Vascular dementia

Vascular dementia (VaD) is a common but heterogeneous condition in which there is a clear temporal relationship between the dementia and vascular disease. It may result from multiple large or small vessel strokes or a single strategic stroke. Subcortical ischaemic VaD includes multiple lacunes and subcortical arteriosclerotic encephalopathy (Binswanger’s disease) and imaging shows multiple deep white matter lesions or leukoaraiosis. Large vessel disease may result in VaD by causing multiple cortical and subcortical strokes, while strategic stroke VaD is caused by a single stroke in a specific area of the brain. On the basis of cinical features and imaging, definite, probable and possible VaD can be defined. Vascular risk factor reduction, particularly the use of antihypertensive agents, remains the most important means to prevent VaD. Treatment is limited although acetylcholinesterase inhibitors may have value. Treating behavioural symptoms may be difficult and newer antipsychotics as well as acetylcholinesterase inhibitor therapy should be considered.S Afr Psychiatry Rev 2003;6:16-2

The prevalence of electroencephalographic abnormalities and usefulness of electroencephalography in psychiatry: review article

Clinical electroencephalography (EEG) is a non-invasive, low cost, neurodiagnostic technique widely available in general and psychiatric hospitals in South Africa. Psychiatric patients are regularly referred for EEG's. The major indication for EEG in psychiatric practice is to rule out an organic cause of mental illness. Organic disease can closely mimic functional psychiatric illness. This has major implications in developing countries such as South Africa where the psychiatric effects of physical disease are particularly widespread. Organic brain syndromes often arise from potentially treatable causes. South African Psychiatry Review Vol.7(2) 2004: 23-26, 2

A racial and urban-rural comparison of the nature of stroke in South Africa

ABSTRACT Sub-Saharan Africa is thought to be undergoing a health (or epidemiological) and demographic transition, moving from a pattern of disease dominated by infection, perinatal illness and other diseases of poverty, to one dominated by noncommunicable disease, in particular vascular disease. If such a transition is occurring, then the burden of vascular disease including stroke will increase. Stroke is a heterogeneous condition and it is likely that the nature of stroke (pathological types, subtypes, and causes) will change during this transition. However, little is known about the burden and nature of stroke in Sub-Saharan Africa, as it is now. This information is essential to inform health services to appropriately plan and deliver health care for the future, to develop strategies for stroke prevention, and to test the theory of the health and demographic transition. My overall aim was to assess and compare the burden and nature of stroke in rural and urban South Africa, and to establish whether there is any evidence of a health transition. Specifically I aimed to: • review what is known about stroke in Sub-Saharan Africa; • establish the prevalence and nature of prevalent stroke in rural South Africa; • compare the nature of hospital-based stroke in urban and rural stroke patients; • compare the nature of urban hospital-based stroke in different population groups; and • validate two stroke scores in the urban stroke register to enable us to diagnose pathological stroke type in rural stroke patients who do not have access to brain imaging. Methods: The following methods were used to achieve these aims: • I systematically searched the literature for, and critically reviewed, studies of stroke from Sub-Saharan Africa (literature review). • The rural Agincourt Health and Population Unit demographic surveillance site was screened for stroke using two questions during the annual census. Anyone who screened positive for stroke was examined to decide whether they had had a stroke (stroke prevalence study). • The Tintswalo Hospital Stroke Register was established to ascertain and assess rural stroke patients over 20 months (rural hospital-based stroke), and • The Johannesburg Hospital Stroke Register similarly established to assess urban stroke patients over 23 months (urban hospital-based stroke). • The accuracy of the Siriraj and Guy’s Hospital stroke scores was compared to the CT brain scan “gold-standard” in the Johannesburg Hospital Stroke Register. Results: Using these approaches I found that: • Very little is currently known about the burden and nature of stroke in Sub- Saharan Africa. • The prevalence of rural stroke was about half that found in high-income countries, and double that found in Tanzania. However, disabling stroke was at least as prevalent as it is in high-income countries. • Both rural and urban black South Africans are probably in early phases of the health transition, and this is impacting on the nature of stroke, particularly the cause of cardioembolic stroke. • Neither the Siriraj nor Guy’s Hospital stroke score are sufficiently accurate for use in epidemiological studies or clinical management of stroke in Sub- Saharan Africa. Conclusion: There is already a heavy burden of stroke in Sub-Saharan Africa, and there is some evidence of a health transition in the black population. However, it is not possible to accurately assess the burden and nature of stroke without communitybased incidence studies using early brain imaging to distinguish ischaemic stroke from cerebral haemorrhage. Until we have these studies, we will never know the precise burden and nature of stroke, the effect of the health transition, or the optimal approach to preventing a stroke epidemic in our population

Towards Social Services System Integration: A report from Alberta’s Elder Care Support Provision Community

Family caregivers are a significant unpaid labour force that provides at least 70% of all care to seniors in the community. It was estimated in 2009 that the formal Canadian healthcare system would have to spend $25 billion annually to replace the contributions of family caregivers. More recent estimates have placed the value of family caregiver labour as high as$66.5 billion.  While a wide range of public and private services are generally available to support family caregivers, many potential clients have difficulty both gaining access, and navigating those services once they have gained access. In this sense, they experience a highly fragmented ‘system’ of social support provision. As the population of older adults living in the community grows, and with it the demand for family caregivers’ provided support, policy attention has become increasingly focused on integration as a solution to the fragmentation challenge.  The family caregiver support sector was singled out by a Special Senate Committee in 2009 as particularly likely to benefit from integration.  Integration, the committee found, would allow the sectors to better address the needs of community-dwelling older adults with chronic health conditions, improve the financial sustainability of the formal healthcare system, and make necessary support services more accessible. Beyond the specifics of family caregiving, policy conversations and major reforms around the world have similarly focused on the need for increased integration of care, both in health and social services.Recognizing that integrating fragmented social and healthcare systems is a wicked problem generally, and a particularly urgent matter for the family caregiver support services (FCSS[1]) ‘system,’ the School of Public Policy (SPP) organized a day-long event drawing stakeholders together.  The event originated in the FCSS community’s own desire to better understand and accomplish integration.  As a facilitated discussion, it was designed as a space for participants to move away from talking about integration, and towards making both it, and the concept of a ‘system’ of care, real.In organizing the event and in line with a well-developed scholarly literature, we framed the problem of fragmentation as a ‘structural’ issue caused by, among other factors, divergent mandates, competitive funding models, disjointed assessment processes, and a lack of co-ordinated transition. Similar to other researchers, we saw the solution to fragmentation as integration through the lens of organizational structures, joint services, shared assessments, and coordinated planning. However, when we presented these concepts to the FCSS community, they initially connected with them, but quickly diverged away from the structural recommendations and instead generated their own initiatives through conversations and relationship building.  We found that the act of bringing service providers together to share experiences, learn about each other, and develop their knowledge of services is the foundation upon which the various structural elements are built. The structural interventions are not the pathway to real integration, because they cannot be undertaken without a number of preconditions in place. Trust, consensus, and collaborative relationships are the necessary preconditions to integration, in whatever form it may take. In other words, an unsiloed system does not emerge from structural reforms, but rather from trusting relationships, consensus, and the resources and space for collaboration.  The event provided participants with the opportunity to set agreed-upon goals for the sector to work on together. The collaborative space that FCSS community members envisioned during the event, along with the ambitious work packages they prioritized for action inside that space, were practical, implementable visions of integration as an activity emerging from a community working together.[1] The acronym FCSS is also commonly used in Alberta's social support community for Family and Community Support Services, which is a unique 80/20 funding partnership between the Government of Alberta and participating municipalities or Métis Settlements. 

Clinicopathological Case Conference : a 17 year old with progressive gait difficulty and a complex family history : case report

This case was presented and discussed at the Annual Neurology Course, held in Johannesburg, October 2004. The content represents a narrative account of the actual presentation and discussion. Key words: Clinical conference, Genetics, Spastic paraparesis South African Psychiatry Review Vol.8(2) 2005: 70-7

Eating Disorders in Men: A Comprehensive Summary

Eating disorders (EDs) have detrimental effects on an individual’s physical and mental health, along with significant interpersonal, social and economic effects. Furthermore, men who are suffering with an ED face unique challenges with this. Men suffering with EDs have historically received little attention within ED research, diagnosis and intervention. However, the number of men suffering with these issues is significant and growing. Understanding of EDs tend to ignore male experiences, meaning many are left to suffer in silence until the ED has developed to a critical point. However, many now recognize the need to understand the issues facing men suffering with an ED. By improving our understanding, we can better improve early detection, diagnosis and treatment for those who are suffering. This paper aims to provide a comprehensive general introduction to this growing area of research and it is hoped that it will be of good use to interested researchers, students and the general public. Prevalence, presentation, history, diagnosis and more will be covered in order to provide a well-rounded understanding of EDs in men

Use of applied theatre in health research dissemination and data validation: a pilot study from South Africa

This article reports on a pilot study of the use of applied theatre in the dissemination of health research findings and validation of data. The study took place in South Africa, as part of the Southern Africa Stroke Prevention Initiative (SASPI) and was based at the University/Medical Research Council Rural Public Health and Health Transitions Research Unit (also known as the Agincourt Unit). The aim of SASPI was to investigate the prevalence of stroke and understand the social context of stroke. It was decided to use an applied theatre approach for validating the data and disseminating findings from the anthropological component of the study. The pilot study found that applied theatre worked better in smaller community groups. It allowed data validation and it elicited ideas for future interventions resulting from the health research findings. Evaluation methods of the impact of applied theatre as a vehicle for the dissemination and communication of research findings require further development

Root responses to domestication, precipitation and silicification: weeping meadow grass simplifies and alters toughness

Background and aims Plant breeding usually focuses on conspicuous above-ground plant traits, yet roots fundamentally underpin plant fitness. Roots show phenotypic plasticity in response to soil conditions but it is unclear whether domesticated plants respond like their ancestors. We aimed to determine how root traits differed between ancestral and domesticated types of a meadow grass (Microlaena stipoides) under altered regimes of precipitation and soil silicon availability. Methods We subjected the two grass types to three simulated precipitation regimes (ambient, +50%/deluge and −50%/drought) in soil with (Si+) and without (Si−) silicon supplementation and then characterised root biomass, architectural complexity and toughness in addition to shoot traits. Results Domestication increased root tissue density, decreased specific root length (SRL) and decreased root architectural complexity. Domestication also increased root strength under Si− conditions but not Si+ conditions. Fine roots, SRL, architectural complexity and the force required to tear the roots all decreased under deluge. The ancestral and domesticated grasses responded similarly to precipitation, except that the latter had weaker roots (decreased fracture strain) under drought. Conclusions Domestication and increased precipitation caused changes in M. stipoides root traits that could be beneficial against some stresses (e.g. soil compaction, herbivory) but not others (e.g. drought)

The South African stroke risk in general practice study

Background. Incidence of stroke is increasing in sub-Saharan Africa and stroke prevention is an essential component of successful stroke management. General practitioners (GPs) are well placed to manage stroke risk factors. To design appropriate strategies for risk factor reduction we need to know the risk factor prevalence in each of the population groups attending GPs. The aim of this study was to establish the prevalence of stroke risk factors in the South African general practice population. Method. We conducted a multicentre, observational study of patients attending general practice in South Africa. Two hundred general practices were randomly selected from lists provided by pharmaceutical representatives. Each GP approached 50 consecutive patients aged 30 years and older. Patients completed an information sheet and the GP documented the patient’s risk factors. The resulting sample is relevant if not necessarily representative in a statistical sense. Results. A total of 9 731 questionnaires were returned out of a possible 10 000. The mean age of particpants was 50.7 years. Seventy-six per cent had 1 or more risk factors and 40% had 2 or more risk factors. Hypertension was the commonest risk factor in all population groups (55%) but was highest in black patients (59%). Dyslipidaemia was commonest in whites (37%) and least common in blacks (5%). Diabetes was commonest in Asians (24%) but least common in whites (8%). Risk factors other than smoking increased with age. Conclusion. This study provides unique data on the prevalence of stroke risk factors in a South African general practice population. Risk factors are common in all population groups, but differ in distribution among the groups. There is considerable opportunity to reduce the burden of stroke in South Africa through GP screening for and treatment of risk factors

HIV infection and stroke: current perspectives and future directions

HIV infection can result in stroke via several mechanisms, including opportunistic infection, vasculopathy, cardioembolism, and coagulopathy. However, the occurrence of stroke and HIV infection might often be coincidental. HIV-associated vasculopathy describes various cerebrovascular changes, including stenosis and aneurysm formation, vasculitis, and accelerated atherosclerosis, and might be caused directly or indirectly by HIV infection, although the mechanisms are controversial. HIV and associated infections contribute to chronic infl ammation. Combination antiretroviral therapies (cART) are clearly benefi cial, but can be atherogenic and could increase stroke risk. cART can prolong life, increasing the size of the ageing population at risk of stroke. Stroke management and prevention should include identifi cation and treatment of the specifi c cause of stroke and stroke risk factors, and judicious adjustment of the cART regimen. Epidemiological, clinical, biological, and autopsy studies of risk, the pathogenesis of HIVassociated vasculopathy (particularly of arterial endothelial damage), the long-term eff ects of cART, and ideal stroke treatment in patients with HIV are needed, as are antiretrovirals that are without vascular risk