Ritchie, 2002; Peter, 2003) REVERSIBLE DEMENTIAS Studies indicate that 10% to 33% of all dementias are potentially reversible (Rabins, et Al., 1983). The percentage is higher in inpatient and tertiary referral centers. Clearly, Age of onset is a very important consideration. Treatable causes of dementia occur in 21% of those under 65 and 5% of those over 65. Unfortunately, even in the potentially Treatable group of illnesses, response rate is not 100%. Common examples of reversible Causes of dementia are depression ("pseudo dementia"), dementia due to drug Intoxication, metabolic-endocrine derangements, Hypothyroidism and normal pressure Hydrocephalus (Rabin’s, 1983). In a prospective study done in India, 18% had reversible cause. However this was a Study done in a tertiary referral centre (Srikanth, et al., 2005). 1.1.4 RISK FACTORS FOR DEMENTIA The known risk factors for dementia are Age Genetic factors Head injuries (Mehta, 1999). History of stroke (Breteler, 1998) Vascular disease (Breteler, 1998) Alcohol Abuse Low education (Ott et al., 1995) Untreated infectious and metabolic disease Brain tumor Cardiovascular disease (e.g., hypertension, atherosclerosis) Kidney failure Liver disease and Thyroid disease, Vitamin deficiencies (B12, folic acid and thiamine). 1.1.5 MANAGEMENT OF DEMENTIA CLINICAL PRACTICE GUIDELINES - SUMMARY OF RECOMMENDATIONS (Doody, 2001) Dementia is often progressive and symptoms will change over time. Similarly, Treatment must evolve with time as new issues will emerged as symptoms change. At Each stage the physician should be alert and help the patient and family anticipate Future symptoms and care that may be required. Psychiatric Aspects of Management The core treatment of a patient with dementia is psychiatric care which must be based On a close alliance with the family/caregiver. A thorough psychiatric, neurological and General medical evaluation to determine the nature of deficits is required for every Patient. It is critical to identify and treat the general medical conditions that may Contribute to the dementia and associated behavioural symptoms. Ongoing assessment includes periodic monitoring of cognitive and non-cognitive Psychiatric symptoms and their responses to intervention. It is generally necessary to Routinely review patients every 3-6 months. More frequent visits may be required for Patients with complex or potentially dangerous symptoms or during administration of Specific therapies. Safety measures need to be constantly evaluated. Educating the Patient and family about the illness, treatment, sources of care and support, and Financial and legal issues is important. NON-PHARMACOLOGICAL INTERVENTIONS Non-pharmacological interventions should always be considered along with drug Options before treatment is started. These include behaviour oriented treatment Approaches, stimulation oriented treatment approaches and emotion oriented treatment Approaches. A care plan should be made for each individual and treatment reviewed Every 3-6 months. PHARMACOLOGICAL INTERVENTIONS Acetylcholinesterase inhibitors show modest efficacy in improving cognition in Patients with mild to moderate Alzheimer’s disease. Drugs like Donepezil, Rivastigmine, Memantine, etc., must only be used after a thorough discussion of their Potential risks and benefits. There is insufficient evidence at present to recommend the Routine use of other cognitive enhancers such as vitamin E, selegiline, gingko biloba Etc. Neuroleptic drugs are often required for the management of psychosis, serious Emotional distress or danger from behavioural disturbances. The choice of drug Depends on their side-effect profile. Low doses should be prescribed initially with a Slow and cautious increase, if necessary. Treatment should normally be short term and Should be reviewed regularly. Awareness of potential side-effects including akathisia And tardive dyskinesia is important; the risk of severe side-effects is greater in Lewy Body dementia. The routine use of anticholinergics should be avoided. Marked and persistent depression should be treated with antidepressant medication. Severe and persistent anxiety and insomnia may require short-term symptomatic Treatment. 1.1.6 PROGNOSIS OF DEMENTIA The mode of onset and subsequent course of dementia depend on the underlying Etiology. Dementia may be progressive, static or remitting. The reversibility of Dementia depends on the underlying pathology, the availability and timely application Of effective treatment. The prognosis for reversible dementia related to nutritional or Thyroid problems is usually good once the cause has been identified and treated. The Prognoses for dementias related to alcoholism or HIV infection depend on the patient's Age and the severity of the underlying disorder (Wolfson, 2001). Irreversible causes of Dementia often result in gradual deterioration of the patient's functioning ending in Death. The natural history of the disease is that of a decline due to progressive damage To widespread areas of the brain. The length of time varies. Patients with Alzheimer's Disease may live from two–20 years with the disease, with an average of seven years. Patients with frontal lobe dementia or Pick's disease live on average between five and 10 years after diagnosis. The course of Creutzfeldt-Jakob disease is much more rapid, With patients living between five and 12 months after diagnosis (Wolfson, 2001) 1.1.7 BURDEN OF DISEASE Dementia was estimated to be the 10th leading cause of non-fatal burden in the world in 1990, accounting for 2.6% of total YLD (Years Lived with a Disability); this is around The same percentage as congenital malformations. In the Version 2 estimates for the Global Burden of Disease 2000 study, published in the World Health Report 2002, Dementia is the 11th leading cause of ylds at global level, accounting for 2.0% of total Global ylds. Despite the difficulties of determining its prevalence and incidence, it is Clear that dementia causes a substantial burden globally (Mathers, 2000). Dementia Poses considerable medical, social, and economic concerns as it impacts individuals, Families and health-care systems throughout the world (National Institute on Aging and National Institutes of Health 1999; O'Shea and O'Reilly 2000). The annual costs of Treating Alzheimer's disease alone, including medical and nursing costs and lost Productivity have been estimated to be $67 billion (Langa, et al., 2001) to$100 billion (Ernst, et al., 1994). With the majority of persons with dementia being cared for in the community, it has Been suggested that the coping mechanisms and resources of families may be severely Tested (O'Shea and O'Reilly 2000). During the prolonged care period characteristic of Alzheimer's disease and other demential conditions, caregivers face the potential for Social isolation; financial drain; and physical duress (Clyburn et al. 2000). Women are Particularly vulnerable, as they make up the majority of care providers (Gwyther 2000). 1.2 PREVALENCE OF DEMENTIA 1.2.1 INTERNATIONAL DATA Prevalence refers to the number of people with dementia in the population at a given Point in time. There are a large number of prevalence surveys, which have been carried Out throughout the world. These tend to give slightly different results depending on the Methods used in the study. However, all studies show a sharp rise in the prevalence of Dementia with age In the United States, approximately 5 to 8 percent of people over the age of sixty-five Suffer from dementia (Tinker 2000). For the oldest old (age seventy-five and over), the Risk of dementia is much greater. Approximately 18 to 20 percent of those over the age Of seventy-five have dementia and between 35 to 40 percent of people eighty-five years Of age or older are affected (Ikels 1998; Rabins et al. 1999; Tinker 2000). Thus the prevalence of dementia increases steadily with age, roughly doubling every 5 Years. Studies of community-dwelling elderly have reported dementia in 0.8-1.6% of Persons 65-74 years old, 7-8% of persons 75-84 years old, and 18-32% of persons over 85.5. Estimates of the annual incidence of dementia in community-based studies in the West are 0.6-1% for ages 65-74, 2-3% for ages 75-84, and 4-8% for ages 85 or older (Ritchie, et al., 1992). In the famous Rotterdam study 474 cases of dementia were detected, giving an overall Prevalence of 6.3%. Prevalence ranged from 0.4% (5/1181 subjects) at age 55-59 years To 43.2% (19/44) at 95 years and over. Alzheimer's disease was the main sub diagnosis (339 cases; 72%); it was also the main cause of the pronounced increase in dementia With age. The relative proportion of vascular dementia (76 cases; 16%), Parkinson's Disease dementia (30; 6%), and other dementias (24; 5%) decreased with age. A Substantially higher prevalence of dementia was found in subjects with a low level of Education (Ott, et al., 1995). In the Canadian study, 1994, the prevalence of dementia was 8.0% among all Canadians aged 65 and over and the female: male ratio was 2:1. The age-standardized Rate ranged from 2.4%, among those aged 65 to 74 years, to 34.5%, among those aged 85 and over. The corresponding figures for Alzheimer's disease were 5.1% overall, Ranging from 1.0% to 26.0%; for vascular dementia it was 1.5% overall, ranging from 0.6% to 4.8%. 1.2.2 INCREASE IN PREVALENCE Because of the ageing of the world’s population, in the future there will be relatively More people in the age groups at most risk for dementia. In the absence of effective Prevention or treatment, the increase in the numbers of people with dementia will come About as a simple consequence of an increase in the size of the population most at risk, I.e. Of those aged 65 years and over. Between 1990 and 2010, the number of dementia Cases in the more developed countries is projected to increase from 7.4 million to 10.2 Million (a 37% increase), the elderly population (aged 65+) from 143 million to 185 Million (a 30% increase) and the total population in these countries is projected to Increase from 1,143 million to 1,213 million (6% increase). Because of the lack of Prevalence data from the less developed countries, it is difficult to make projections of The future number of dementia cases. However, these countries are also ageing rapidly And are therefore expected to show an increase in dementia cases. The prevalence rate Might also conceivably increase if, for example, better care of people with dementia Meant that they survived longer (Ferri, 2005). 1.2.3 INDIAN STUDIES Investigators have documented prevalence rates for dementia in various community Surveys in India. In a study conducted in an urban setting in South India to investigate The prevalence, psychosocial correlates and risk factors of various dementias, the Prevalence of dementia was 33.6 per 1000 (95% CI 27.3-40.7). Alzheimer's disease was The most common type (54%) followed by vascular dementia (39%), and 7% of cases Were due to causes such as infection, tumor and trauma. Family history of dementia was Found to be a risk factor for Alzheimer's disease while a history of hypertension was a Risk factor for vascular dementia. (Shaji, et al., 2005) In a 3-year epidemiological survey for dementia in an urban community-resident Population in Mumbai, India, the prevalence rates were as follows: the prevalence rate For dementia in those aged 40 years and more was 0.43% and for persons aged 65 and Above was 2.44%. The overall prevalence rate of dementia was 0.32% and a prevalence Rate of 1.81% for those aged 65 years and older. The overall prevalence rate for Alzheimer's disease (AD) in the population was 0.25%, and 1.5% for those aged 65 Years and above. AD (n = 62; 65%) was the most common cause of dementia followed By vascular dementia (n = 23; 22%). There were more women (n = 38) than men (n = 24) in the AD group (Sachdeva, 2001). 1.2.4 VARIATION IN RATES In various studies the reported prevalence has been lower in India (1.36% to 3.50%) Compared to the West (5.9% to 9.4%) (Chandra, et al., 1998; Ferri, et al., 2005). True Differences may be attributed to Differing genetic factors Environmental factors Life expectancy Duration with disease and age specific incidence (Prince, et al., 2000). Variation in rates may also be as a result of Different survey procedures (one stage/two stage) Diagnostic criteria used (Henderson,1994) Assessment schedules Diagnostic instruments used (most instruments not validated in developing World) (Jacob, 2007). In a study done to examine the effect of different diagnostic criteria on the prevalence Of dementia, 10000 subjects aged above 65 years were recruited in a community survey Using a one-stage procedure. The results showed that the prevalence of dementia was Different on using different diagnostic criteria. Minor differences in criteria had a Significant impact on the diagnosis. The assessment was influenced by Education (Ott, et al., 1995) Level of baseline function Lifestyle and demand on the person Tolerance of impairment Expectation by relatives Differences between hospital and community based populations. The prevalence according to this study showed wide variation in rates of prevalence When different criteria were used. Criteria for dementia Prevalence GMS (using AGECAT) 63.4 %( 60.3-69.6) 10/66 algorithm (Prince et al., 2003) 21.2% (18.7-23.9) Education adjusted 10/66 algorithm (Prince et al., 2004) 10.6% (8.8-12.7) DSM IV full criteria 0.8% (0.4-1.6%) (Jacob, et al., 2007) 1.3 ISSUES RELATED TO DIAGNOSIS OF DEMENTIA 1.3.1 ADVANTAGES OF EARLY DETECTION: There are several potential benefits of detecting dementia before patients are severely Impaired: Reversible causes of dementia may be identified and treated. Treatments to slow the progression of disease can be instituted. Measures can be taken to reduce the morbidity associated with dementia. Patients and their family members can anticipate, prepare for problems and plan For the future. Better control of risk factors for cerebrovascular disease. Treatment of associated disorders may improve function in patients with Dementia. Effective interventions can be planned to prevent falls or accidents. Decisions about durable power of attorney can be made while the patient is still Competent to participate. 1.3.2 PROBLEM OF UNDERRECOGNITION Dementia continues to be under-recognized within community practice settings (Bair, 1998). Dementia is easily recognized in its advanced stages, but numerous studies Indicate that clinicians often overlook the early signs of dementia. Clinicians fail to Detect an estimated 21% to 72% of patients with dementia, especially when the disease Is early in its course. Thus around two thirds of the cases of dementia may remain Undetected. A population-based study found that the prevalence of undiagnosed Dementia among individuals aged 65 years and older was 1.8 percent (Sternberg, et al., 2000). Another population-based study found that about half of the relatives of men With mild dementia failed to recognize a problem with thinking or memory. Among the Undiagnosed patients the majority had dementia of were mild to moderate severity. These low detection rates, the availability of therapy, and the opportunity to elucidate Patients' preferences for future health planning drives the interest in dementia screening Programs in primary care. 1.3.3 BARRIERS TO DISEASE DIAGNOSIS The barriers to the diagnosis of dementia include: Difficulty in distinguishing early disease from normal aging Definitions usually depend upon the impact of the condition on social, Functional or occupational activities, which can be biased. Patients, fearing a label, deliberately minimize their symptoms Patients with more advanced dementia may not be aware of their deficits. The “homelessness” of clinical management of dementia between various Medical specialties Most psychiatrists do not incorporate a cognitive screen in daily practice. Clinicians in

A study of the attitudes of the families of ten patients over sixty years of age requiring placement on trial visit from Boston State Hospital

Thesis (M.S.)--Boston Universit

From a synchronous systems model to an ecological approach to rehabilitation of the stroke patient

The literature on stroke reveals an increasing interest in the role played by social and emotional factors in rehabilitation after stroke. A comprehensive literature survey shows profiles of spontaneous recovery, the significance of a team approach to rehabilitation, patterns of prognostic significance for long-term recovery and adaptation and formulations of rehabilitation models for the Western world. The importance of depression as a major factor in demotivation to participate in rehabilitation and achieve long-term quality of life post-stroke emerges. From the literature survey a research design was formulated for the ecological study of a sample of 51 stroke patients at Ga-Rankuwa Hospital near Pretoria. The questionnaire was structured according to the Synchronous Systems Model, and data gathered from the biological, personal and environmental spheres of patients. Data was collected by a multidisciplinary team at three assessment times, three days, two weeks and three months post-stroke. These corresponded to the acute physical phase of stroke, the end of the hospitalisation period, and an assessment of patients once they had been discharged back into the community. Descriptive statistics were obtained on all variables and principle axis factor analysis was performed to verify the factorial structure of the tests. In order to establish whether group scores changed between assessments, t-tests for dependent measures were applied. Pearson Product Moment correlations were computed for the purpose of establishing relationships between variables. The results revealed dramatically differing biographical characteristics of the sample of stroke patients both premorbidly and at three months after the stroke. Significant recovery profiles emerged in both the physical and neuropsychological spheres at both the 14 day and 3 month assessments. Depression and the functioning at home and at work social sphere of role emerged as profiles of deterioration. At 14 days, depression was related to physical and cerebral functioning. This changed at three months, with depression also being significantly related to aspects of social functioning. On the basis of these results, depression after stroke was conceptualised as a severance of relational connectedness in the social ecological functioning of stroke patients. An ecological approach to rehabilitation is proposed that would seek to reframe the identity of stroke patients and establish relational connectedness post-stroke.PsychologyD. Litt. et Phil. (Psychology

A public survey on electroconvulsive therapy

Health care professionals have debated the use and effects of electroconvulsive therapy (ECT) for more than 65 years. Yet, the attitudes towards, and knowledge about, ECT have not been thoroughly researched within the Australian community. There is also little empirical research documenting ECT recipient characteristics, the number of ECT administrations and the number of patients treated. This study aimed to develop an Australian perspective on: (1) the level of Public knowledge about and attitudes towards ECT and (2) the practice of ECT. The objectives were achieved through the development of questionnaires, and the distribution of these questionnaires to the public to survey knowledge about and attitudes towards ECT. The Mental Health Information System (MHIS) together with data of some State psychiatric hospitals, was examined in order to estimate the characteristics of ECT recipients, and the frequency of the practice. Results from 379 questionnaires indicated that more than 60% of respondents have some knowledge about the main aspects of ECT. Furthermore, participants were generally opposed to the use of ECT on individuals with psychosocial issues; children; and those who refuse to have ECT. This study showed that public perceptions of ECT were mainly negative. Furthermore, this thesis revealed that most WA ECT recipients were adult females who were diagnosed with affective disorders. ECT usage appeared to be a constant proportion of the psychiatric population in WA over a five-year period, although the number of ECT recipients rose dramatically each year. The findings of this thesis suggested that clinicians should ensure that individuals recommended for ECT are at least knowledgeable about basic ECT processes and their implications. With this basic awareness, individuals would then be able to give informed consent. Another recommendation was that a more comprehensive State ECT register be created. This would allow more accurate estimations of the number of ECT administrations in future, and facilitate more effective and efficient monitoring of ECT practice. Overall, it was anticipated that the result of this thesis would contribute towards the prescribing practice of clinicians, and direct mental health education programmers, researchers and policy makers

Stem Cell Oncology

Stem cell research is one of the fascinating areas of contemporary biology, but, as with many expanding fields of scientific inquiry, research on stem cells raises scientific questions as rapidly as it generates discoveries. Research on stem cell treatment continues to advance knowledge about how an organism develops from a single cell and how healthy cells replace damaged cells in adult organisms. The most important potential application of human stem cells is the generation of cells and tissues that could be used for cell-based therapies, especially oncology. The Faculty of Medicine, Universitas Sumatera Utara, collaborated with the center of excellence and innovation (Pusat Unggulan Inovasi /PUI). The Stem Cell center of the Universitas Sumatera Utara (USU) organized an International Conference. The International Stem Cell and Oncology Conference (ISCOC) 2017 was an comprehensive academic conference in the field of stem cell and oncology research and also tropical medicine and related scientific topics. We expect this conference will benefit academics and practitioners in the field of health sciences in Indonesia. During the two day conference, researchers presented the most recent discoveries in stem cell and oncology and also general medical topics, and served as well in establishing networking for joint researchers and collaboration among participants. The editors and the scientific committee would like to thank the participants and express their gratitude to Faculty of Medicine of the Universitas Sumatera Utara for their support to ISCOC 2017. Lastly, we are most indebted for the generous support given by Universitas Sumatera Utara, Medan, Sumatera Utara, Indonesia

The role of subjective and objective social isolation as predictors of mental health recovery

Background Loneliness is increasingly being acknowledged as a more pervasive experience for people with mental health problems than the general population. Research also suggests that people with mental health problems tend to be more objectively socially isolated than people without mental health diagnoses. However, with most research to date are restricted to their cross-sectional design, more longitudinal studies exploring the impact of both issues on mental health outcomes are of high value. Method Drawing the data from the Crisis Team Optimisation and Relapse Prevention (CORE) study, this PhD thesis established whether baseline loneliness and social network size were associated with self-rated personal recovery and overall psychiatric symptom severity at 18-month follow-up among people with mental health issues. This PhD thesis also determined whether persistent severe loneliness and persistent objective social isolation were associated with poor self-rated personal recovery at 18-month follow-up. Additionally, a systematic review was carried out to evaluate the effectiveness of potential interventions for subjective and objective social isolation among people with mental health problems. Results The quantitative analyses indicate that greater baseline loneliness was associated with poorer personal recovery and greater symptom severity at 18-month follow-up, after adjusting for three blocks of baseline confounding variables. Persistent severe loneliness group was associated with the poorest self-rated personal recovery at 18-month follow-up, followed by the intermittent severe loneliness group and never severe loneliness group. Persistent objective social isolation group was also associated with poorer personal recovery at 18-month follow-up, compared to the never objective social isolation group. The systematic review provides preliminary evidence supporting promising interventions with cognition modification for subjective social isolation, interventions with supported socialisation and mixed strategies for objective social isolation. Conclusion This research advances our existing evidence-base in the field of loneliness research. The need for more rigorous work with a longitudinal research design is warranted

Tick-borne encephalitis : clinical and pathogenetic aspects

The aims of this study were to investigate the morbidity associated with tick-borne encephalitis (TBE) in the acute stage and at long-term follow-up, to identify the possible host risk factors for development of clinical TBE with special reference to the role of the genetic polymorphism, and to investigate neurochemical changes in the brain induced by TBE virus (TBEV) and their possible role on severity of TBE with special reference to endogenous kynurenic acid (KYNA). Paper I: Of 250 consecutively admitted patients with central nervous system (CNS) infections treated during a 1-year period, all 133 patients with TBE participated in the prospective follow-up study. TBE presented as mild (meningeal), moderate or severe (encephalitic) forms in 43.6%, 43.6% and 12.8%, respectively. Paralytic disease was observed in 3.8%, and cranial nerve injury in 5.3% of the TBE patients. Permanent CNS dysfunction after 1 year was found in 30.8% of patients; in 8.5% of all TBE cases, severe disabilities required adjustment of daily activities. Cognitive CNS dysfunction was the dominant symptom in patients with more pronounced sequelae. A higher risk for incomplete recovery was seen for the encephalitic form of TBE (odds ratio (OR), 4.066; 95% confidence interval (CI), 1.848–8.947). Papers II and III: A prospectively collected material from patients with TBE (n=129), aseptic meningoencephalitis of non-TBEV aetiology (n=79) and healthy TBEV-naive Lithuanians (n=135) were used in studies on chemokine receptor 5 (CCR5) and Toll-like receptor 3 (TLR3) rs3775291 gene polymorphisms. In addition, children TBE cohort (n=117) and a cohort of adults with severe TBE (n=103) were recruited in Paper III. The prevalence of CCR5Δ32 homozygotes was higher among the adults with TBE (2.3%), among children with TBE (2.5%), among adults with severe TBE (1.9%), and in the overall cohort of TBE patients (2.3%) than in controls (0%) (p<0.05). Hence, the CCR5 polymorphism was identified as a significant risk factor for clinical TBE. The CCR5Δ32 allele prevalence was higher in the combined children and adult TBE cohort compared with TBEV-naive individuals, and suggested CCR5Δ32 allele being a risk factor for clinical TBEV infection (OR 1.672; 95% CI 1.005–2.782). The nonfunctional homozygous TLR3 genotype was less prevalent among the combined TBE cohort (11.5%) than among controls (19.9%) (p = 0.025), but did not differ between children TBE and controls. The genotype and allele prevalence of CCR5 and TLR3 did not differ in children nor adult TBE cohorts stratified by disease severity. In adults with severe TBE, homozygous functional TLR3 genotype and wt allele were less prevalent than in adults with the whole disease severity spectrum (44.4% vs 59.8% p = 0.022 and 65.2% vs 76.4% p = 0.009; respectively). Paper IV has shown that cerebrospinal fluid (CSF) KYNA levels were considerably higher in patients with TBE recruited from Paper I (5.3 nmol L-1) than in control subjects (0.99 nmol L-1) and increased (p<0.05) with severity of TBE. Conclusion: TBE is the main CNS infection in adults in Lithuania, causing a considerable morbidity with long-lasting sequelae in one-third of patients. Cognitive CNS dysfunction dominates and is the major cause of long-lasting impairment of the quality of life. High levels of KYNA in CSF of TBE patients serve as a marker of severity of TBE. Host genetic polymorphism plays a role in the development of clinical TBE and may even be linked to the disease severity