Outcome of first contact schizophrenia in Jamaica

Several previous studies have identified high incidence rates, high relapse rates and poor short term outcome for schizophrenia in African-Caribbeans in the United Kingdom (UK). Studies in the Caribbean have found the incidence of schizophrenia to be within worldwide levels, and one-year outcome to be much lower than that reported for African Caribbean patients in the UK. First contact patients with schizophrenia identified prospectively by the Present Status Examination were followed prospectively for one year. The main outcome measures which were collected from case notes included: clinical status and medication usage at contact with clinical service, employment status, outpatient clinic compliance, relapse rate and in-patient hospital status, after 12 months. Three hundred and seventeen patients between ages 15 and 55 years who had made first contact with the psychiatric service in Jamaica in 1992 received a computer diagnostic programme for the present status examination (CATEGO) diagnosis of schizophrenia. The majority 197 (62 percent) were treated at home, and 120 (38 percent) were admitted to hospital for treatment. Two hundred and sixty four (83 percent) were still being seen after one year. The relapse rate was 13 percent (41 patients), higher for admissions (24, 20 percent) than for those treated at home (17, 9 percent; p<0.001). The relapse rate was higher for patients brought into care by the police and mental health officers (p<0.005). One hundred and thirty five (43 percent) were in gainful employment within the 12 month period of follow up, contrasted with the 40 percent unemployment rate for the 2.4 million population of the island (chi square = 39.322, p<0.001). There was a self-reported use of medication in 213 (67 percent) patients, with 142 (45 percent) on monthly intramuscular depot medication. The low relapse rates and good outcome measures after 12 months of first srevice contact with schizophrenia are related to high levels of gainful employment and good intramuscular medication compliance. The favourable short term outcome in Jamaica does not correspond to the high relapse rate for this condition found in African Caribbeans in the UK. (AU)

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of thier illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More that half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and s everity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients, superior to the outcome of treatment in conventional psychiatric facilities.(Au)

Treatment of acute schizophrenia in open medical wards

The aim of this study was to compare the pathways to care and outcome of first contact patients with schizophrenia admitted to open medical wards with those treated in closed community psychiatric units and in acute wards of a custodial mental hospital. First contact with patients with schizophrenia who were identified in Jamaica in 1992 and admitted to the three different types of acute treatment facility across the island were followed in a blinded prospective study. Their pathways to care and standard clinical and sociological outcome parameters were identified and compared. 65 first contact patients were admitted to 3 acute wards of the Bellevue Mental Hospital, 20 patients to two closed psychiatric units in general hospitals, and 35 patients admitted to 8 general hospitals islandwide. The mean length of stay in the mental hospital wards was 88.3 days; in the psychiatric units was 29.9 days (p<0.01), and in the general hospitals was 14.1 days (p<0.0001). Clinical outcome variable were significantly better (p<0.03) for patients treated in open medical wards compared with those admitted to acute mental hospital wards. Fewer patients were admitted to open medical wards by the police (p<0.01), or by compulsory legal section (p<0.01). Compared with admissions to conventional psychiatric units, admissions to open medical wards had shorter lengths of stay (p<0.02), fewer admissions by compulsory detention (p<0.05) and had attained relative numerical but not statistical significance for most clinical outcome and pathway to care variables.(AU)

Jamaican neuropathy: the unfinished story

Jamaican neuropathy was first reported in a 1956 publication of 100 cases in the WIMJ. This study commenced in 1952 when Cruickshank came to Jamaica as the first Professor of Medicine of the new medical school at the University College of the West Indies. Recognising that the spinal cord disorders he encountered most frequently in the wards and clinics did not conform to the pattern of any disease he had previously seen, and unable to identify the aetiology and pathology, he described them as a "neuropathic syndrome of uncertain aetiology", and coined the vague name Jamaican neuropathy. He described two groups of patients, those with chronic spastic paraparesis (80 patients), now called tropical spastic paraparesis (TSP), and the rest (20 patients) with an ataxic syndrome, now called tropical ataxic neuropathy (TAN). This publication led to the recognition of similar disorders in other tropical countries, and each gave its individual name to the disease. Laboratory tests were unable to identify evidence of nutritional or vitamin deficiency, toxicity or of either bacterial or viral infection. Cerebrospinal fluid (CSF) examination sometimes showed mild evidence of infection. Serological tests for syphilis (STS) were positive in serum and cerebrospinal fluid in 45 to 80 percent of patients in some countries, even where yaws was not endemic. Histopathology showed a non-specific chronic inflammatory reaction in the spinal cord and to a lesser extent in the brain. First world neurologist showed little interest in these disorders, especially as they occurred in persons of African descent and low socioeconomic status. In 1985 the findings of IgG antibodies to the HTLV virus in serum and CFS of patients of several countries and in a variety of ethnic groups suggested HTLV as the causative agent of TSP. However, this is not the whole answer as a high seropositive rate is not found in all countries while TAN has been shown to be due to cyanide toxicity in some countries, though not in Jamaica. The search continues. (AU)

Incidence of HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) in Jamaica and Trinidad

HTLV-I is sexually transmitted more efficiently from men to women than vice versa, and the majority of HTLV-I endemic areas report a female preponderance of HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) cases. The objective of this study was to estimate the gender and age specific incidence rates of HAM/TSP in the general population as well as in the HTLV-I-infected population in Jamaica and Trinidad and Tobago. Incidence rates for HAM/TSP were computed based on all reported incident cases in both countries between 1990 and 1994. Population cenus reports for 1990 were used to calculate the population at risk. The age-standardized HAM/TSP incidence rate (mean +/- standard error of the mean) in Jamaica was 1.8 +/- 0.2/100,000 person years (PY). Among individuals of African descent in Trinidad and Tobago, the rate was 1.7 +/- 0.4/100,000 PY. As in HTLV-I seroprevalence, the incidence rate of HAM/TSP increased with age through the fifth decade of life and was three time as high in women than in men. The HAM/TSP incidence rate, calculated as a function of the number of HTLV-I infection persons in each age stratum, is higher in women (24.7/100,000 PY) than in men 17.3/100,000 PY). With HTLV-I infection, the lifetime risk of developing HAM/TSP was estimated to be 1.9 percent overall and is slightly higher in women (1.8 percent) than in men (1.3 percent). Thus, the higher prevalence of HTLV-I in women in endemic areas does not fully explain the preponderance of female HAM/TSP, suggesting that other cofactors must be present. The higher incidence rate in women between the ages of 40 and 59 years, as well as the increase in HAM/TSP incidence rates with age, are indicative of the importance of adult-acquired HTLV-I infection, presumably through sexual transmission(AU)

Tropical spastic paraparesis: then and now

Tropical spastic paraparesis (TSP) is a chronic myelopathy that was initially recogized in tropical countries in the nineteen century. For several decades no aetiological agent was identified until in 1985 when IgG antibodies to human T-cell lymphotropic virus Type 1 (HTLV-I) were found in serum and cerebrospinal fluid of patients from Jamaica, Columbia and Martinique. Soon after, a similar clinical syndrome named HTLV-I associated myelopathy (HAM) was described from the temperate region of Kyushu in Japan. In 988 the name TSP/HAM was introduced to include all HTLV-I positive patients with the clinical criteria of this chronic myelopathy. No major changes have been noted in the clinical features of these patients over the years but with the increased numbers of patients studied many more HTLV-I associated syndromes have been identified. Non HTLV-I positive TSP is still reported in several countries and the conclusion must be that this chronic spastic paraparesis has diverse aetiologies. (AU)

Pathways to care and outcome of first contact schizophrenia in Jamaica - abstract

The study was to identify pathways to care and determine clinical outcome after one year in a cohort with first contact schizophrenia in Jamaica. 317 first contact patients identified prospectively were followed blind by psychiatrists and mental health officers and clinical outcome variables were recorded monthly. Relapse was identified as admission/readmission to hospital, re-emergence of symptoms and/or the return of abnormal behaviour. Data in the first 12-month period following first contact were analyzed by the Chi-squared method. 65 percent were males, 98 percent were of African origin, and 90 percent of social classes IV and V. They were treated at home (63 percent), in the mental hospital (20 percent) and community psychiatric beds (17 percent). Only 5 percent were admitted using a compulsory detention section order. The mean length of stay in the mental hospital was 93 days, and in the community beds was 24 days. 70 percent were still being followed in clinics and 21 percent had ceased contact and had been discharged. The relapse rate was 7 percent and these patients were more likely to have come into care through the police or mental health officers (p<0.05), and more likely to have been treated in hospitals (p>0.05) and more likely to have received an increase in psychotropic medication (p>0.05). The relapse status of an additional 7 percent patients could not be ascertained. We concluded that low relapse rate in schizophrenia is related to close involvement of families of the patients as caregivers, early recognition and treatment in community and home settings, significant reduction in the use of compulsory detention, and the provision of high compliance pharmacological follow-up treatment. (AU)

Anterior horn cell degeneration in polymyositis associated with human T lymphotropic virus Type-1 in patients from Barbados

Anterior horn cell degeneration has only ocassionally been noted in patients with tropical spastic paraparesis associated with human T lymphotropic virus type-1 (HTLV-1) infection. We report on three adult patients with HTLV-1-associated polymyositis who had clinical evidence of anterior horn cell degeneration. One patient had moderate proximal weakness and muscle wasting in all four limbs, while two had mild upper limb weakness with more profound proximal weakness and wasting in the lower limbs. In all three patients, elctromyographic findings were compatible with motor unit loss and muscle biopsies showed mononuclear inflammatory cell infiltration; muscle cell biopsies in two patients showed features of denervation. Immunoglobulin G (IgG) antibodies to HTLV-1 were detected by enzyme-linked immunosorbent assay (ELISA) and confirmed by Western immunoblot in serum and cerobrospinal fluid in all three patients. In two, cell cultures were established from peripheral blood lymphocytes and HTLV-1 antigen was identified by immunofluorescence and the ELISA antigen-capture technique using an anti-p19 HTLV-1 mouse monoclonal antibody. The three cases illustrate the variety of neuromuscular disease, other than spastic paraparesis, that may occur in HTLV-1 infection. In some cases of HTLV-1-associated polymyositis, anterior horn cell degeneration may make a significant contribution to the muscle atrophy observed. (AU)

HLA DRBI *DQB1* haplotype in HTLV-I-associated familial infective dermatitis may predict development of HTLV-I-associated myelopathy/tropical spastic paraparesis

A possible causal association between infective dematitis and HTLV-I infection was reported familial infective dematitis (ID) occurring in a 26-year-old mother and her 9-year-old son. The mother was first diagnosed with ID in 1969 at the age of 2 years in the Dermatology Unit at the University Hospital of the West indies (U.H.W.I.) in Jamaica. The elder of her 2 sons was diagnosed with ID at the age of 3 years, also at U.H.W.I. Both mother and son are HTLV-I-seropositive. A second, younger son, currently age 2 years, is also HTLV-I-seropositive, but without clinical evidence of ID. Major hitocompatibility complex (MHC), class II, human leucocyte antigen (HLA) genotyping documented a shared class II haplotype, DRB*DQBI* (1101-0301), in the mother and her 2 sons. This same haplotype has been described among Japanese patients with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP), and has been associated with a possible pathologically heightened immune repsonse to HTLV-I infection. The presence of this haplotype in these familial ID cases with clinical signs of HAM/TSP may have contributed to their risk for development of HAM/TSP. The unaffected, HTLV-I seropositive younger son requires close clinical follow-up. (AU)

Dopamine D4 receptor variant in Africans, D4 valine 194 glycine, is insensitive to dopamine and clozapine: report of a homozygous individual

The D4 valine 194 glycine receptor is a variant of the dopamine D4 receptor and is found in 12.5 percent of the Afro-Caribbean population. Glycine replaces valine at a position one amino acid away from a serine which is critical for the attachment of dopamine. To determine whether this mutation had an effect on the properties of the dopamine D4 receptor, we constructed this variant and tested the sensitivity of the expressed protein with various drugs. We found that the variant receptor was two orders of magnitude less sensitive to dopamine, clozapine and olanzapine. The variant receptor was insensitive to guanine nucleotide, indicating the absence of high-affinity state or functional state. The one 15-year-old individual found homozygous for this variant also had sickle cell disease. The patient revealed an overall pattern of low weight and no axillary or pubic hair. (AU)

Retroviruses and schizophrenia in Jamaica

Reports of an 18-fold higher incidence of schizophrenia among second-generation Afro-Caribbeans, and especially Jamaican migrants in the United Kingdom were soon called an epidemic of schizophrenia, with the inference that a novel virus, likely to be perinatally transmitted, was a possible etiological agent. This intriguing observation led us to explore a possible link with human T-cell lympotropic virus type one (HTLV-I), because it is a virus that is endemic in the Caribbean Island, is perinatally transmitted, known to be neuropathogenic, and the cause of a chronic myelopathy tropical spastic paraparesis/HTLV-I associated myelopathy. We therefore examined inpatients as the Bellevue Mental Hospital, Kingston, Jamaica and did standard serological tests for retroviruses HTLV-I and HTLV-II and HIV-I and HIV-II on 201 inpatients who fulfilled ICD-9 and DSM II-R criteria for schizophrenia. Our results produced important negative data, since the seropositivity rates for HTLV-I, the most likely pathogen, were no greater than the seropositivity range for HTLV-I carriers in this island population, indicating the HTLV-I and the other retroviruses tested do not play a primary etiological role in Jamaican schizophrenics(AU)

Risk factors and cofactors for human T-cell lymphotropic virus type 1 (HTLV-1) - associated myelopathy/tropical spastic paraparesis (HAM/TSP) in Jamaica

Human T-cell lymphotrophic virus type 1 (HTLV-1) has been etiologically associated with a neurologic syndrome called HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP) as well as with adult T-cell leukemia/lymphoma. The authors sought to quantify the risk in Jamaica of HAM/TSP associated with HTLV-1 infection and cofactors associated with this disease among infected individuals. Between 1988 and 1989, prevalent and incident HAM/TSP patients and controls with other neurologic diseases were enrolled in a retrospective study. A second control group was composed of HTLV-1-seropositive, asymptomatic carriers in Jamaica, ascertained in a separate study conducted in 1988. Although HTLV-1 seropositivity was not a component of the case definition for HAM/TSP, all 43 HAM/TSP patients were HTLV-1 seropsitive compared with two (4.0 percent) of the controls with other neurologic diseases. Given HTLV-1 seropositivity, one cofactor associated with the risk of HAM/TSP was young age at initial heterosexual intercourse (odds ratio = 4.00, 95 percent confidence interval 1.29-12.46 for individuals aged ó15; odds ratio = 4.26, 95 percent confidence interval 1.41-12.90 for individuals aged 16-17 years at initial intercourse). Among individuals who reported this early age at initial sexual intercourse, an increased risk of HAM/TSP was associated with having reported more than five lifetime sexual partners (odds ratio = 2.88, 95 percent confidence interval 0.90-8.70). Neither an early age at initial sexual intercourse nor the number of lifetime sexual partners was a risk factor for adult T-cell leukemia/lymphoma. These data support the hypothesis that HAM/TSP is associated with sexually acquired HTLV-1 infection, whereas adult T-cell leukemia/lymphoma is not. (AU)

The echocardiographic features of polymyositis - abstract

Two dimensional echocardiography with doppler studies were performed in 30 patients at the UWI with the diagnosis of dermatomyositis/polymyositis established by the usual clinical and investigative criteria. This was done in order to elucidate the echocardiographic features of this condition which had not been clearly defined before. There were 25 females and 5 males, age range 28-65 years (mean - 48 years), with the majority of patients (70 percent) being in the 41 - 70 year age group. No valvular abnormalities were observed, and left ventricular internal dimension in systole LVIDs-1.9-3.7 cm, mean-2.8cm) and contractility (ejection fraction - range 43 - 89 percent, mean - 69 percent) were normal. No regional wall motion abnormalities were observed. Only 3 patients (10 percent) had evidence of global reduction in systolic function. There was hypertrophy of the interventricular septum in 9 patients (30 percent), and in the left ventricular posterior wall in 6 patients (20 percent). The dimensions of the left atrium (2.6-3.7 cm; mean - 3.2 cm), aorta (2.5-3.6 cm; mean 3.2 cm) and right ventricle (range 1.6-2.5 cm; mean - 2.1 cm) were normal. Doppler studies did not reveal any significant valvular regurgitation, and pulmonary artery velocities documented normal mean pulmonary artery pressures (mean 18 mm Hg) in all patients. Left ventricular diastolic function as indicated by E/A ratios (0.55-1.39;mean-1.23) from mitral valve inflow studies was normal. Conclusion: Echocardiographic doppler studies in patients with dermatomyositis/polymyositis were largely normal apart from minor degrees of left ventricular hypertrophy in a minority of patients (AU)

Patterns of HTLV-1 infection among family members of patients with adult T-cell leukemia/lymphoma and HTLV-1 associated myelopathy/tropical spastic paraparesis - abstract

Human T-cell lymphotropic virus type 1 (HTLV-1) is strongly associated with both ATL and HAM/TSP. Only a small proportion of HTLV-1 infected individuals develop either of these diseases with lifelong risk estimates between 1 percent and 5 percent. ATL is believed to be related to early childhood infection via mother to child and HAM/TSP is thought to result from sexually or parenterally acquired infection in adulthood. Through the evaluation of HTLV-1 seroprevalence among family members of ATL and HAM/TSP patients we provide data that early life exposure is important for later development of ATL. Cases of ATV and HAM/TSP and their first degree relatives were enrolled in the study at the UWI, Jamaica, HTLV-1 seroprevalence rates were compared. We enrolled 25 ATL and 31 HAM/TSP families. All cases were HTLV-1 positive. Females accounted for 56 percent of ATL cases and 80 percent of HAM/TSP cases with mean ages of 43 and 49 respectively. The seroprevalence of HTLV-1 among mothers of ATL patients was 100 percent compared to 27 percent among mothers of HAM/TSP patients (p=0.0003). Among fathers of ATL subjects the seroprevalence was 80 percent vs 0 percent for HAM/TSP (p=0.05). The seroprevalence among all family members was 49 percent for ATL and 20 percent for HAM/TSP (p=0.0003). In contrast spouses ofHAM/TSP cases had a 86 percent seroprevalence compared to 57 percent among spouses of ATL cases. ATL and HAM/TSP evolve from distinct pathogenic pathways supported by differences in epidemiologic association. This premise is strongly supported by our observation that family members of ATL patients, particularly mothers have a significantly higher prevalence of HTLV-1 infection (AU)

Human T-cell lymphotropic virus: overview and update on the clinical spectrum - abstract

The first human retrovirus, human T-cell lymphotropic virus type 1 (HTLV -1) was isolated in 1980 and was soon identified as the cause of adult T-cell leukemia (ATL), a fatal lymphoproliferative hematologic malignancy first designated as a clinical entity by Takatsuki in Japan. Five years later we discovered that this virus was the causative agent of a chronic myelopathy, first called Jamaican neuropathy by Cruikshank in 1956 and now called tropical spastic paraparesis (TSP). HTLV-1 was soon recognized to be the causative agent of similar neurological disorder (HTLV-1 associated myelopathy (HAM) in southern Japan because by definition all patients had to be HTLV-1 seropositive. Thus in less than a decade, a century of research and speculation was resolved when it was found that this myelopathy, thought only to occur in blacks of poor socioeconomic status in tropical countries, existed in non-blacks in a temperate climate. HTLV-1 causes chronic inflammation but the pathogenesis of HTLV-1 disease is undetermined despite extensive definitive laboratory studies. The two most major diseases, ATL and TSP/HAM are rarely found in the same patient although other manifestations of HTLV-1 infection such as skin involvement, arthropathy and broncho alveolitis are not infrequently seen. We remain uncertain of the definitive factors which precipitate clinical infection and recognize that the absence of HTLV-1 seropositivity by routine laboratory tests does not in itself exclude HTLV-1 disease (AU)

Identification of human T-cell leukemia/lymphoma virus type I antibodies, DNA, and protein in patients with polymyositis

OBJECTIVE: To investigate a possible association between human T cell leukemia/lymphoma virus type I (HTLV-I) and polymyositis (PM). METHODS: Sera and muscle biopsy samples from 9 Jamaican PM patients were compared with specimens from American HTLV-I positive PM patients and normal controls. Sera were evaluated for HTLV antibodies by enzyme-linked immunosorbent assay and Western blot. The biopsy samples were analyzed for HTLV-I/II DNA by polymerase chain reaction and were also immunohistochemically stained for HTLV gp46 envelope protein. RESULTS: Seven of the 8 Jamaican PM patients from whom sera were available were HTLV-I seropositive. The muscle biopsies of all 9 Jamaican patients demonstrated severe lymphocytic infiltration, cellular degeneration, myofiber atrophy, and fibrosis. Each muscle biopsy specimen contained HTLV-I DNA. Two of 6 samples demonstrated intense staining for HTLV-I gp46 in many of the invading mononuclear cells and weak staining for HTLV-I gp46 in many of the other specimens were weakly positive for gp46 in rare mononuclear cells. All controls specimens were negative for the presence of HTLV-I DNA and protein. CONClUSION: HTLV-I is associated with an inflammatory muscle disease characterized by direct invasion of the affected muscle by HTLV-I-infected mononuclear cells.(AU)

Anterior horn cell degeneration in HTLV-1 associated polymyositis in patients from Barbados - abstract

Anterior horn cell degeneration has only been noted occasionally in patients with tropical spastic paraparesis associated with human T-lymphotropic virus type I infection (HTLV-I). We report on three adult patients with HTLV-I associated polymyositis who had evidence of anterior horn cell degeneration. One patient had moderate proximal weakness in all 4 limbs, while 2 had mild upper limb weakness and profound proximal weakness in the lower limbs. Electromyographic findings indicated motor unit loss. Muscle biopsies in 2 patients showed features of denervation, as well as mono-nuclear inflammatory cell infiltration. HTLV-1 IgG antibodies were detected by enzyme-linked immunosorbent assay, and confirmed by Western-immunoblot, in serum and cerebrospinal fluid in all 3 patients. In two, cell cultures were established from peripheral blood lymphocytes and HTLV-1 antigen was identified by immunofluorescence and the ELISA antigen capture technique, using an anti-p 19 HTLV-1 mouse monoclonal antibody. These 3 cases illustrate the variety of neuromuscular disease, other than spastic paraparesis, that may occur in HTLV-1 infection. Anterior horn cell degeneration may coexist with HTLV-1 associated polymyositis and may make a significant contribution to the muscle atrophy observed in these cases (AU)