Epithelial IL-1R2 acts as a homeostatic regulator during remission of ulcerative colitis

Ulcerative colitis (UC) is a chronic intestinal inflammatory disease that may undergo periods of activity followed by remission. We aimed to identify the endogenous regulatory mechanisms that may promote disease remission. Transcriptional and protein analysis of the intestinal mucosa revealed that the IL-1 decoy receptor, interleukin-1 receptor type 2 (IL1R2), was upregulated in remission compared with active UC and controls. We identified epithelial cells as being responsible for increased IL-1R2 production during remission. Expression of IL1R2 was negatively regulated by Wnt/beta-catenin signals in colonic crypts or epithelial stem cell cultures; accordingly, epithelial stem cells upregulated IL-1R2 upon differentiation. Blocking IL-1R2 in isolated colonic crypt cultures of UC patients in remission and T-cell cultures stimulated with biopsy supernatant from UC patients in remission boosted IL-1β-dependent production of inflammation-related cytokines. Finally, IL1R2 transcription was significantly lower in patients that relapsed during a 1-year follow-up period compared with those in endoscopic remission. Collectively, our results reveal that the IL-1/IL-1R2 axis is differentially regulated in the remitting intestinal mucosa of UC patients. We hypothesize that IL-1R2 in the presence of low concentrations of IL-1β may act locally as a regulator of intestinal homeostasis.

The utility of omega-3 fatty acids in depression

Introduction

Recent studies have reported therapeutic benefit from the use of omega-3 fatty acids (EPA and DHA) as adjunctive treatment of depression.

Objectives

The goal of this work is to assess the effectiveness and tolerability of dietary supplementation with omega-3 in the treatment of depressed patients.

Method

Prospective, descriptive, observational study in a general psychiatry outpatient clinic. Consecutive inclusion of depressed patients started on dietary supplementation with omega-3 because of partial response to antidepressants and/or intolerance to high doses or combination of antidepressant drugs between January and May 2015. Sociodemographic variables, clinical data and information about tolerability were recorded. Clinical response to treatment over time was assessed at 4–6 months follow up using the 5-item CGI (Clinical Global Impression) scale.

Results

We included 30 depressed patients started on omega-3. None of them reported side effects. Seventy-three percent of patients reported clinical improvement (40% much improvement, 33% some improvement). None of them got worse. We did not find association between clinical response and age, sex, type of depression nor duration of illness.

Conclusion

Despite the limitations of this study, our work support previous positive results on the use of omega-3 fatty acids (EPA and DHA) as adjunctive treatment of depression. Giving the safety of its use, clinicians might recommend omega-3 as adjunctive treatment of depression in cases with a partial response to antidepressants.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The Prevalence, Correlates, Detection and Control of Diabetes among Older People in Low and Middle Income Countries. A 10/66 Dementia Research Group Population-Based Survey

Background

Little is known of the epidemiology of diabetes among older people in low and middle income countries. We aimed to study and compare prevalence, social patterning, correlates, detection, treatment and control of diabetes among older people in Latin America, India, China and Nigeria.

Methods

Cross-sectional surveys in 13 catchment area sites in nine countries. Diagnosed diabetes was assessed in all sites through self-reported diagnosis. Undiagnosed diabetes was assessed in seven Latin American sites through fasting blood samples (glucose > = 7mmol/L).

Results

Total diabetes prevalence in catchment sites in Cuba (prevalence 24.2%, SMR 116), Puerto Rico (43.4%, 197), and urban (27.0%, 125), and rural Mexico (23.7%, 111) already exceeds that in the USA, while that in Venezuela (20.9%, 100) is similar. Diagnosed diabetes prevalence varied very widely, between low prevalences in sites in rural China (0.9%), rural India (6.6%) and Nigeria (6.0%). and 32.1% in Puerto Rico, explained mainly by access to health services. Treatment coverage varied substantially between sites. Diabetes control (40 to 61% of those diagnosed) was modest in the Latin American sites where this was studied. Diabetes was independently associated with less education, but more assets. Hypertension, central obesity and hypertriglyceridaemia, but not hypercholesterolaemia were consistently associated with total diabetes.

Conclusions

Diabetes prevalence is already high in most sites. Identifying undiagnosed cases is essential to quantify population burden, particularly in least developed settings where diagnosis is uncommon. Metabolic risk factors and associated lifestyles may play an important part in aetiology, but this requires confirmation with longitudinal data. Given the high prevalence among older people, more population research is indicated to quantify the impact of diabetes, and to monitor the effect of prevention and health system strengthening on prevalence, treatment and control.

A comparative cross-cultural study of the prevalence of late life depression in low and middle income countries

BACKGROUND

Current estimates of the prevalence of depression in later life mostly arise from studies carried out in Europe, North America and Asia. In this study we aimed to measure the prevalence of depression using a standardised method in a number of low and middle income countries (LMIC).

METHODS

A one-phase cross-sectional survey involving over 17,000 participants aged 65 years and over living in urban and rural catchment areas in 13 sites from 9 countries (Cuba, Dominican Republic, Puerto Rico, Mexico, Venezuela, Peru, China, India and Nigeria). Depression was assessed and compared using ICD-10 and EURO-D criteria.

RESULTS

Depression prevalence varied across sites according to diagnostic criteria. The lowest prevalence was observed for ICD-10 depressive episode (0.3 to 13.8%). When using the EURO-D depression scale, the prevalence was higher and ranged from 1.0% to 38.6%. The crude prevalence was particularly high in the Dominican Republic and in rural India. ICD-10 depression was also associated with increased age and being female.

LIMITATIONS

Generalisability of findings outside of catchment areas is difficult to assess.

CONCLUSIONS

Late life depression is burdensome, and common in LMIC. However its prevalence varies from culture to culture; its diagnosis poses a significant challenge and requires proper recognition of its expression.

Whole mitochondrial DNA sequencing in Alpine populations and the genetic history of the Neolithic Tyrolean Iceman

The Tyrolean Iceman is an extraordinarily well-preserved natural mummy that lived south of the Alpine ridge ~5,200 years before present (ybp), during the Copper Age. Despite studies that have investigated his genetic profile, the relation of the Iceman´s maternal lineage with present-day mitochondrial variation remains elusive. Studies of the Iceman have shown that his mitochondrial DNA (mtDNA) belongs to a novel lineage of haplogroup K1 (K1f) not found in extant populations. We analyzed the complete mtDNA sequences of 42 haplogroup K bearing individuals from populations of the Eastern Italian Alps - putatively in genetic continuity with the Tyrolean Iceman-and compared his mitogenome with a large dataset of worldwide K1 sequences. Our results allow a re-definition of the K1 phylogeny, and indicate that the K1f haplogroup is absent or rare in present-day populations. We suggest that mtDNA Iceman´s lineage could have disappeared during demographic events starting in Europe from ~5,000 ybp. Based on the comparison of our results with published data, we propose a scenario that could explain the apparent contrast between the phylogeographic features of maternal and paternal lineages of the Tyrolean Iceman within the context of the demographic dynamics happening in Europe from 8,000 ybp.

Frailty and the prediction of dependence and mortality in low- and middle-income countries: a 10/66 population-based cohort study

BACKGROUND

In countries with high incomes, frailty indicators predict adverse outcomes in older people, despite a lack of consensus on definition or measurement. We tested the predictive validity of physical and multidimensional frailty phenotypes in settings in Latin America, India, and China.

METHODS

Population-based cohort studies were conducted in catchment area sites in Cuba, Dominican Republic, Venezuela, Mexico, Peru, India, and China. Seven frailty indicators, namely gait speed, self-reported exhaustion, weight loss, low energy expenditure, undernutrition, cognitive, and sensory impairment were assessed to estimate frailty phenotypes. Mortality and onset of dependence were ascertained after a median of 3.9 years.

RESULTS

Overall, 13,924 older people were assessed at baseline, with 47,438 person-years follow-up for mortality and 30,689 for dependence. Both frailty phenotypes predicted the onset of dependence and mortality, even adjusting for chronic diseases and disability, with little heterogeneity of effect among sites. However, population attributable fractions (PAF) summarising etiologic force were highest for the aggregate effect of the individual indicators, as opposed to either the number of indicators or the dichotomised frailty phenotypes. The aggregate of all seven indicators provided the best overall prediction (weighted mean PAF 41.8 % for dependence and 38.3 % for mortality). While weight loss, underactivity, slow walking speed, and cognitive impairment predicted both outcomes, whereas undernutrition predicted only mortality and sensory impairment only dependence. Exhaustion predicted neither outcome.

CONCLUSIONS

Simply assessed frailty indicators identify older people at risk of dependence and mortality, beyond information provided by chronic disease diagnoses and disability. Frailty is likely to be multidimensional. A better understanding of the construct and pathways to adverse outcomes could inform multidimensional assessment and intervention to prevent or manage dependence in frail older people, with potential to add life to years, and years to life.

Association of naturally occurring radionuclides in sludges from Drinking Water Treatment Plants previously optimized for their removal

The raw water used in Drinking Water Treatment Plants (DWTPs) can present high values of naturally occurring radionuclides. In order to reduce this content, the routine working conditions of DWTPs were successfully modified. This meant that those radionuclides were accumulated in the sludges generated, whose radioactive content was frequently above the exemption levels. It therefore becomes necessary to assess the association of naturally occurring radionuclides in the sludges for their potential use as agricultural fertilizers. Two approaches were studied: (a) the effect of different sequential extraction methods applied to a selected sludge; and (b) the effect of the different contents of inorganic complexes dissolved in the input water on the composition of the sludges generated by two DWTPs with different origins of their input water. Uranium and radium were mainly associated with the carbonated and reducible fractions, while (210)Po and (228)Th were associated with the residual fraction. There were differences between the two speciation methods, but the order of bioavailable radionuclides was roughly the same: (226)Ra≈(234,238)U>(228)Th>(210)Po. The major inorganic complexes content, mainly carbonate, in the raw water affected the radionuclide association. The greater the carbonate content in the raw water, the greater was the association of uranium and radium with the carbonated and easily reducible fractions.

Dementia incidence and mortality in middle-income countries, and associations with indicators of cognitive reserve: a 10/66 Dementia Research Group population-based cohort study

BACKGROUND

Results of the few cohort studies from countries with low incomes or middle incomes suggest a lower incidence of dementia than in high-income countries. We assessed incidence of dementia according to criteria from the 10/66 Dementia Research Group and Diagnostic and Statistical Manual of Mental Disorders (DSM) IV, the effect of dementia at baseline on mortality, and the independent effects of age, sex, socioeconomic position, and indicators of cognitive reserve.

METHODS

We did a population-based cohort study of all people aged 65 years and older living in urban sites in Cuba, the Dominican Republic, and Venezuela, and rural and urban sites in Peru, Mexico, and China, with ascertainment of incident 10/66 and DSM-IV dementia 3-5 years after cohort inception. We used questionnaires to obtain information about age in years, sex, educational level, literacy, occupational attainment, and number of household assets. We obtained information about mortality from all sites. For participants who had died, we interviewed a friend or relative to ascertain the likelihood that they had dementia before death.

FINDINGS

12,887 participants were interviewed at baseline. 11,718 were free of dementia, of whom 8137 (69%) were reinterviewed, contributing 34,718 person-years of follow-up. Incidence for 10/66 dementia varied between 18·2 and 30·4 per 1000 person-years, and were 1·4-2·7 times higher than were those for DSM-IV dementia (9·9-15·7 per 1000 person-years). Mortality hazards were 1·56-5·69 times higher in individuals with dementia at baseline than in those who were dementia-free. Informant reports suggested a high incidence of dementia before death; overall incidence might be 4-19% higher if these data were included. 10/66 dementia incidence was independently associated with increased age (HR 1·67; 95% CI 1·56-1·79), female sex (0·72; 0·61-0·84), and low education (0·89; 0·81-0·97), but not with occupational attainment (1·04; 0·95-1·13).

INTERPRETATION

Our results provide supportive evidence for the cognitive reserve hypothesis, showing that in middle-income countries as in high-income countries, education, literacy, verbal fluency, and motor sequencing confer substantial protection against the onset of dementia.

FUNDING

Wellcome Trust Health Consequences of Population Change Programme, WHO, US Alzheimer's Association, FONACIT/ CDCH/ UCV.

Strain and its correlates among carers of people with dementia in low-income and middle-income countries. A 10/66 Dementia Research Group population-based survey

OBJECTIVES

In a multi-site population-based study in several middle-income countries, we aimed to investigate relative contributions of care arrangements and characteristics of carers and care recipients to strain among carers of people with dementia. Based on previous research, hypotheses focused on carer sex, care inputs, behavioural and psychological symptoms (BPSD) and socioeconomic status, together with potential buffering effects of informal support and employing paid carers.

METHODS

In population-based catchment area surveys in 11 sites in Latin America, India and China, we analysed data collected from people with dementia and care needs, and their carers. Carer strain was assessed with the Zarit Burden Interview.

RESULTS

With 673 care recipient/carer dyads interviewed (99% of those eligible), mean Zarit Burden Interview scores ranged between 17.1 and 27.9 by site. Women carers reported more strain than men. The most substantial correlates of carer strain were primary stressors BPSD, dementia severity, needs for care and time spent caring. Socioeconomic status was not associated with carer strain. Those cutting back on work experienced higher strain. There was tentative evidence for a protective effect of having additional informal or paid support.

CONCLUSIONS

Our findings underline the global impact of caring for a person with dementia and support the need for scaling up carer support, education and training. That giving up work to care was prevalent and associated with substantial increased strain emphasizes the economic impact of caring on the household. Carer benefits, disability benefits for people with dementia and respite care should all be considered.

Enhancement of natural radionuclides in the surroundings of the four largest coal-fired power plants in Spain

The production of electricity in coal-fired power plants (CFPP) is considered a NORM (Naturally Occurring Radioactive Materials) activity because the coals they burn can present relatively high contents of the naturally occurring radionuclides. In this study, the main radiological impact pathways into the surrounding environments of the four largest coal-fired power plants in Spain were analyzed. These pathways are, first, atmospheric evacuations and wind resuspension and, second, effluent evacuations to nearby rivers or directly to the sea. The atmospheric releases of radionuclides were evaluated by the analyses of soil profiles in the vicinities of the CFPPs. No significant enhancement of radionuclides in the surface soil was observed at the points of maximum deposition of combustion gases, located from 4.3 to 13 km away depending on the considered CFPP. However, an increase of (40)K, (226)Ra, and (232)Th in the surface soils was observed in the first kilometre from the chimney for two CFPPs. This suggested that these radionuclides were released in particulate form. There was also a net influence of the climate in which the CFPPs were located. This was observed in the two CFPPs that were in dry environments, while no increase was observed in the other two, located in more humid environments. The liquid effluents released usually presented an enhancement of dissolved chemical species regarding the initial intake water. Enrichments of the (234,238)U and (226)Ra contents in the water used in the plants' routine procedures were observed, and of (210)Po in the wastewater of just one of the plants. In any case, this enhancement was below the parametric value for the Total Indicative Dose for the hypothetical human consumption of the released waters. As a consequence of these releases of radionuclides, local products destined for human consumption produced in the vicinity of the facilities might incorporate natural radionuclides by these pathways, finding no significant enhancement of the natural radionuclide contents due to the CFPPs.

Influence of alkali and alkaline earth elements on the uptake of radionuclides by Pleurototus eryngii fruit bodies

In the literature, there are many data available on radionuclide contents and their transfer to different species of mushrooms. There are some variables, however, which affect the transfer but are very difficult to observe in collected wild mushrooms. An example is the effect of different concentrations of alkali and alkaline earth elements in the soil. Modification of these concentrations in the soil solution has traditionally been used as a countermeasure to deal with radioactively contaminated areas. In the present work, fruiting bodies of Pleurotus eryngii, a saprophytic mushroom, were grown under controlled laboratory conditions, varying the content of alkali (potassium and cæsium) and alkaline earth (calcium and strontium) elements. The transfer of (134)Cs, (85)Sr, and (60)Co (added to the cultures) and of natural (210)Pb was analysed by increasing the content of each stable element considered. A significant, but nonlinear, enhancement of stable cæsium and (134)Cs was observed with increasing content of stable cæsium in the substrate/mycelium. The transfer of (85)Sr decreased with the addition of each stable cation, whereas the (60)Co and (210)Pb transfers were unaffected.

Prevalence, distribution, and impact of mild cognitive impairment in Latin America, China, and India: a 10/66 population-based study

BACKGROUND

Rapid demographic ageing is a growing public health issue in many low- and middle-income countries (LAMICs). Mild cognitive impairment (MCI) is a construct frequently used to define groups of people who may be at risk of developing dementia, crucial for targeting preventative interventions. However, little is known about the prevalence or impact of MCI in LAMIC settings.

METHODS AND FINDINGS

Data were analysed from cross-sectional surveys established by the 10/66 Dementia Research Group and carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India on 15,376 individuals aged 65+ without dementia. Standardised assessments of mental and physical health, and cognitive function were carried out including informant interviews. An algorithm was developed to define Mayo Clinic amnestic MCI (aMCI). Disability (12-item World Health Organization disability assessment schedule [WHODAS]) and informant-reported neuropsychiatric symptoms (neuropsychiatric inventory [NPI-Q]) were measured. After adjustment, aMCI was associated with disability, anxiety, apathy, and irritability (but not depression); between-country heterogeneity in these associations was only significant for disability. The crude prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Country differences changed little (range 0.6%-4.6%) after standardization for age, gender, and education level. In pooled estimates, aMCI was modestly associated with male gender and fewer assets but was not associated with age or education. There was no significant between-country variation in these demographic associations.

CONCLUSIONS

An algorithm-derived diagnosis of aMCI showed few sociodemographic associations but was consistently associated with higher disability and neuropsychiatric symptoms in addition to showing substantial variation in prevalence across LAMIC populations. Longitudinal data are needed to confirm findings-in particular, to investigate the predictive validity of aMCI in these settings and risk/protective factors for progression to dementia; however, the large number affected has important implications in these rapidly ageing settings.

Socioeconomic factors and all cause and cause-specific mortality among older people in Latin America, India, and China: a population-based cohort study

BACKGROUND

Even in low and middle income countries most deaths occur in older adults. In Europe, the effects of better education and home ownership upon mortality seem to persist into old age, but these effects may not generalise to LMICs. Reliable data on causes and determinants of mortality are lacking.

METHODS AND FINDINGS

The vital status of 12,373 people aged 65 y and over was determined 3-5 y after baseline survey in sites in Latin America, India, and China. We report crude and standardised mortality rates, standardized mortality ratios comparing mortality experience with that in the United States, and estimated associations with socioeconomic factors using Cox's proportional hazards regression. Cause-specific mortality fractions were estimated using the InterVA algorithm. Crude mortality rates varied from 27.3 to 70.0 per 1,000 person-years, a 3-fold variation persisting after standardisation for demographic and economic factors. Compared with the US, mortality was much higher in urban India and rural China, much lower in Peru, Venezuela, and urban Mexico, and similar in other sites. Mortality rates were higher among men, and increased with age. Adjusting for these effects, it was found that education, occupational attainment, assets, and pension receipt were all inversely associated with mortality, and food insecurity positively associated. Mutually adjusted, only education remained protective (pooled hazard ratio 0.93, 95% CI 0.89-0.98). Most deaths occurred at home, but, except in India, most individuals received medical attention during their final illness. Chronic diseases were the main causes of death, together with tuberculosis and liver disease, with stroke the leading cause in nearly all sites.

CONCLUSIONS

Education seems to have an important latent effect on mortality into late life. However, compositional differences in socioeconomic position do not explain differences in mortality between sites. Social protection for older people, and the effectiveness of health systems in preventing and treating chronic disease, may be as important as economic and human development.

Tobacco use and dementia: evidence from the 1066 dementia population-based surveys in Latin America, China and India

OBJECTIVES

To assess the association between tobacco consumption and dementia using the same methodology in seven developing countries, testing the specific hypotheses that higher exposure to tobacco is associated with a higher prevalence of dementia, that the association is limited to smoked tobacco and is stronger for vascular dementia compared to Alzheimer's disease.

METHODS

Cross-sectional surveys conducted on individuals aged 65+. A total of 15 022 residents in specified catchment areas were assessed face-to-face using a standardised protocol, which included dementia diagnosis and detailed information on past and current tobacco consumption, and on important potential confounders of this association.

RESULTS

A high proportion of participants were never smokers (52% in Dominican Republic to 83% in Peru), most of those who ever used tobacco in China and India were still smoking at age 65 and above (80% and 84%, respectively). There was a positive association between history of tobacco smoke exposure (pack years up to age 50) and dementia (pooled PR = 1.003; 95%CI 1.001-1.005), Alzheimer's disease (pooled PR = 1.007; 95% CI, 1.003-1.011) and Vascular Dementia (pooled PR = 1.003; 95% CI = 1.001-1.005). These associations were attenuated but remained significant if exposure after the age of 50 was included. In India there was no association between smokeless tobacco and dementia.

CONCLUSIONS

Dementia in developing countries appears to be positively associated with history of tobacco smoking but not smokeless tobacco use. Selective quitting in later life may bias estimation of associations.

Prevalence of stroke and related burden among older people living in Latin America, India and China

OBJECTIVES

Despite the growing importance of stroke in developing countries, little is known of stroke burden in survivors. The authors investigated the prevalence of self-reported stroke, stroke-related disability, dependence and care-giver strain in Latin America (LA), China and India.

METHODS

Cross-sectional surveys were conducted on individuals aged 65+ (n=15 022) living in specified catchment areas. Self-reported stroke diagnosis, disability, care needs and care giver burden were assessed using a standardised protocol. For those reporting stroke, the correlates of disability, dependence and care-giver burden were estimated at each site using Poisson or linear regression, and combined meta-analytically.

RESULTS

The prevalence of self-reported stroke ranged between 6% and 9% across most LA sites and urban China, but was much lower in urban India (1.9%), and in rural sites in India (1.1%), China (1.6%) and Peru (2.7%). The proportion of stroke survivors needing care varied between 20% and 39% in LA sites but was higher in rural China (44%), urban China (54%) and rural India (73%). Comorbid dementia and depression were the main correlates of disability and dependence.

CONCLUSION

The prevalence of stroke in urban LA and Chinese sites is nearly as high as in industrialised countries. High levels of disability and dependence in the other mainly rural and less-developed sites suggest underascertainment of less severe cases as one likely explanation for the lower prevalence in those settings. As the health transition proceeds, a further increase in numbers of older stroke survivors is to be anticipated. In addition to prevention, stroke rehabilitation and long-term care needs should be addressed.

A brief dementia screener suitable for use by non-specialists in resource poor settings--the cross-cultural derivation and validation of the brief Community Screening Instrument for Dementia

OBJECTIVE

Brief screening tools for dementia for use by non-specialists in primary care have yet to be validated in non-western settings where cultural factors and limited education may complicate the task. We aimed to derive a brief version of cognitive and informant scales from the Community Screening Instrument for Dementia (CSI-D) and to carry out initial assessments of their likely validity.

METHODS

We applied Mokken analysis to CSI-D cognitive and informant scale data from 15 022 participants in representative population-based surveys in Latin America, India and China, to identify a subset of items from each that conformed optimally to item response theory scaling principles. The validity coefficients of the resulting brief scales (area under ROC curve, optimal cutpoint, sensitivity, specificity and Youden's index) were estimated from data collected in a previous cross-cultural validation of the full CSI-D.

RESULTS

Seven cognitive items (Loevinger H coefficient 0.64) and six informant items (Loevinger H coefficient 0.69) were selected with excellent hierarchical scaling properties. For the brief cognitive scale, AUROC varied between 0.88 and 0.97, for the brief informant scale between 0.92 and 1.00, and for the combined algorithm between 0.94 and 1.00. Optimal cutpoints did not vary between regions. Youden's index for the combined algorithm varied between 0.78 and 1.00 by region.

CONCLUSION

A brief version of the full CSI-D appears to share the favourable culture- and education-fair screening properties of the full assessment, despite considerable abbreviation. The feasibility and validity of the brief version still needs to be established in routine primary care.

Equity in the delivery of community healthcare to older people: findings from 10/66 Dementia Research Group cross-sectional surveys in Latin America, China, India and Nigeria

BACKGROUND

To describe patterns of recent health service utilisation, and consequent out-of-pocket expenses among older people in countries with low and middle incomes, and to assess the equity with which services are accessed and delivered.

METHODS

17,944 people aged 65 years and over were assessed in one-phase population-based cross-sectional surveys in geographically-defined catchment areas in nine countries - urban and rural sites in China, India, Mexico and Peru, urban sites in Cuba, Dominican Republic, Puerto Rico and Venezuela, and a rural site in Nigeria. The main outcome was use of community health care services in the past 3 months. Independent associations were estimated with indicators of need (dementia, depression, physical impairments), predisposing factors (age, sex, and education), and enabling factors (household assets, pension receipt and health insurance) using Poisson regression to generate prevalence ratios and fixed effects meta-analysis to combine them.

RESULTS

The proportion using healthcare services varied from 6% to 82% among sites. Number of physical impairments (pooled prevalence ratio 1.37, 95% CI 1.26-1.49) and ICD-10 depressive episode (pooled PR 1.21, 95% CI 1.07-1.38) were associated with service use, but dementia was inversely associated (pooled PR 0.93, 95% CI 0.90-0.97). Other correlates were female sex, higher education, more household assets, receiving a pension, and health insurance. Standardisation for age, sex, physical impairments, depression and dementia did not explain variation in service use. There was a strong borderline significant ecological correlation between the proportion of consultations requiring out-of-pocket costs and the prevalence of health service use (r = -0.50, p = 0.09).

CONCLUSIONS

While there was little evidence of ageism, inequity was apparent in the independent enabling effects of education and health insurance cover, the latter particularly in sites where out-of-pocket expenses were common, and private health insurance an important component of healthcare financing. Variation in service use among sites was most plausibly accounted for by stark differences in the extent of out-of-pocket expenses, and the ability of older people and their families to afford them. Health systems that finance medical services through out-of-pocket payments risk excluding the poorest older people, those without a secure regular income, and the uninsured.

Analysis of the different source terms of natural radionuclides in a river affected by NORM (Naturally Occurring Radioactive Materials) activities

The present work studied the radioacitivity impact of a coal-fired power plant (CFPP), a NORM industry, on the water of the Regallo river which the plant uses for cooling. Downstream, this river passes through an important irrigated farming area, and it is a tributary of the Ebro, one of Spain's largest rivers. Although no alteration of the (210)Po or (232)Th content was detected, the (234,238)U and (226)Ra contents of the water were significantly greater immediately below CFPP's discharge point. The (226)Ra concentration decreased progressively downstream from the discharge point, but the uranium content increased significantly again at two sampling points 8 km downstream from the CFPP's effluent. This suggested the presence of another, unexpected uranium source term different from the CFPP. The input from this second uranium source term was even greater than that from the CFPP. Different hypotheses were tested (a reservoir used for irrigation, remobilization from sediments, and the effect of fertilizers used in the area), with it finally being demonstrated that the source was the fertilizers used in the adjacent farming areas.

The association between common physical impairments and dementia in low and middle income countries, and, among people with dementia, their association with cognitive function and disability. A 10/66 Dementia Research Group population-based study

OBJECTIVE

Chronic physical comorbidity is common in dementia. However, there is an absence of evidence to support good practice guidelines for attention to these problems. We aimed to study the extent of this comorbidity and its impact on cognitive function and disability in population-based studies in low and middle income countries, where chronic diseases and impairments are likely to be both common and undertreated.

METHODS

A multicentre cross-sectional survey of all over 65 year old residents (n = 15 022) in 11 catchment areas in China, India, Cuba, Dominican Republic, Venezuela, Mexico and Peru. We estimated the prevalence of pain, incontinence, hearing and visual impairments, mobility impairment and undernutrition according to the presence of dementia and its severity, and, among those with dementia, the independent contribution of these impairments to cognitive function and disability, adjusting for age, gender, education and dementia severity.

RESULTS

Incontinence, hearing impairment, mobility impairment and undernutrition were consistently linearly associated with the presence of dementia and its severity across regions. Among people with dementia, incontinence, hearing impairment and mobility impairment were independently associated with disability in all regions while the contributions of pain, visual impairment and undernutrition were inconsistent. Only hearing impairment made a notable independent contribution to cognitive impairment.

CONCLUSIONS

There is an urgent need for clinical trials of the feasibility, efficacy and cost-effectiveness of regular physical health checks and remediation of identified pathologies, given the considerable comorbidity identified in our population based studies, and the strong evidence for independent impact upon functioning.

Antlers of Cervus elaphus as biomonitors of ⁹⁰Sr in the environment

Adequate radioprotection of the environment requires the identification of biomonitors sensitive to the variation of its radionuclide content. Due to the chemical similarities between calcium and strontium, calcified tissues of mammals are considered to be good ⁹⁰Sr biomonitors. This work considered Cervus elaphus antlers which, being shed annually, can give information about the importance of radiostrontium contamination in an ecosystem in the time period required for the growth of the antler. The samples were collected at various points of W and SW Spain. The mean value of their ⁹⁰Sr content was (70 ± 43 (S.D.)) Bq/kg d.w., range (16-218) Bq/kg d.w., and the radionuclide was evenly distributed in the different parts of the antler. There was a good correlation between the antlers' ⁹⁰Sr content and the ⁹⁰Sr deposited in the soil. The antlers' content of ²²⁶Ra (from the natural uranium series) and the contents of some stable elements (Ca, Mg, Sr, and K) were also determined. The values for these stable elements were practically constant in the analyzed samples, and the concentrations measured decreased in the following order: Ca » Mg > K > Sr » ⁹⁰Sr > ²²⁶Ra.

The prevalence of coeliac disease is significantly higher in children compared with adults

BACKGROUND

Some limited studies of coeliac disease have shown higher frequency of coeliac disease in infancy and adolescence than in adulthood. This finding has remained unnoticed and not adequately demonstrated.

AIM

To assess whether there are age and gender differences in coeliac disease prevalence.

METHODS

A total of 4230 subjects were included consecutively (1 to ≥80 years old) reproducing the reference population by age and gender. Sample size was calculated assuming a population-based coeliac disease prevalence of 1:250. After an interim analysis, the paediatric sample was expanded (2010 children) due to high prevalence in this group. Anti-transglutaminase and antiendomysial antibodies were determined and duodenal biopsy was performed if positive. Log-linear models were fitted to coeliac disease prevalence by age allowing calculation of percentage change of prevalence. Differences between groups were compared using Chi-squared test.

RESULTS

Twenty-one subjects had coeliac disease (male/female 1:2.5). Coeliac disease prevalence in the total population was 1:204. Coeliac disease prevalence was higher in children (1:71) than in adults (1:357) (P = 0.00005). A significant decrease of prevalence in older generations was observed [change of prevalence by age of -5% (95% CI: -7.58 to -2.42%)]. In the paediatric expanded group (1-14 years), a decrease of coeliac disease prevalence was also observed [prevalence change: -17% (95% CI: -25.02 to -6.10)].

CONCLUSIONS

The prevalence of coeliac disease in childhood was five times higher than in adults. Whether this difference is due to environmental factors influencing infancy, or latency of coeliac disease in adulthood, remains to be demonstrated in prospective longitudinal studies.

The contribution of chronic diseases to the prevalence of dependence among older people in Latin America, China and India: a 10/66 Dementia Research Group population-based survey

BACKGROUND

The number of older people is set to increase dramatically worldwide. Demographic changes are likely to result in the rise of age-related chronic diseases which largely contribute to years lived with a disability and future dependence. However dependence is much less studied although intrinsically linked to disability. We investigated the prevalence and correlates of dependence among older people from middle income countries.

METHODS

A one-phase cross-sectional survey was carried out at 11 sites in seven countries (urban sites in Cuba, Venezuela, and Dominican Republic, urban and rural sites in Peru, Mexico, China and India). All those aged 65 years and over living in geographically defined catchment areas were eligible. In all, 15,022 interviews were completed with an informant interview for each participant. The full 10/66 Dementia Research Group survey protocol was applied, including ascertainment of depression, dementia, physical impairments and self-reported diagnoses. Dependence was interviewer-rated based on a key informant's responses to a set of open-ended questions on the participant's needs for care. We estimated the prevalence of dependence and the independent contribution of underlying health conditions. Site-specific prevalence ratios were meta-analysed, and population attributable prevalence fractions (PAPF) calculated.

RESULTS

The prevalence of dependence increased with age at all sites, with a tendency for the prevalence to be lower in men than in women. Age-standardised prevalence was lower in all sites than in the USA. Other than in rural China, dementia made the largest independent contribution to dependence, with a median PAPF of 34% (range 23%-59%). Other substantial contributors were limb impairment (9%, 1%-46%), stroke (8%, 2%-17%), and depression (8%, 1%-27%).

CONCLUSION

The demographic and health transitions will lead to large and rapid increases in the numbers of dependent older people particularly in middle income countries (MIC). The prevention and control of chronic neurological and neuropsychiatric diseases and the development of long-term care policies and plans should be urgent priorities.

Measuring disability across cultures--the psychometric properties of the WHODAS II in older people from seven low- and middle-income countries. The 10/66 Dementia Research Group population-based survey

We evaluated the psychometric properties of the 12-item interviewer-administered screener version of the World Health Organization Disability Assessment Schedule-version II (WHODAS II) among older people living in seven low- and middle-income countries. Principal component analysis (PCA), confirmatory factor analysis (CFA) and Mokken analyses were carried out to test for unidimensionality, hierarchical structure, and measurement invariance across 10/66 Dementia Research Group sites. PCA generated a one-factor solution in most sites. In CFA, the two-factor solution generated in Dominican Republic fitted better for all sites other than rural China. The two factors were not easily interpretable, and may have been an artefact of differing item difficulties. Strong internal consistency and high factor loadings for the one-factor solution supported unidimensionality. Furthermore, the WHODAS II was found to be a 'strong' Mokken scale. Measurement invariance was supported by the similarity of factor loadings across sites, and by the high between-site correlations in item difficulties. The Mokken results strongly support that the WHODAS II 12-item screener is a unidimensional and hierarchical scale confirming to item response theory (IRT) principles, at least at the monotone homogeneity model level. More work is needed to assess the generalizability of our findings to different populations.

Late Crohn's disease patients present an increase in peripheral Th17 cells and cytokine production compared with early patients

BACKGROUND

Th1 and Th17 cells have been implicated in Crohn's disease (CD) pathophysiology and may play a role in disease persistence. Aim To determine Th1 and Th17 responses in intestine and peripheral blood of early (<32 weeks since initial symptoms) and late (>2 years) CD patients.

METHODS

Cytokine mRNA in intestinal biopsies was determined by RT-PCR. Cytokine concentration in culture was measured by ELISA and cytokine-producing cells were identified by intracellular staining.

RESULTS

The inflamed mucosa showed significantly increased IL-17 mRNA levels compared with non-inflamed areas, both in early and late CD patients. However, only patients with late (n = 12), but not early (n = 9), active disease showed increased IL-17 production, as well as a significantly higher percentage of IL-17(+)CD4(+) cells in blood, compared with controls (n = 12) or patients in remission (n = 13). Moreover, cultured peripheral CD4(+) cells from late active CD patients presented significantly higher percentages of IL-17(+), IL-22(+) and IFN-gamma(+) and a significantly increased production of IL-17 and IL-22, but not IFN-gamma(+).

CONCLUSIONS

Increased IL-17 gene transcription is common to early and late CD mucosa. However, exacerbated Th17 responses in the peripheral blood appear only in late disease. We propose that this population may constitute a mechanism of perpetuating the disease.

Late-life depression in Peru, Mexico and Venezuela: the 10/66 population-based study

BACKGROUND

The proportion of the global population aged 60 and over is increasing, more so in Latin America than any other region. Depression is common among elderly people and an important cause of disability worldwide.

AIMS

To estimate the prevalence and correlates of late-life depression, associated disability and access to treatment in five locations in Latin America.

METHOD

A one-phase cross-sectional survey of 5886 people aged 65 and over from urban and rural locations in Peru and Mexico and an urban site in Venezuela. Depression was identified according to DSM-IV and ICD-10 criteria, Geriatric Mental State-Automated Geriatric Examination for Computer Assisted Taxonomy (GMS-AGECAT) algorithm and EURO-D cut-off point. Poisson regression was used to estimate the independent associations of sociodemographic characteristics, economic circumstances and health status with ICD-10 depression.

RESULTS

For DSM-IV major depression overall prevalence varied between 1.3% and 2.8% by site, for ICD-10 depressive episode between 4.5% and 5.1%, for GMS-AGECAT depression between 30.0% and 35.9% and for EURO-D depression between 26.1% and 31.2%; therefore, there was a considerable prevalence of clinically significant depression beyond that identified by ICD-10 and DSM-IV diagnostic criteria. Most older people with depression had never received treatment. Limiting physical impairments and a past history of depression were the two most consistent correlates of the ICD-10 depressive episode.

CONCLUSIONS

The treatment gap poses a significant challenge for Latin American health systems, with their relatively weak primary care services and reliance on private specialists; local treatment trials could establish the cost-effectiveness of mental health investment in the government sector.

Contribution of chronic diseases to disability in elderly people in countries with low and middle incomes: a 10/66 Dementia Research Group population-based survey

BACKGROUND

Disability in elderly people in countries with low and middle incomes is little studied; according to Global Burden of Disease estimates, visual impairment is the leading contributor to years lived with disability in this population. We aimed to assess the contribution of physical, mental, and cognitive chronic diseases to disability, and the extent to which sociodemographic and health characteristics account for geographical variation in disability.

METHODS

We undertook cross-sectional surveys of residents aged older than 65 years (n=15 022) in 11 sites in seven countries with low and middle incomes (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Disability was assessed with the 12-item WHO disability assessment schedule 2.0. Dementia, depression, hypertension, and chronic obstructive pulmonary disease were ascertained by clinical assessment; diabetes, stroke, and heart disease by self-reported diagnosis; and sensory, gastrointestinal, skin, limb, and arthritic disorders by self-reported impairment. Independent contributions to disability scores were assessed by zero-inflated negative binomial regression and Poisson regression to generate population-attributable prevalence fractions (PAPF).

FINDINGS

In regions other than rural India and Venezuela, dementia made the largest contribution to disability (median PAPF 25.1% [IQR 19.2-43.6]). Other substantial contributors were stroke (11.4% [1.8-21.4]), limb impairment (10.5% [5.7-33.8]), arthritis (9.9% [3.2-34.8]), depression (8.3% [0.5-23.0]), eyesight problems (6.8% [1.7-17.6]), and gastrointestinal impairments (6.5% [0.3-23.1]). Associations with chronic diseases accounted for around two-thirds of prevalent disability. When zero inflation was taken into account, between-site differences in disability scores were largely attributable to compositional differences in health and sociodemographic characteristics.

INTERPRETATION

On the basis of empirical research, dementia, not blindness, is overwhelmingly the most important independent contributor to disability for elderly people in countries with low and middle incomes. Chronic diseases of the brain and mind deserve increased prioritisation. Besides disability, they lead to dependency and present stressful, complex, long-term challenges to carers. Societal costs are enormous.

FUNDING

Wellcome Trust; WHO; US Alzheimer's Association; Fondo Nacional de Ciencia Y Tecnologia, Consejo de Desarrollo Cientifico Y Humanistico, Universidad Central de Venezuela.

Population normative data for the 10/66 Dementia Research Group cognitive test battery from Latin America, India and China: a cross-sectional survey

Background

1) To report site-specific normative values by age, sex and educational level for four components of the 10/66 Dementia Research Group cognitive test battery; 2) to estimate the main and interactive effects of age, sex, and educational level by site; and 3) to investigate the effect of site by region and by rural or urban location.

Methods

Population-based cross-sectional one phase catchment area surveys were conducted in Cuba, Dominican Republic, Venezuela, Peru, Mexico, China and India. The protocol included the administration of the Community Screening Instrument for Dementia (CSI 'D', generating the COGSCORE measure of global function), and the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) verbal fluency (VF), word list memory (WLM, immediate recall) and recall (WLR, delayed recall) tests. Only those free of dementia were included in the analysis.

Results

Older people, and those with less education performed worse on all four tests. The effect of sex was much smaller and less consistent. There was a considerable effect of site after accounting for compositional differences in age, education and sex. Much of this was accounted for by the effect of region with Chinese participants performing better, and Indian participants worse, than those from Latin America. The effect of region was more prominent for VF and WLM than for COGSCORE and WLR.

Conclusion

Cognitive assessment is a basic element for dementia diagnosis. Age- and education-specific norms are required for this purpose, while the effect of gender can probably be ignored. The basis of cultural effects is poorly understood, but our findings serve to emphasise that normative data may not be safely generalised from one population to another with quite different characteristics. The minimal effects of region on COGSCORE and WLR are reassuring with respect to the cross-cultural validity of the 10/66 dementia diagnosis, which uses only these elements of the 10/66 battery.

Dietary fish and meat intake and dementia in Latin America, China, and India: a 10/66 Dementia Research Group population-based study

BACKGROUND

Evidence of an association between fish and meat consumption and risk of dementia is inconsistent and nonexistent in populations in developing countries.

OBJECTIVE

The objective was to investigate associations between fish and meat consumption with dementia in low- and middle-income countries.

DESIGN

One-phase cross-sectional surveys were conducted in all residents aged > or =65 y in 11 catchment areas in China, India, Cuba, the Dominican Republic, Venezuela, Mexico, and Peru. A total of 14,960 residents were assessed by using the 10/66 standardized protocol, which includes face-to-face interviews for dietary habits and a cross-culturally validated dementia diagnosis.

RESULTS

Dietary intakes and the prevalence of dementia varied between sites. We combined site-specific Poisson regression prevalence ratios (PRs) for the association between fish and meat consumption and dementia in 2 fixed-effect model meta-analyses adjusted for sociodemographic and health characteristics and fish and meat consumption as appropriate. We found a dose-dependent inverse association between fish consumption and dementia (PR: 0.81; 95% CI: 0.72, 0.91) that was consistent across all sites except India and a less-consistent, dose-dependent, direct association between meat consumption and prevalence of dementia (PR: 1.19; 95% CI: 1.07, 1.31).

CONCLUSIONS

Our results extend findings on the associations of fish and meat consumption with dementia risk to populations in low- and middle-income countries and are consistent with mechanistic data on the neuroprotective actions of omega-3 (n-3) long-chain polyunsaturated fatty acids commonly found in fish. The inverse association between fish and prevalent dementia is unlikely to result from poorer dietary habits among demented individuals (reverse causality) because meat consumption was higher in those with a diagnosis of dementia.

Testing the performance of mtSNP minisequencing in forensic samples

There is a growing interest among forensic geneticists in developing efficient protocols for genotyping coding region mitochondrial DNA (mtDNA) SNPs (mtSNPs). Minisequencing is becoming a popular method for SNP genotyping, but it is still used by few forensic laboratories. In part, this is due to the lack of studies testing its efficiency and reproducibility when applied to real and complex forensic samples. Here we tested a minisequencing design that consists of 71 mtSNPs (in three multiplexes) that are diagnostic of known branches of the R0 phylogeny, in real forensic samples, including degraded bones and teeth, hair shafts, and serial dilutions. The fact that amplicons are short coupled with the natural efficiency of the minisequencing technique allow these assays to perform well with all the samples tested either degraded and/or those containing low DNA amount. We did not observe phylogenetic inconsistencies in the 71 mtSNP haplotypes generated, indicating that the technique is robust against potential artefacts that could arise from unintended contamination and/or spurious amplification of nuclear mtDNA pseudogenes (NUMTs).

Reducing the string test intra-gastric downtime for detection of Mycobacterium tuberculosis

OBJECTIVES

To explore the potential for reducing the procedural duration of the string test for the diagnosis of tuberculosis (TB) using microscopic observation drug susceptibility (MODS) culture.

METHODS

Twelve patients already diagnosed with pulmonary TB, four each with sputum smear acid-fast bacilli grade 1+, 2+ and 3+, underwent four consecutive string tests of varying intra-gastric downtime (IGDT) of 30 min, 1, 2 and 4 h. Each retrieved string was cut into three-one oesophageal and two gastric sections. Eluates from one of the gastric sections and the oesophageal section were cultured in MODS after a decontamination procedure; eluate from the other gastric section was cultured in MODS with no decontamination.

RESULTS

No significant difference was observed in the retrieval efficacy of Mycobacterium tuberculosis (P = 0.29) or time to positive MODS culture (P = 0.80) among string tests of varying IGDTs. Every patient with a sample that was positive after a 4-h IGDT also had positive culture of a 1-h IGDT sample. A pre-inoculation sample decontamination step significantly reduced culture contamination (P < 0.001).

CONCLUSION

In smear-positive patients, reducing the IGDT to 1 h did not affect the M. tuberculosis retrieval efficacy of the string test. Future evaluations in non-expectorating human immunodeficiency virus and paediatric populations should include a 1-h IGDT.

Determining factors in the elimination of uranium and radium from groundwaters during a standard potabilization process

We studied the physico-chemical and radioactive characteristics of four waters of subsurface origin. They were chosen for having the highest natural radioactivity levels of waters for human consumption in the Autonomous Community of Extremadura, Spain Their activity levels for alpha emitting radionuclides are between 120 and 19300 mBq L(-1), all exceeding the 100 mBq L(-1) threshold established in the European Union above which radioactive isotopes that are present in water should be investigated to determine which corrective action, if any, is needed. These waters were used to compare the efficiency in eliminating their uranium and radium content of two potabilization processes - one the standard chlorination-only process used by their respective municipalities, and the other a procedure consisting of coagulation, flocculation, settling, filtration, and chlorination stages, specifically designed to maximize the elimination of their natural radioactive content. The results showed the uranium and radium elimination efficiencies to depend strongly on the water's hydrogencarbonate, calcium, and magnesium ion concentrations. In particular, with increasing concentrations of any of these ions, the uranium elimination efficiency fell from 90% to 60% at its optimal working pH, pH=6, while the radium elimination efficiency rose from 50% to 90% at its optimal working pH, pH=10.

The mtDNA ancestry of admixed Colombian populations

A total of 185 individuals from Colombia were sequenced for the first hypervariable region (HVS-I) of the mitochondrial DNA (mtDNA) genome, and a subset of these individuals were additionally genotyped for the second hypervariable segment (HVS-II). These individuals were collected according to their "self-reported ethnicity" in Colombia, comprising "Mestizos," "Mulatos," and "Afro-Colombians." We used databases containing more than 4,300 Native American lineages, 6,800 Africans, and 15,600 Europeans for population comparisons and phylogeographic inferences. We observe that Mulatos and Afro-Colombians have a dominant African mtDNA component, whereas Mestizos carry predominantly Native American haplotypes. All the populations analyzed have high diversity indices and there are no signatures of dramatic genetic drift episodes. Central and South America are the main candidate source populations of the Colombian Native American lineages, whereas west-central, southwest, and southeast Africa are the main original mtDNA sources for the African Colombian mtDNAs. We found that our results differ from those obtained in other studies for the same "population groups" in terms of haplogroup frequencies. This observation leads us to conclude that (i) self-reported ancestry is not a reliable proxy to indicate an individual's "ethnicity" in Colombia, (ii) our results do not support the use of outmoded race descriptions (Mestizos, Mulatos, etc.) mainly because these labels do not correspond to any genetically homogeneous population group, and (iii) studies relying on these terms to describe the population group of the individual, which then treat them as genetically homogeneous, carry a high risk of type I error (false positives) in medical studies in this country and of misinterpretation of the frequency of observed variation in forensic casework.

Prevalence of dementia in Latin America, India, and China: a population-based cross-sectional survey

BACKGROUND

Studies have suggested that the prevalence of dementia is lower in developing than in developed regions. We investigated the prevalence and severity of dementia in sites in low-income and middle-income countries according to two definitions of dementia diagnosis.

METHODS

We undertook one-phase cross-sectional surveys of all residents aged 65 years and older (n=14 960) in 11 sites in seven low-income and middle-income countries (China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru). Dementia diagnosis was made according to the culturally and educationally sensitive 10/66 dementia diagnostic algorithm, which had been prevalidated in 25 Latin American, Asian, and African centres; and by computerised application of the dementia criterion from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). We also compared prevalence of DSM-IV dementia in each of the study sites with that from estimates in European studies.

FINDINGS

The prevalence of DSM-IV dementia varied widely, from 0.3% (95% CI 0.1-0.5) in rural India to 6.3% (5.0-7.7) in Cuba. After standardisation for age and sex, DSM-IV prevalence in urban Latin American sites was four-fifths of that in Europe (standardised morbidity ratio 80 [95% CI 70-91]), but in China the prevalence was only half (56 [32-91] in rural China), and in India and rural Latin America a quarter or less of the European prevalence (18 [5-34] in rural India). 10/66 dementia prevalence was higher than that of DSM-IV dementia, and more consistent across sites, varying between 5.6% (95% CI 4.2-7.0) in rural China and 11.7% (10.3-13.1) in the Dominican Republic. The validity of the 847 of 1345 cases of 10/66 dementia not confirmed by DSM-IV was supported by high levels of associated disability (mean WHO Disability Assessment Schedule II score 33.7 [SD 28.6]).

INTERPRETATION

As compared with the 10/66 dementia algorithm, the DSM-IV dementia criterion might underestimate dementia prevalence, especially in regions with low awareness of this emerging public-health problem.

Ageing and dementia in low and middle income countries-Using research to engage with public and policy makers

While two thirds of the 24 million people with dementia worldwide live in low and middle income countries, very little research has been conducted to support policy making in these regions. Among the non-communicable diseases, dementia (in common with other chronic NCDs linked more to long-term disability than to mortality) has been relatively under-prioritized. International agreements, plans and policy guidelines have called for an end to ageist discrimination and a focus upon reducing disadvantage arising from poverty and the consequences of ill health. Social protection, access to good quality age-appropriate healthcare and addressing the problem of disability are all key issues. However, as yet, little progress has been made in addressing these concerns. In this review we outline the current international policy agenda for older individuals, and its specific relevance to those with dementia and other disabling non-communicable diseases. We consider the potential for epidemiological research to raise awareness, refine the policy agenda, and promote action, using the example of the dissemination strategy developed by the 10/66 Dementia Research Group.

Pseudomitochondrial genome haunts disease studies

The accidental amplification of nuclear mitochondrial pseudogenes (NUMTs) can pose a serious problem for mitochondrial disease studies. This report shows that the mutation spectrum left by spurious amplification of a NUMT can be detected because it usually differs considerably from the authentic natural spectrum. This study examined the problem introduced by an ND5 gene NUMT that was recorded in a proband with hearing loss and reviews other disease studies erroneously reporting NUMT variation as genuine mutations in their patients. NUMTs can emerge in population genetic studies, as exemplified here by cases in this study and from published sources. Appropriate database searches and a phylogenetic approach can prevent hasty claims for novelty of mitochondrial DNA (mtDNA) variants inadvertently derived from NUMTs and help to direct investigators to the real source.

The 10/66 Dementia Research Group's fully operationalised DSM-IV dementia computerized diagnostic algorithm, compared with the 10/66 dementia algorithm and a clinician diagnosis: a population validation study

Background

The criterion for dementia implicit in DSM-IV is widely used in research but not fully operationalised. The 10/66 Dementia Research Group sought to do this using assessments from their one phase dementia diagnostic research interview, and to validate the resulting algorithm in a population-based study in Cuba.

Methods

The criterion was operationalised as a computerised algorithm, applying clinical principles, based upon the 10/66 cognitive tests, clinical interview and informant reports; the Community Screening Instrument for Dementia, the CERAD 10 word list learning and animal naming tests, the Geriatric Mental State, and the History and Aetiology Schedule – Dementia Diagnosis and Subtype. This was validated in Cuba against a local clinician DSM-IV diagnosis and the 10/66 dementia diagnosis (originally calibrated probabilistically against clinician DSM-IV diagnoses in the 10/66 pilot study).

Results

The DSM-IV sub-criteria were plausibly distributed among clinically diagnosed dementia cases and controls. The clinician diagnoses agreed better with 10/66 dementia diagnosis than with the more conservative computerized DSM-IV algorithm. The DSM-IV algorithm was particularly likely to miss less severe dementia cases. Those with a 10/66 dementia diagnosis who did not meet the DSM-IV criterion were less cognitively and functionally impaired compared with the DSMIV confirmed cases, but still grossly impaired compared with those free of dementia.

Conclusion

The DSM-IV criterion, strictly applied, defines a narrow category of unambiguous dementia characterized by marked impairment. It may be specific but incompletely sensitive to clinically relevant cases. The 10/66 dementia diagnosis defines a broader category that may be more sensitive, identifying genuine cases beyond those defined by our DSM-IV algorithm, with relevance to the estimation of the population burden of this disorder.

Diagnostic value of duodenal antitissue transglutaminase antibodies in gluten-sensitive enteropathy

BACKGROUND

In gluten-sensitive enteropathy, antitissue transglutaminase antibodies are synthesized in the duodenum.

AIM

To compare the diagnostic yield of these autoantibodies in cultured duodenal biopsies, duodenal aspirate and serum.

METHODS

Patients (n = 315, 135 female, 180 male; age: 37.3 +/- 1.1 years) referred for duodenal biopsies, were recruited and HLA-DQ2/DQ8 haplotyped. Histological measurements were made from duodenal biopsies and cultured duodenal biopsies were used for antitissue transglutaminase antibodies analysis by enzyme-linked immunosorbent assay. Duodenal aspirate was collected in a subgroup of 81 patients. Patients were classified, according to their histology, response to a gluten-free diet and DQ2/DQ8 status, as definite, likely or nongluten-sensitive enteropathy.

RESULTS

Histology was normal in 59% of patients; 28% had lymphocytic enteritis, 1% had crypt hyperplasia and 13% showed atrophy. In Marsh III patients, there was complete agreement between duodenal and serological antitissue transglutaminase antibodies measurements. Marsh I patients showed a slight antitissue transglutaminase antibodies sensitivity improvement in cultured duodenal biopsy compared to serum in definite (22% vs. 19%) and likely gluten-sensitive enteropathy (20% vs. 14%) patients. Combined serum and cultured duodenal biopsy antitissue transglutaminase antibodies assessment increased serological sensitivity from 19% to 30% in Marsh I patients.

CONCLUSION

Duodenal antitissue transglutaminase antibodies detection improves serological determination sensitivity in Marsh I patients, providing diagnostic value and therapeutic impact.

Resolving relationship tests that show ambiguous STR results using autosomal SNPs as supplementary markers

When using a standard battery of STRs for relationship testing a small proportion of analyses can give ambiguous results - where the claimed relationship cannot be confirmed by a high enough paternity index or excluded with fully incompatible genotypes. The majority of such cases arise from unknowingly testing a brother of the true father and observing only a small number of exclusions that can each be interpreted as one- or two-step mutations. Although adding extra STRs might resolve a proportion of cases, there are few properly validated extra STRs available, while the commonly added hypervariable SE33 locus is four times more mutable than average, increasing the risk of ambiguous results. We have found SNPs in large multiplexes are much more informative for both low initial probabilities or ambiguous exclusions and at the same time provide a more reliable genotyping approach for the highly degraded DNA encountered in many identification cases. Eight relationship cases are outlined where the addition of SNP data resolved analyses that had remained ambiguous even with extended STR typing. In addition we have made simulations to ascertain the frequency of failing to obtain exclusions or conclusive probabilities of paternity with different marker sets when a brother of the true father is tested. Results indicate that SNPs are statistically more efficient than STRs in resolving cases that distinguish first-degree relatives in deficient pedigrees.