Malaria with neurological involvement in Ugandan children: effect on cognitive ability, academic achievement and behaviour

<p>Abstract</p> <p>Background</p> <p>Malaria is a leading cause of ill health and neuro-disability in children in sub-Saharan Africa. Impaired cognition is a common outcome of malaria with neurological involvement. There is also a possibility that academic achievement may be affected by malaria with neurological involvement given the association between cognitive ability and academic achievement. This study investigated the effect of malaria with neurological involvement on cognitive ability, behaviour and academic achievement.</p> <p>Methods</p> <p>This prospective case-control study was carried out in Kampala City, Uganda between February 2008 and October 2010. Sixty-two children with a history of malaria with neurological involvement were followed up and given assessments for cognitive ability (working memory, reasoning, learning, visual spatial skills and attention), behaviour (internalizing and externalizing problems) and academic achievement (arithmetic, spelling and reading) three months after the illness. Sixty-one community controls recruited from the homes or neighbouring families of the cases were also given the same assessments. Tests scores of the two groups were compared using analysis of covariance with age, sex, level of education, nutritional status and quality of the home environment as covariates. This study was approved by the relevant ethical bodies and informed consent sought from the caregivers.</p> <p>Results</p> <p>Children in the malaria group had more behavioural problems than the community controls for internalizing problems (estimated mean difference = -3.71, 95% confidence interval (CI), = -6.34 to -1.08, p = 0.007). There was marginal evidence of lower attention scores (0.40, CI = -0.05 to 0.86, p = 0.09). However, excluding one child from the analyses who was unable to perform the tests affected the attention scores to borderline significance (0.32, CI, = 0.01 to 0.62, p = 0.05). No significant differences were observed in other cognitive abilities or in academic achievement scores.</p> <p>Conclusion</p> <p>Malaria with neurological involvement affects behaviour, with a minimal effect on attention but no detectable effect on academic achievement at three months post discharge. This study provides evidence that development of cognitive deficits after malaria with neurological involvement could be gradual with less effect observed in the short term compared to the long term.</p

Cognition, behaviour and academic skills after cognitive rehabilitation in Ugandan children surviving severe malaria: a randomised trial

<p>Abstract</p> <p>Background</p> <p>Infection with severe malaria in African children is associated with not only a high mortality but also a high risk of cognitive deficits. There is evidence that interventions done a few years after the illness are effective but nothing is known about those done immediately after the illness. We designed a study in which children who had suffered from severe malaria three months earlier were enrolled into a cognitive intervention program and assessed for the immediate benefit in cognitive, academic and behavioral outcomes.</p> <p>Methods</p> <p>This parallel group randomised study was carried out in Kampala City, Uganda between February 2008 and October 2010. Sixty-one Ugandan children aged 5 to 12 years with severe malaria were assessed for cognition (using the Kaufman Assessment Battery for Children, second edition and the Test of Variables of Attention), academic skills (Wide Range Achievement Test, third edition) and psychopathologic behaviour (Child Behaviour Checklist) three months after an episode of severe malaria. Twenty-eight were randomised to sixteen sessions of computerised cognitive rehabilitation training lasting eight weeks and 33 to a non-treatment group. Post-intervention assessments were done a month after conclusion of the intervention. Analysis of covariance was used to detect any differences between the two groups after post-intervention assessment, adjusting for age, sex, weight for age z score, quality of the home environment, time between admission and post-intervention testing and pre-intervention score. The primary outcome was improvement in attention scores for the intervention group. This trial is registered with Current Controlled Trials, number ISRCTN53183087.</p> <p>Results</p> <p>Significant intervention effects were observed in the intervention group for learning mean score (SE), [93.89 (4.00) vs 106.38 (4.32), <it>P </it>= 0.04] but for working memory the intervention group performed poorly [27.42 (0.66) vs 25.34 (0.73), <it>P </it>= 0.04]. No effect was observed in the other cognitive outcomes or in any of the academic or behavioural measures.</p> <p>Conclusions</p> <p>In this pilot study, our computerised cognitive training program three months after severe malaria had an immediate effect on cognitive outcomes but did not affect academic skills or behaviour. Larger trials with follow-up after a few years are needed to investigate whether the observed benefits are sustained.</p> <p>Trial registration</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/ISRCTN53183087">ISRCTN53183087</a></p

Life-charting patients with treatment-refractory affective disorder

Introduction:In treatment-refractory affective illness there are several hypothesis to suggest alterations in the neurobiological systems in relation to illness course. The underlying mechanisms have been scantily investigated. The sensitisation hypothesis suggests a sensitisation process over time for affective disorder the affective illness course shows a tendency towards more frequent, deeper, and less stress related episodes over time. There are reasons to believe that these alterations in biological systems are a result of the wear-and-tear of the affective illness itself, a change from homeostasis to allostasis. By means of the Life-charting method, a graphical method to visualise the illness course in relation to stress and treatments over a lifetime, these hypothesis can be further analysed. Earlier Life-charting research has exclusively focussed on illness course per se, or in relation to stressing life events and treatment. Childhood experiences and its impact on later vulnerability for psychopathology have been emphasized earlier. The Life-charting method can help shed light on this vulnerability in relation to illness course. Aims:The current study was undertaken to explore the Life charting method in measuring illness course in 38 treatment refractory affective disorder patients in relation to the Sensitisation hypothesis, the HPA axis, monoamine metabolites in cerebrospinal fluid as well as experience of parental rearing. Subjects:The patients were consecutively admitted over a three-year period, to a Treatment Refractory Affective Disorder Program at the Sahlgrenska University Hospital at Mölndal, Sweden.Results: Our results partially support the sensitisation hypothesis of affective disorders in demonstrating this phenomenon in more than half of our affectively recurring patients. However, a substantial minority clearly were non-sensitisers showing a stable but more malignant illness course.We found cerebrospinal fluid (CSF) concentrations of the noradrenalin metabolite, 3-methoxy-4-hydroxyphenylglycol (MHPG), to be positively related to the accumulated burden of mood swings (defined as time spent in illness &#61620; depth of episodes) over a lifetime, irrespective of age, gender, uni- or bipolarity, and current severity of depression. Thus, the involvement of noradrenalin turnover in the long-term burden of affective illness is a likely reality. These results point towards a shift in the biological set-points from homeostasis to allostasis.Also, the HPA axis, determined by the CRH challenge test, seemed to shift to a new biological set-point, an allostatic shift, as the individual experienced three or more illness episodes.We found that a patient with severe treatment refractory affective illness who perceived himself/herself as not wanted by his/her parents in childhood can be expected to have a more malignant illness course, as compared to a similar patient who instead perceived himself or herself as wanted during childhood.Conclusions: In conclusion, the life-charting method is useful in investigating psychological and biological variables in relation to illness course. Our findings support the hypothesis of altered neurobiological systems in relation to illness course in patients suffering from treatment refractory affective disorders. Furthermore, our findings also point towards a more malignant illness course in individuals with a more negative perception of parental rearing

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När vi människor har det svårt tänker många av oss automatiskt pådöd och självmord. Det är normalt och ofta nyttig. Hos de flesta klingarsådanatankar av spontant och ersätts av mer konstruktiva problemlösningar.Hos personer som lider av ångest, depression, utmattning, enkänsla av utanförskap och annan psykisk smärta kan dock tankarna pådöden som en möjlig utväg bli mycket farliga. Situationen förvärras oftaav en svårighet att be om hjälp. I stället drar sig personen inom sig självoch utarbetar en självmordsplan. En ytterligare, ibland mycket ringa, påfrestningkan göra att planen sätts i verket. Den suicidala patienten kommertill psykiatern/behandlaren fylld av dessa svårigheter. Det är viktigtatt börja samtalet där hen är och följa upp med ett problemlösningsperspektiv.Tvåforskarsamtal är en bra modell för att bryta patientens känslaav isolering och möta de aktuella behoven. Frågan är om inte patologisksuicidalitet bör ses som ett eget psykiatriskt syndrom.Fortfarande dör ca 1.500 svenskar i suicid varje år. År 2013 var siffran1.606. Läget är således ständigt akut. Låt oss därför snabbt försökakomma fram till en någorlunda välfungerande modell för bemötandet avdessa personer!In severe trouble many people immediately and automatically associateto death and suicide. This is a normal and in fact often a rationalreaction. Usually such ideas spontaneously fade away and are substitutedby more constructive problem solving. For people suffering fromanxiety, depression, exhaustion, feelings of being an outsider and otherforms of mental pain the thoughts of death as a convenient rescue canbe very dangerous. The situation can be still worse if the person hasdifficulties to ask for help. Instead the person may draw him/herselfback and start to develop a suicidal plan. Sometimes new even trivialstrains can trigger the acting out of the plan. When the suicidal personat last try to get help and meets a psychiatrist or some other helper he/she is totally occupied by these mental problems. It is then importantto meet such persons in exactly that situation and applicate a problemsolving perspective. The model «Two researchers» is a valuable modelto counteract the patient’s feelings of loneliness and to meet his/herimmediate needs. Furthermore we need to discuss if not pathologicalsuicidality should be perceived as a psychiatric syndrome in its ownright.In Sweden still about 1.500 persons commit suicide every year. In2013 the number was 1606. The situation is thus acute. Let us thereforerapidly develop a well-functioning model for meeting these persons ina rational way!När vi människor har det svårt tänker många av oss automatiskt pådöd och självmord. Det är normalt och ofta nyttig. Hos de flesta klingarsådanatankar av spontant och ersätts av mer konstruktiva problemlösningar.Hos personer som lider av ångest, depression, utmattning, enkänsla av utanförskap och annan psykisk smärta kan dock tankarna pådöden som en möjlig utväg bli mycket farliga. Situationen förvärras oftaav en svårighet att be om hjälp. I stället drar sig personen inom sig självoch utarbetar en självmordsplan. En ytterligare, ibland mycket ringa, påfrestningkan göra att planen sätts i verket. Den suicidala patienten kommertill psykiatern/behandlaren fylld av dessa svårigheter. Det är viktigtatt börja samtalet där hen är och följa upp med ett problemlösningsperspektiv.Tvåforskarsamtal är en bra modell för att bryta patientens känslaav isolering och möta de aktuella behoven. Frågan är om inte patologisksuicidalitet bör ses som ett eget psykiatriskt syndrom.Fortfarande dör ca 1.500 svenskar i suicid varje år. År 2013 var siffran1.606. Läget är således ständigt akut. Låt oss därför snabbt försökakomma fram till en någorlunda välfungerande modell för bemötandet avdessa personer

Suicidalitet ur evolutionärt och neurofysiologiskt perspektiv

SAMMANFATTNINGUnder de fyra miljarder år som livet funnits på jorden har det visat enenorm anpassnings- och utvecklingskapacitet. Framväxandet av detmoderna samhället under de senaste 250 åren har emellertid lett tillsåväl fysiska som psykosociala felkonstruktioner, som kan vara svåraatt hantera. Neurofysiologiskt ligger problemen på flera olika nivåersåsom svårigheter att differentiera mellan sexualitet och behovetav sensuell kontakt, det synnerligen snabba arousalsystemet ochtill detta knutna kroppsliga reaktioner samt svårigheter i samspeletmellan system 1 och 2 i den mänskliga storhjärnan.ABSTRACTIn a first article (Suicidologi nr 1 2015), the authors suggested thatit is necessary to meet suicidal persons in their present painfulsituation from a problem-oriented perspective. In a second article(Suicidologi nr 2 2015), they suggested that the goal of the destructivedrive is to kill their own perceived incapable self, or perhapsthe contrary, to find ways to resist this drive and thus survive. In thisthird article, the evolutionary and neurophysiological backgroundas well as inherent weaknesses of importance for problem-solvingand suicidality is described. The construction of the modern societyduring the last 250 years has created both physical and psychosocialrisks leading to injuries and deaths. Concerning neurophysiologythere are problems on different levels, which may be of importancefor suicidality, such as difficulties to differentiate between sexualityand sensuality and difficulties to control the sometimes very rapidarousal systemSAMMANFATTNINGUnder de fyra miljarder år som livet funnits på jorden har det visat enenorm anpassnings- och utvecklingskapacitet. Framväxandet av detmoderna samhället under de senaste 250 åren har emellertid lett tillsåväl fysiska som psykosociala felkonstruktioner, som kan vara svåraatt hantera. Neurofysiologiskt ligger problemen på flera olika nivåersåsom svårigheter att differentiera mellan sexualitet och behovetav sensuell kontakt, det synnerligen snabba arousalsystemet ochtill detta knutna kroppsliga reaktioner samt svårigheter i samspeletmellan system 1 och 2 i den mänskliga storhjärnan.ABSTRACTIn a first article (Suicidologi nr 1 2015), the authors suggested thatit is necessary to meet suicidal persons in their present painfulsituation from a problem-oriented perspective. In a second article(Suicidologi nr 2 2015), they suggested that the goal of the destructivedrive is to kill their own perceived incapable self, or perhapsthe contrary, to find ways to resist this drive and thus survive. In thisthird article, the evolutionary and neurophysiological backgroundas well as inherent weaknesses of importance for problem-solvingand suicidality is described. The construction of the modern societyduring the last 250 years has created both physical and psychosocialrisks leading to injuries and deaths. Concerning neurophysiologythere are problems on different levels, which may be of importancefor suicidality, such as difficulties to differentiate between sexualityand sensuality and difficulties to control the sometimes very rapidarousal system

Självet och suicidaliteten

SAMMANFATTNINGDen psykiatriska sjukdomsmodellen är inte någon bra modell föratt förstå suicidalitet. I denna uppsats prövar vi möjligheten av att istället se självmord som ett mord på självet. Självets utveckling, dess forsvarsmekanismer och revir skisseras. Det moderna västerländska samhället är på många sätt felkonstruerat, vilket ständigt producerar lidande. Personer med suicidalitet skall ej i första hand uppfattas som offer utan som tappra hjältar och nödvändiga informatörer. Deras erfarenheter kan öka vår medvetenhet och bidra till att denna jord blir en något bättre plats att leva på.ENGELSK ABSTRACTThe model of mental disorders is not adequate in understandingsuicidality. In this paper we investigate the possibility to perceivesuicide as a murder of the self. We describe the development of theself, its defense mechanisms and its territories. The modern westernsociety is in many respects constructed in a deficient way, whichcontinuously results in suffering for its members. Suicidal personsshall not be comprehended as sacrifices but as brave heroes andimportant informants. Their experience can increase our awarenessand contribute to the efforts making this earth a somewhat betterplace to live in.SAMMANFATTNINGDen psykiatriska sjukdomsmodellen är inte någon bra modell föratt förstå suicidalitet. I denna uppsats prövar vi möjligheten av att istället se självmord som ett mord på självet. Självets utveckling, dess forsvarsmekanismer och revir skisseras. Det moderna västerländska samhället är på många sätt felkonstruerat, vilket ständigt producerar lidande. Personer med suicidalitet skall ej i första hand uppfattas som offer utan som tappra hjältar och nödvändiga informatörer. Deras erfarenheter kan öka vår medvetenhet och bidra till att denna jord blir en något bättre plats att leva på.ENGELSK ABSTRACTThe model of mental disorders is not adequate in understandingsuicidality. In this paper we investigate the possibility to perceivesuicide as a murder of the self. We describe the development of theself, its defense mechanisms and its territories. The modern westernsociety is in many respects constructed in a deficient way, whichcontinuously results in suffering for its members. Suicidal personsshall not be comprehended as sacrifices but as brave heroes andimportant informants. Their experience can increase our awarenessand contribute to the efforts making this earth a somewhat betterplace to live in

Supplemental Material - The Meaning of Mental Imagery in Acute Suicidal Episodes: A Qualitative Exploration of Lived Experiences

Supplemental Material for The Meaning of Mental Imagery in Acute Suicidal Episodes: A Qualitative Exploration of Lived Experiences by Anna Maria Nilsson, Margda Waern, Anna Ehnvall, and Ingela Skärsäter in OMEGA - Journal of Death and Dying</p

Adaptation of the multidimensional scale of perceived social support in a Ugandan setting

Background: The Multidimensional Scale of Perceived Social Support (MSPSS) was developed in the USA. The adequacy of its use in Uganda to guarantee its reliability and validity has not been ascertained.Aim: Thus the aim of the present study was to adapt the MSPSS scale by testing the validity and reliability of the scale in a Ugandan setting.Methods: A cross-sectional design was employed and 240 respondents were consecutively recruited from postnatal clinics in Mulago hospital. Analysis of reliability and validity of the adapted MSPSS was done. Cronbach alpha and principal component analyses were respectively generated.Results: Three subscales of the MSPSS that had been identified in other populations were evident in the Ugandan population. Using the Cronbach’s alpha, the MSPSS demonstrated good internal consistency at .83. A dendrogram indicated that all sub items of the MSPSS were inter-linked. Exploratory Factor analysis derived three components. Principal Component analysis using rotated varimax generated high loadings on all subscales.Conclusion: The adapted MSPSS can reliably be used in Uganda.Key Words: Multidimensional Scale of Perceived social support, (MSPSS), adaptation, social support, validity, reliabilityAfrican Health Sciences 2009; 9(S): 35-4