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HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities.
A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March–May 2016 and followed up March–May 2017.
HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records.
In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9–53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0–28.6 n = 16) was observed.
HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.
The conventional understanding of due diligence in international law appears to be that it is a concept that forms part of primary rules. During the preparatory stages in creating the Articles on Responsibility of States for Internationally Wrongful Acts (ARSIWA), the International Law Commission (ILC) focused on due diligence as though it could have formed part of secondary rules. Despite this process, no due diligence provision forms part of the ARSIWA. Yet a number of the final provisions are based on primary rules. This is because the ILC relied on the method of extrapolation in attempts to create secondary rules. Extrapolation is a method of international law-making by which the output of an analytical process is reproduced in a different form following an examination of its content that exists in other forms. In using this method, the ILC attempted to create secondary rules by extrapolating from primary rules. Yet it did not do so with respect to due diligence. However, due diligence can be formulated and applied differently by using this same method. This article analyses the steps of this process to construct a vision of where international legal practice should venture in the future. In learning from and amalgamating the dominant trends in different areas of international and domestic law, this article proposes that due diligence could exist as a secondary rule of general international law. By formulating and applying due diligence as a secondary rule, there is potential to develop the general international law applicable to determining state responsibility for the conduct of non-state actors.
Emotional cognition and effective interpretation of affective information is an important factor in social interactions and everyday functioning, and difficulties in these areas may contribute to aetiology and maintenance of mental health conditions. In younger people with depression and anxiety, research suggests significant alterations in behavioural and brain activation aspects of emotion processing, with a tendency to appraise neutral stimuli as negative and attend preferentially to negative stimuli. However, in ageing, research suggests that emotion processing becomes subject to a ‘positivity effect’, whereby older people attend more to positive than negative stimuli.
This review examines data from studies of emotion processing in Late-Life Depression and Late-Life Anxiety to attempt to understand the significance of emotion processing variations in these conditions, and their interaction with changes in emotion processing that occur with ageing.
We conducted a systematic review following PRISMA guidelines. Articles that used an emotion-based processing task, examined older persons with depression or an anxiety disorder and included a healthy control group were included.
In Late-Life Depression, there is little consistent behavioural evidence of impaired emotion processing, but there is evidence of altered brain circuitry during these processes. In Late-Life Anxiety and Post-Traumatic Stress disorder, there is evidence of interference with processing of negative or threat-related words.
How these findings fit with the positivity bias of ageing is not clear. Future research is required in larger groups, further examining the interaction between illness and age and the significance of age at disease onset.
Children and young people with intellectual disability and/or Autism Spectrum Disorder (autism) experience higher rates of mental health problems, including depression, than their typically developing peers. Although international guidelines suggest psychological therapies as first-line intervention for children and young people, there is limited evidence for psychological therapy for depression in children and young people with intellectual disability and/or autism.
To evaluate the current evidence base for psychological interventions for depression in children and young people with intellectual disability and/or autism, and examine the experiences of children and young people with intellectual disability and/or autism, their families and therapists, in receiving and delivering psychological treatment for depression.
Databases were searched up to 30 April 2020 using pre-defined search terms and criteria. Articles were independently screened and assessed for risk of bias. Data were synthesised and reported in a narrative review format.
A total of 10 studies met the inclusion criteria. Four identified studies were clinical case reports and six were quasi-experimental or experimental studies. All studies were assessed as being of moderate or high risk of bias. Participants with intellectual disability were included in four studies. There was limited data on the experiences of young people, their families or therapists in receiving or delivering psychological treatment for depression.
Well-designed, randomised controlled trials are critical to develop an evidence base for psychological treatment for young people with intellectual disability and/or autism with depression. Future research should evaluate the treatment experiences of young people, their families and therapists.
Remote delivery of evidence-based psychological therapies via video conference has become particularly relevant following the COVID-19 pandemic, and is likely to be an on-going method of treatment delivery post-COVID. Remotely delivered therapy could be of particular benefit for people with social anxiety disorder (SAD), who tend to avoid or delay seeking face-to-face therapy, often due to anxiety about travelling to appointments and meeting mental health professionals in person. Individual cognitive therapy for SAD (CT-SAD), based on the Clark and Wells (1995) model, is a highly effective treatment that is recommended as a first-line intervention in NICE guidance (NICE, 2013). All of the key features of face-to-face CT-SAD (including video feedback, attention training, behavioural experiments and memory-focused techniques) can be adapted for remote delivery. In this paper, we provide guidance for clinicians on how to deliver CT-SAD remotely, and suggest novel ways for therapists and patients to overcome the challenges of carrying out a range of behavioural experiments during remote treatment delivery.
Key learning aims
(1) To learn how to deliver all of the core interventions of CT-SAD remotely.
(2) To learn novel ways of carrying out behavioural experiments remotely when some in-person social situations might not be possible.
Depression in older people is likely to become a growing global health problem with aging populations. Significant cultural variation exists in beliefs about depression (terminology, symptomatology, and treatments) but data from sub-Saharan Africa are minimal. Low-resource interventions for depression have been effective in low-income settings but cannot be utilized without accurate diagnosis. This study aimed to achieve a shared understanding of depression in Tanzania in older people.
Using a qualitative design, focus groups were conducted with participants aged 60 and over. Participants from rural villages of Kilimanjaro, Tanzania, were selected via randomized sampling using census data. Topic guides were developed including locally developed case vignettes. Transcripts were translated into English from Swahili and thematic analysis conducted.
Ten focus groups were held with 81 participants. Three main themes were developed: a) conceptualization of depression by older people and differentiation from other related conditions (“too many thoughts,” cognitive symptoms, affective and biological symptoms, wish to die, somatic symptoms, and its difference to other concepts); b) the causes of depression (inability to work, loss of physical strength and independence, lack of resources, family difficulties, chronic disease); c) management of depression (love and comfort, advice, spiritual support, providing help, medical help).
This research expands our understanding of how depression presents in older Tanzanians and provides information about lay beliefs regarding causes and management options. This may allow development of culturally specific screening tools for depression that, in turn, increase diagnosis rates, support accurate diagnosis, improve service use, and reduce stigma.
This year 2018 has great historical and current significance for stellar spectral classification. Two hundred years ago in Reggio Emilia, Italy, was born Angelo Secchi, a pioneer of observing and classifying the spectra of stars. At the beginning of the IAU, almost a hundred years ago, one of its original Commissions was entitled the Spectral Classification of Stars, from which was generated Commission 45, Spectral Classification and Multi-band Colour Indices. And seventy-five years ago, was published the system-changing MKK, An Atlas of Stellar Spectra. Through this necessarily brief, historical view we shall recall how spectral classification, supported internationally by the IAU, continually updated its techniques, while remaining anchored to standards. This has ensured that the MK classification process stays very relevant to the initial characterizing of stars in the 21st century era of large spectral surveys.
The number of people living with dementia in sub-Saharan Africa (SSA) is expected to increase rapidly in the coming decades. However, our understanding of how best to reduce dementia risk in the population is very limited. As a first step in developing intervention strategies to manage dementia risk in this setting, we investigated rates of cognitive decline in a rural population in Tanzania and attempted to identify associated factors.
The study was conducted in the rural Hai district of northern Tanzania. In 2014, community-dwelling people aged 65 years and over living in six villages were invited to take part in a cognitive screening program. All participants from four of the six villages were followed-up at two years and cognitive function re-tested. At baseline and follow-up, participants were assessed for functional disability, hypertension, and grip strength (as a measure of frailty). At follow-up, additional assessments of visual acuity, hearing impairment, tobacco and alcohol consumption, and clinical assessment for stroke were completed.
Baseline and follow-up data were available for 327 people. Fifty people had significant cognitive decline at two-year follow-up. Having no formal education, low grip strength at baseline, being female and having depression at follow-up were independently associated with cognitive decline.
This is one of the first studies of cognitive decline conducted in SSA. Rates of decline at two years were relatively high. Future work should focus on identification of specific modifiable risk factors for cognitive decline with a view to developing culturally appropriate interventions.
W49 A is a star-forming region (SFR) found in the constellation of Aquila. It contains 3 active regions: W49 North (W49 N), W49 South West (W49 SW) and W49 South (W49 S). We present preliminary results from two epochs (e-)MERLIN observations of all ground-state OH masers towards the star-forming region (SFR) complex W49 A. The first epoch of observations was done in full-polarization mode with MERLIN in 2005 while the second epoch was obtained only in dual circular polarization during the test observations of the upgraded e-MERLIN in 2013. The overall maser spatial distributions in both epochs are in good agreement. We found several new high velocity maser features up to +34 km s−1 and −28 km s−1. The magnetic field strengths are between 1.1 to 10.8 mG. All three sources show evidence of magnetic field reversal.
Outstanding problems concerning mass-loss from evolved stars include initial wind acceleration and what determines the clumping scale. Reconstructing physical conditions from maser data has been highly uncertain due to the exponential amplification. ALMA and e-MERLIN now provide image cubes for five H2O maser transitions around VY CMa, at spatial resolutions comparable to the size of individual clouds or better, covering excitation states from 204 to 2360 K. We use the model of Gray et al. 2016, to constrain variations of number density and temperature on scales of a few au, an order of magnitude finer than is possible with thermal lines, comparable to individual cloud sizes or locally almost homogeneous regions. We compare results with the models of Decin et al. 2006 and Matsuura et al. 2014 for the circumstellar envelope of VY CMa; in later work this will be extended to other maser sources.
Regulatory impact analyses (RIAs) weigh the benefits of regulations against the burdens they impose and are invaluable tools for informing decision makers. We offer 10 tips for nonspecialist policymakers and interested stakeholders who will be reading RIAs as consumers.
1. Core problem: Determine whether the RIA identifies the core problem (compelling public need) the regulation is intended to address.
2. Alternatives: Look for an objective, policy-neutral evaluation of the relative merits of reasonable alternatives.
3. Baseline: Check whether the RIA presents a reasonable “counterfactual” against which benefits and costs are measured.
4. Increments: Evaluate whether totals and averages obscure relevant distinctions and trade-offs.
5. Uncertainty: Recognize that all estimates involve uncertainty, and ask what effect key assumptions, data, and models have on those estimates.
6. Transparency: Look for transparency and objectivity of analytical inputs.
7. Benefits: Examine how projected benefits relate to stated objectives.
8. Costs: Understand what costs are included.
9. Distribution: Consider how benefits and costs are distributed.
10. Symmetrical treatment: Ensure that benefits and costs are presented symmetrically.
Care-home residents with dementia can experience behavioural and psychological symptoms such as aggression, agitation, anxiety, wandering, calling out and sexual disinhibition. Care-home staff have a duty to keep residents safe. However, residents with dementia can pose particular challenges in this area. In this paper, we draw on a study which explored how care-home staff manage dementia-related behaviours. In-depth ethnographic case studies at four separate care homes were conducted in England. These involved interviews with 40 care-home staff and 384 hours of participant observation. Our analysis showed that some residents with dementia experience behaviours which can either create risks for, or negatively impact on, themselves and/or other residents or staff members. It emerged that the consequences of the behaviours, rather than the behaviours themselves, created difficulties for staff. To cope with the risk and impact of behaviours, staff employed multiple strategies such as surveillance, resident placement, restrictions and forced care. Using the data, we explore how actions taken by staff to manage the risk and impact of behaviours in these communal settings relate to residents’ human rights. Our findings have particular relevance for care-home staff who need support and guidance in this area, for service development worldwide and for the global ageing population whose valued human rights may become under threat, if they require long-term care.
In the above article (Paddick, 2017) The corresponding author's details were previously listed incorrectly. The correct details are; contact number +44 191 293 2709 and email address William.email@example.com. The original article has been updated with the correct contact details. The publishers apologise for any inconvenience and confusion this error has caused.
This study aimed to assess the feasibility of a low-literacy adaptation of the Alzheimer’s Disease Assessment Scale – Cognitive (ADAS-Cog) for use in rural sub-Saharan Africa (SSA) for interventional studies in dementia. No such adaptations currently exist.
Tanzanian and Nigerian health professionals adapted the ADAS-Cog by consensus. Validation took place in a cross-sectional sample of 34 rural-dwelling older adults with mild/moderate dementia alongside 32 non-demented controls in Tanzania. Participants were oversampled for lower educational level. Inter-rater reliability was conducted by two trained raters in 22 older adults (13 with dementia) from the same population. Assessors were blind to diagnostic group.
Median ADAS-Cog scores were 28.75 (interquartile range (IQR), 22.96–35.54) in mild/moderate dementia and 12.75 (IQR 9.08–16.16) in controls. The area under the receiver operating characteristic curve (AUC) was 0.973 (95% confidence interval (CI) 0.936–1.00) for dementia. Internal consistency was high (Cronbach’s α 0.884) and inter-rater reliability was excellent (intra-class correlation coefficient 0.905, 95% CI 0.804–0.964).
The low-literacy adaptation of the ADAS-Cog had good psychometric properties in this setting. Further evaluation in similar settings is required.
The majority of older adults with dementia live in low- and middle-income countries (LMICs). Illiteracy and low educational background are common in older LMIC populations, particularly in rural areas, and cognitive screening tools developed for this setting must reflect this. This study aimed to review published validation studies of cognitive screening tools for dementia in low-literacy settings in order to determine the most appropriate tools for use.
A systematic search of major databases was conducted according to PRISMA guidelines. Validation studies of brief cognitive screening tests including illiterate participants or those with elementary education were eligible. Studies were quality assessed using the QUADAS-2 tool. Good or fair quality studies were included in a bivariate random-effects meta-analysis and a hierarchical summary receiver operating characteristic (HSROC) curve constructed.
Forty-five eligible studies were quality assessed. A significant proportion utilized a case–control design, resulting in spectrum bias. The area under the ROC (AUROC) curve was 0.937 for community/low prevalence studies, 0.881 for clinic based/higher prevalence studies, and 0.869 for illiterate populations. For the Mini-Mental State Examination (MMSE) (and adaptations), the AUROC curve was 0.853.
Numerous tools for assessment of cognitive impairment in low-literacy settings have been developed, and tools developed for use in high-income countries have also been validated in low-literacy settings. Most tools have been inadequately validated, with only MMSE, cognitive abilities screening instrument (CASI), Eurotest, and Fototest having more than one published good or fair quality study in an illiterate or low-literate setting. At present no screening test can be recommended.
Cognitive stimulation therapy (CST) is a psychosocial group-based intervention for dementia shown to improve cognition and quality of life with a similar efficacy to cholinesterase inhibitors. Since CST can be delivered by non-specialist healthcare workers, it has potential for use in low-resource environments, such as sub-Saharan Africa (SSA). We aimed to assess the feasibility and clinical effectiveness of CST in rural Tanzania using a stepped-wedge design.
Participants and their carers were recruited through a community dementia screening program. Inclusion criteria were DSM-IV diagnosis of dementia of mild/moderate severity following detailed assessment. No participant had a previous diagnosis of dementia and none were taking a cholinesterase inhibitor. Primary outcomes related to the feasibility of conducting CST in this setting. Key clinical outcomes were changes in quality of life and cognition. The assessing team was blind to treatment group membership.
Thirty four participants with mild/moderate dementia were allocated to four CST groups. Attendance rates were high (85%) and we were able to complete all 14 sessions for each group within the seven week timeframe. Substantial improvements in cognition, anxiety, and behavioral symptoms were noted following CST, with smaller improvements in quality of life measures. The number needed to treat was two for a four-point cognitive (adapted Alzheimer's Disease Assessment Scale-Cognitive) improvement.
This intervention has the potential to be low-cost, sustainable, and adaptable to other settings across SSA, particularly if it can be delivered by non-specialist health workers.
The literature on the λ Boo stars has grown to become somewhat heterogenous, as different authors have applied different criteria across the UV, optical, and infrared regions to determine the membership status of λ Boo candidates. We aim to clear up the confusion by consulting the literature on 212 objects that have been considered as λ Boo candidates, and subsequently evaluating the evidence in favour of their admission to the λ Boo class. We obtained new spectra of ~ 90 of these candidates and classified them on the MK system to aid in the membership evaluations. The re-evaluation of the 212 objects resulted in 64 members and 103 non-members of the λ Boo class, with a further 45 stars for which membership status is unclear. We suggest observations for each of the stars in the latter category that will allow them to be confidently included or rejected from the class. Our reclassification facilitates homogenous analysis on group members, and represents the largest collection of confirmed λ Boo stars known.