Nous Avons Research Articles

Environmental factors associated with American cutaneous leishmaniasis in a new Andean focus in Colombia

To evaluate the environmental and ecological factors associated with Leishmania transmission and vector abundance in Chaparral, Tolima-Colombia. First, we compared the ecological characteristics, abundance of phlebotomies and potential reservoir hosts in the peridomestic environment (100 m radius) of randomly selected houses, between two townships with high and low cutaneous leishmaniasis incidence. Second, we examined peridomestic correlates of phlebotomine abundance in all 43 houses in the higher risk township. The high transmission township had higher coverage of forest (23%vs. 8.4%) and shade coffee (30.7%vs. 11%), and less coffee monoculture (16.8%vs. 26.2%) and pasture (6.3%vs. 12.3%), compared to the low transmission township. Lutzomyia were more abundant in the high transmission township 2.5 vs. 0.2/trap/night. Lutzomyia longiflocosa was the most common species in both townships: 1021/1450 (70%) and 39/80 (49%). Numbers of potential wild mammal reservoirs were small, although four species were found to be infected with Leishmania (Viannia) spp. In the high transmission township, the overall peridomiciliary capture rate of L. longiflocosa was 1.5/trap/night, and the abundance was higher in houses located nearer to forest (ρ = -0.30, P = 0.05). The findings are consistent with a domestic transmission cycle with the phlebotomies dependent on dense vegetation near the house.

L’évaluation des fonctions neurocognitives dans la schizophrénie : de l’examen complémentaire à la fonction thérapeutique

Resume Il est reconnu aujourd’hui que le trouble des fonctions neurocognitives peut concerner jusqu’a 80 % des patients dans la schizophrenie, engendrant une alteration plus ou moins marquee des capacites de traitement de l’information. Celle-ci a pour consequence une deterioration du fonctionnement cognitif et social, source d’un handicap important. La remediation cognitive est une approche reeducative recente en psychiatrie qui vise a reduire l’impact de ces perturbations et a ameliorer le fonctionnement cognitif et metacognitif du sujet. Il est necessaire au prealable d’evaluer quantitativement et qualitativement ces deficits avec des tests neurocognitifs precisant son profil. A la suite de cette evaluation, les resultats sont restitues au patient afin notamment de presenter l’interet d’une aide reeducative adaptee. Nous avons pu cliniquement observer que, bien au-dela d’une simple information, cette rencontre avec le sujet lors du retour des resultats de l’evaluation neurocognitive pouvait avoir un effet benefique tant sur la perception que le patient a de lui-meme et de sa maladie que sur la connaissance et l’acceptation de cette derniere. Nous avons egalement pu noter l’influence positive sur les capacites d’insight et le renforcement de l’alliance therapeutique. L’objet de cet article est d’analyser, en s’appuyant sur des exemples cliniques, la fonction therapeutique potentielle chez le patient schizophrene du retour des resultats de l’evaluation neurocognitive.

Screening patients with Diabetes Mellitus for Tuberculosis in China

There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and as DM increases the risk of TB and adversely affects TB treatment outcomes, there is a need for bidirectional screening of the two diseases. How this is best performed is not well determined. In this pilot project in China, we aimed to assess the feasibility and results of screening DM patients for TB within the routine healthcare setting of five DM clinics. Agreement on how to screen, monitor and record was reached in May 2011 at a national stakeholders meeting, and training was carried out for staff in the five clinics in July 2011. Implementation started in September 2011, and we report on 7 months of activities up to 31 March 2012. DM patients were screened for TB at each clinic attendance using a symptom-based enquiry, and those positive to any symptom were referred for TB investigations. In the three quarters, 72% of 3174 patients, 79% of 7196 patients and 68% of 4972 patients were recorded as having been screened for TB, resulting in 7 patients found who were already known to have TB, 92 with a positive TB symptom screen and 48 of these newly diagnosed with TB as a result of referral and investigation. All patients except one were started on anti-TB treatment. TB case notification rates in screened DM patients were several times higher than those of the general population, were highest for the five sites combined in the final quarter (774/100 000) and were highest in one of the five clinics in the final quarter (804/100 000) where there was intensive in-house training, special assignment of staff for screening and colocation of services. This pilot project shows that it is feasible to carry out screening of DM patients for TB resulting in high detection rates of TB. This has major public health and patient-related implications.

Approche psychodynamique et médicolégale de la mythomanie constitutionnelle : à propos d’une observation

Constitutional mythomania presents several diagnostic, aetiopathogenic and forensic problems for the doctor. We have discussed these aspects through the analysis of a case report. The case report relates to a 43 year-old man, who was subjected to a penal expertise following the emission of cheques without provision. During the examination, he pretended being both a doctor and a lawyer at the same time. He was in charge, among other things, of sale contracts dealing sometimes with high value transactions, obviously without following the required legal procedure. He was pursued subsequently for many other affairs of swindle. Data collected from his medical file indicated that he was the only boy of his family. Since his father had suffered from psychotic episodes, his grandfather had reared him; which he did it in a strictly religious way. He spent his childhood isolated. He was 15 years old when his grandfather died. He had then expressed religious and megalomaniac ideas that had motivated psychiatric management. Later on, he expressed imaginative ideas evoking unsystematized delusion (he pretended to have made a trip to America and to have seen a fish flying and turning into a woman). From a psychodynamic point of view, constitutional mythomania is considered as a borderline personality. It reflects an important narcissisic cleavage. The deceitfulness of the mythomaniac allows him to keep in touch with reality and to avoid mental disintegration. The recognition, by others, of these delusions allows the mythomaniac to have access to his proper level of existence. For a while, to the experts our patient appeared to be suffering from schizophrenia. Therefore, we can apply the Maleval theory to him, which identifies four periods as delusion structuring levels in psychosis: P0 (consequence of the phallic signification deficiency, it includes anxiety, annihilation, perplexity, interrogative attitude), P1 (stage of paranoid delusion), P2 (stage of paranoiac delusion) and P3 (ambitious stage evoking paraphrenia and squaring with mythomaniac behaviour). According to the Maleval theory, our patient would have experimented a repetitive cycle: he tried to escape instable and anxious positions (P0, P1) by committing sacrificial acting out (offence), or by reaching stable positions which are P2 and P3. The mythomaniac behaviour would appear during the latest period. The delusional decompensation would indicate a return to the first two periods. On the other hand, the personal myth might be seen as the result of the failure of the assimilation of actual experiences. Several psychoanalysts consider the use of myths by some psychotics as an attempt to reduce their ego disintegration. The mythomaniac may create his own myth in order to reduce the psychotic anxiety. The personal myth does not represent the pain of the patient but his remedy against his disorders. Therefore, identifying a personal myth may help the psychotic to turn his delusion into supportable logic of life. Myth may also be used in less deep pathologies such as borderline context, where it dominates the clinical picture. On the forensic level, we could a priori postulate that the mythomaniac sufficiently perceives reality to be considered as lucid. In fact, he hardly masters the totality of his intentions, being guided by an irrepressible mechanism that makes mythomania a "serious" and handicapping illness; its prima victim being the patient him/herself. No measures could actually prevent the latter from infringing the law, except, perhaps, a permanent administrative control; but this would not be without practical and ethical problems.

Étude des biais d’interprétation émotionnelle dans l’évaluation de situations futures chez le sujet alcoolodépendant

Resume Dans la prise en charge du sujet alcoolodependant en desintoxication, la representation du futur et son elaboration a une part importante. En effet, la question « comment vivre sans l’alcool ?» est une question fondamentale pour le sujet desirant s’abstenir. Dans l’optique de mieux comprendre le fonctionnement cognitif de la personne alcoolodependante et afin d’ameliorer la prise en charge psychotherapeutique, cette etude a pour objectif de comprendre comment un sujet alcoolodependant en debut de prise en charge evalue emotionnellement son futur. Le materiel utilise est une liste de 15 mots determines comme favorisant l’evocation d’evenements de vie. Pour chaque mot, nous avons demande aux participants d’imaginer un evenement futur lui arrivant et de l’evaluer selon quatre variables qui sont : la valence emotionnelle, l’intensite emotionnelle, la probabilite que cet evenement se produise et sa nettete. Les resultats montrent que le patient alcoolodependant imagine moins de situations positives que le sujet non dependant et autant de souvenirs negatifs. De plus, le patient alcoolodependant evalue ses situations positives imaginees comme plus intenses et les negatives comme moins intenses par rapport au sujet non dependant. Ces resultats demontrent qu’il existe un biais d’interpretation des evenements de vie chez le patient alcoolodependant en debut de prise en charge. Ce biais a pour consequence une evaluation emotionnelle specifique des evenements vie futurs. Jusqu’a present, nous avions tendance a evaluer le sujet face au stimulus « alcool » et avons base la prise en charge en therapie cognitivo-comportementale (TCC) autour du stimulus alcool. Etant donne que notre materiel n’evoque pas l’alcool, nos resultats demontrent que le traitement cognitif du sujet alcoolodependant biaise de facon generale son jugement sur ses evenements de vie. Ce fonctionnement plus general peut etre une phase complementaire de la « prise en compte des situations a haut risque » utilisee dans le modele de Marlatt et Donovan (Marlatt et Donovan, 2008 [23] ) qui est, quant a lui, specifique a l’objet « alcool ».

The Selfless Author: Voltaire’s Apocrypha

Research Article| May 01 2012 The Selfless Author: Voltaire’s Apocrypha Nicholas Cronk Nicholas Cronk Voltaire Foundation, University of Oxford Search for other works by this author on: This Site Google Romanic Review (2012) 103 (3-4): 553–577. https://doi.org/10.1215/26885220-103.3-4.553 Cite Icon Cite Share Icon Share Facebook Twitter LinkedIn MailTo Permissions Search Site Citation Nicholas Cronk; The Selfless Author: Voltaire’s Apocrypha. Romanic Review 1 May 2012; 103 (3-4): 553–577. doi: https://doi.org/10.1215/26885220-103.3-4.553 Download citation file: Zotero Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search Books & JournalsAll JournalsRomanic Review Search Advanced Search The text of this article is only available as a PDF. Copyright © 2012 The Trustees of Columbia University2012 Article PDF first page preview Close Modal You do not currently have access to this content.

Poster #86 CLINICAL AND SOCIAL CORRELATES OF LATE ONSET FIRST-EPISODE PSYCHOSIS: FINDINGS FROM THE AESOP STUDY

Les délires chroniques survenant tardivement ont été étudiés essentiellement par des psychiatres européens, et se sont vus classés de façon variable tant dans les nosographies européennes qu’internationales. En Allemagne, Manfred Bleuler a défini la schizophrénie tardive, les psychiatres britanniques parlent de paraphrénie tardive et en France ces tableaux cliniques sont classés dans la catégorie des psychoses hallucinatoires chroniques. Les classifications internationales qui ont à une époque individualisé la schizophrénie tardive l’intègrent actuellement dans le groupe des schizophrénies. Pourtant ces formes à début tardif présentent des particularités que nous avons tenté de définir dans ce travail et qui soulèvent la question de facteurs déclenchants, de l’existence d’une prédictivité, voire même orientent vers des notions de diagnostic précoce.Chronic delusion occurring late in life has essentially been studied by European psychiatrists. « Late-onset schizophrenia » was first described and defined by Manfred Bleuler in 1943, as a form of schizophrenia which occurs after the age of 40. Later, British psychiatrists often used the term « Late-onset paraphrenia » interchangeably with « Late-onset schizophrenia » to designate this disorder. However, late-onset paraphrenia is a British concept which includes all delusional disorders starting after age 60. American psychiatrists had little interest in this patient group, so it is only within the DSM III-R that a separate category was created for patients who developed schizophrenia after age 44. There is now no longer a « late-onset » category for schizophrenia within the DSM IV, nor age criterion for the diagnosis of schizophrenia. In the French nosography, schizophrenia is excluded when a non-affective, non-organic psychosis begins after the age of 40. These chronic delusion syndromes fall into a specific French category : « Psychose Hallucinatoire Chronique» (chronic hallucinatory psychosis).Basing themselves on the analysis of many studies, the authors endeavor to define the characteristics of late-onset schizophrenia. The exact prevalence is not known, but is considered lower than 1 %. There is a preponderance of women over men in this form of disease, that could be explained by the relative excess of dopamine type 2 (D2) receptors in young men (compared with young women), and by a protective role played by estrogens until the menopause, among women predisposed to schizophrenia. Studies of families reveal a lower lifetime risk of schizophrenia in first degree relatives of patients with late-onset schizophrenia, than those with an early onset. Most of these patients have been or are married, and had worked for a long time. Generally at the onset of the illness they are isolated and unemployed. Paranoid and schizoid abnormal premorbid personality traits are frequently noted with the diagnosis of late-onset schizophrenia. An association between late-onset schizophrenia and sensory impairment (visual and auditory) is frequently observed and appear to be in link with auditory and visual hallucinations. The analysis of clinical features reveal that the later the schizophrenia breaks out, the more the patient shows delusion and hallucinatory symptoms, which remain limited to his surroundings, whereas in younger patients, delusion has no limit. Moreover, late-onset schizophrenic patients have a lower prevalence of looseness of associations and negative symptoms than those with an earlier onset. The authors note from the few studies on the treatment, that a number of patients responded well to low dose of antipsychotic agents. The use of « atypical » anti-psychotic drugs is recommended, in order to reduce the adverse effects, notably the extrapyramidal symptoms which are frequent in elderly people.Finally, they conclude that patients with late-onset schizophrenia have symptoms very similar to those of patients with early-onset schizophrenia. But, when taking the different forms of schizophrenia-even the late onset ones-into account, raises the question of the role of trigger factors that could guide research on predictive factors and early diagnosis. This may be one explanation for the survival of the French entity « Psychose Hallucinatoire Chonique ».

Poster #170 ASSESSMENT AND TREATMENT OF METACOGNITIVE IMPAIRMENT IN PEOPLE WITH PSYCHOSIS

Poster #170 ASSESSMENT AND TREATMENT OF METACOGNITIVE IMPAIRMENT IN PEOPLE WITH PSYCHOSIS

Assessing the validity of an ELISA test for the serological diagnosis of human fascioliasis in different epidemiological situations

To improve the diagnosis of human fascioliasis caused by Fasciola hepatica and Fasciola gigantica, we evaluated the diagnostic accuracy of an enzyme-linked immunosorbent assay (ELISA), with Fasciola antigen from the adult liver fluke, for the detection of IgG against fascioliasis in human sera. The sera of 54 fascioliasis cases, originating from three endemic areas, were used in this evaluation: (i) a hyperendemic F. hepatica area where humans usually shed a great number of parasite eggs in faeces (11 sera); (ii) an epidemic F. hepatica area where humans usually shed small amounts of parasite eggs (24 sera) and (iii) an overlap area of both Fasciola species and where human shedding of parasite eggs in faeces is usually scarce or non-existent (19 sera). One hundred and sixty-eight patients with other parasitic infections and 89 healthy controls were also analysed. The respective sensitivity and specificity of this assay were 95.3% (95% confidence intervals, 82.9-99.2%) and 95.7% (95% confidence intervals, 92.3-97.5%). No correlation between egg output and the OD450 values of the F. hepatica IgG ELISA test was observed. This test could be used both as an individual serodiagnostic test for human fascioliasis when backed up by a compatible clinical history together with a second diagnostic technique for other cross-reactive helminth infections, and in large-scale epidemiological studies of human fascioliasis worldwide.

Clusters of leprosy transmission and of late diagnosis in a highly endemic area in Brazil: focus on different spatial analysis approaches

The Brazilian National Hansen's Disease Control Program recently identified clusters with high disease transmission. Herein, we present different spatial analytical approaches to define highly vulnerable areas in one of these clusters. The study area included 373 municipalities in the four Brazilian states Maranhão, Pará, Tocantins and Piauí. Spatial analysis was based on municipalities as the observation unit, considering the following disease indicators: (i) rate of new cases/100,000 population, (ii) rate of cases <15 years/100,000 population, (iii) new cases with grade-2 disability/100,000 population and (iv) proportion of new cases with grade-2 disabilities. We performed descriptive spatial analysis, local empirical Bayesian analysis and spatial scan statistic. A total of 254 (68.0%) municipalities were classified as hyperendemic (mean annual detection rates >40 cases/100,000 inhabitants). There was a concentration of municipalities with higher detection rates in Pará and in the center of Maranhão. Spatial scan statistic identified 23 likely clusters of new leprosy case detection rates, most of them localized in these two states. These clusters included only 32% of the total population, but 55.4% of new leprosy cases. We also identified 16 significant clusters for the detection rate <15 years and 11 likely clusters of new cases with grade-2. Several clusters of new cases with grade-2/population overlap with those of new cases detection and detection of children <15 years of age. The proportion of new cases with grade-2 did not reveal any significant clusters. Several municipality clusters for high leprosy transmission and late diagnosis were identified in an endemic area using different statistical approaches. Spatial scan statistic is adequate to validate and confirm high-risk leprosy areas for transmission and late diagnosis, identified using descriptive spatial analysis and using local empirical Bayesian method. National and State leprosy control programs urgently need to intensify control actions in these highly vulnerable municipalities.

Maintaining faith in agency under immutable constraints: Cognitive consequences of believing in negotiable fate

Negotiable fate refers to the idea that one can negotiate with fate for control, and that people can exercise personal agency within the limits that fate has determined. Research on negotiable fate has found greater prevalence of related beliefs in Southeast Asia, East Asia, and Eastern Europe than in Western Europe and English-speaking countries. The present research extends previous findings by exploring the cognitive consequences of the belief in negotiable fate. It was hypothesized that this belief enables individuals to maintain faith in the potency of their personal actions and to remain optimistic in their goal pursuits despite the immutable constraints. The belief in negotiable fate was predicted to (a) facilitate sense-making of surprising outcomes; (b) increase persistence in goal pursuits despite early unfavorable outcomes; and (c) increase risky choices when individuals have confidence in their luck. Using multiple methods (e.g., crosscultural comparisons, culture priming, experimental induction of fate beliefs), we found supporting evidence for our hypotheses in three studies. Furthermore, as expected, the cognitive effects of negotiable fate are observed only in cultural contexts where the fate belief is relatively prevalent. Implications of these findings are discussed in relation to the intersubjective approach to understanding the influence of culture on cognitive processes (e.g., Chiu, Gelfand, Yamagishi, Shteynberg, & Wan, 2010), the sociocultural foundations that foster the development of a belief in negotiable fate, and an alternative perspective for understanding the nature of agency in contexts where constraints are severe. Future research avenues are also discussed.

L’équilibre lombopelvien debout et assis chez les patients porteurs de prothèse de hanche : exploration par le système EOS

La pose des prothèses totales de hanches soulève des questions importantes concernant les relations entre l’orientation de l’articulation lombo-sacrée et celle des articulations coxo-fémorales, c’est-à-dire entre position du tronc du patient et orientation tridimensionnelle de ses cotyles. Pour élucider ces relations complexes, nous avons mené une étude morphométrique sur un échantillon de 50 bassins secs. Après la saisie des coordonnées tridimensionnelles de 47 points homologues sur chaque bassin, nous avons traité ces données grâce au logiciel de modelage statistique et visualisation graphique du bassin, le logiciel De-Visu. Nous avons mis en évidence un nouveau paramètre pelvien sagittal, que nous avons appelé « angle d’incidence cotyloïde ». Cet angle a pour sommet le centre des cotyles et pour côtés l’épaisseur pelvienne et la médiane des axes des cotyles. Il est corrélé négativement avec l’angle d’incidence sacrée, avec lequel il partage un côté commun, l’épaisseur. Il rend compte simultanément de la position sagittale du sacrum par rapport aux cotyles et du degré d’antéversion et d’inclinaison des cotyles. Nous montrons que la somme géométrique de ces deux angles, incidence sacrée et incidence cotyloïde, est égale à l’angle sacro-acétabulaire mis en évidence par Lazennec et Saillant. Ces auteurs avaient montré que l’angle sacroacétabulaire est la somme de deux paramètres positionnels, la pente sacrée et la bascule acétabulaire sagittale. Les trois angles – incidence sacrée, incidence cotyloïde et angle sacro-acétabulaire – sont, eux, des angles anatomiques qui ne dépendent pas de la position du bassin.Implantation of total hip arthroplasties raises several important questions concerning the relationship between the orientation of the lumbosacral joint and the acetabular-femoral joint; in other words, between the position of the patients trunk and the orientation of the acetabula. To elucidate better these complex relationships, we conducted a morphometry study on a sample of 51 dry pelves: pelv 26 female and 25 male specimens.Three-dimensional coordinates of 47 homologous points were recorded for each pelvis. Data were then processed with De-Visu, a graphic visualization software. Seven parameters were compared: sacral slope, sacral incidence, and five parameters quantifying the three-dimensional orientation of the acetabula.The graphic modelization enabled an integral 3-D visualization of each pelvis. The sagittal view enabled simultaneous visualization of the sacrum, the sacroiliac joints, the acetabula, and their alignments, as well as the variability of their spatial relation. The position reference chosen to simulate the upright position aligned the anterior iliac spines and the superior pubic point. This position was found pertinent because the mean value of the sacral slope (41.8̊) and the sacral incidence (54̊) were not different from published series. The sacral slope was the most strongly correlated with the acetabular parameters. It exhibited a positive correlation with sagittal acetabular slope (r = 0.59) and acetabular inclination (r = 0.59). It exhibited a negative correlation with acetabular anteversion (R = 0.45). The correlation with the sagittal acetabular slope was very strong for anteversion (r = 0.92), and rose with acetabular inclination (r = –0.66). The angle formed by the two acetabular axes was highly variable (37̊). The correlation between this angle and inclination was very high in males (r = –0.88) and non-significant in females. There was however a very strong correlation with anteversion in females (r = –0.74) which was non-significant in males. This contrasting finding was related to the wide spread of the inclination values in males and anteversion values in females.We demonstrated a new sagittal parameter: the acetabular incidence. The summit of this angle is the center of the acetabulum. The sides are the pelvic thickness and the acetabular axes. This parameter was negatively correlated with the sacral incidence. It account simultaneously for the sagittal position of the sacrum in relation to the acetabula and for the degree of acetabular anteversion and inclination. We have demonstrated that the geometric sum of these two angles, sacral incidence and acetabular incidence, is equivalent to the sacro-acetabular angle demonstrated by Lazennec and Saillant. These authors showed that the sacro-acetabular angle is the sum of two positional parameters, the sacral slope and the sagittal acetabular tilt (or slope). The three angles – sacral incidence, acetabular incidence, sacro-acetabular angle – are anatomic angles which do not vary with the pelvic position.

Incidence of severe acute maternal morbidity associated with abortion: a systematic review

To systematically review articles describing complications of abortion in settings where abortions are thought to be unsafe and to determine the incidence of severe acute maternal morbidity (SAMM) attributed to abortion at the population level. We searched relevant databases using search terms related to abortion and complications. We included population-representative studies that listed complications of abortion. We extracted data on the definitions and numbers of severe complications and SAMM, and we report abortion complication rates (per 100 000 women of reproductive age) and ratios (per 100 000 live births) for SAMM, severe complications and any complications. We included 15 studies representing eleven countries (six in Africa, four in Asia and one in Latin America). We found a median abortion ratio of SAMM of 237 (range 91-1892) per 100 000 live births and a median abortion ratio of severe complications of 596 (range 435-5298). There was a great degree of heterogeneity between definitions and study populations. The burden of SAMM attributed to abortion is much greater than what is reported for deaths caused by abortion. However, the great heterogeneity in definitions makes it difficult to draw firm conclusions. We call for future work on the burden of unsafe abortion to use strict definitions of SAMM.

Affectivité et alexithymie : deux dimensions explicatives des relations entre symptômes dépressifs et anxieux

The main objective of this study was to support the existence of emotional dimensions common to anxiety and depressive symptomatology, and confirm the common elements of emotional vulnerability, characterized by negative affectivity and alexithymia. The second objective of this study was the identification of characteristics specific to each disorder. We made three assumptions: there is a significant relationship between anxiety and depressive symptoms, exists on community processes between these two entities, objectified by the sub dimensions of negative affectivity and the difficulty in identifying emotions certain dimensions are specific to each disorder. The study participants were students from 1st to 4th year of the University of Provence. The sample consisted of 317 subjects (77% female and 23% male; mean age=20, 61 ± 1.55 years), who gave written informed consent and completed questionnaires collectively. We administered a protocol to the subjects consisting of three self-assessment scales to assess emotional dimensions and anxiety and depressive symptomatology. The dimensions of affectivity were assessed by the EPN-31. It consists of 31 items grouped into three factors: positive emotions, negative emotions and feelings of surprise. The emotional functioning was assessed by the scale of the Twenty-item Toronto Alexithymia Scale (TAS-20). It allows an overall assessment of the level of alexithymia, as well as three dimensions as represented by specific sub scales: difficulty identifying emotions (DIE), difficulty differentiating emotions (DDE), and externally oriented thinking (EOT). This scale is most used in the assessment of alexithymia. The anxiety and depressive symptoms were assessed by the subscale of anxiety and depression of the SCL90-R. This scale is widely used in screening for psychiatric symptoms, and has been validated internationally. we performed descriptive analysis, correlational analysis (Bravais-Pearson's correlation) and hierarchical multiple regression using SPSS 15 software. The results validate our assumptions, showing that women are more anxious (M=6.68 ± 6.20 ; P=0.02) and more depressed (M=10.61 ± 8.73 ; P=0.01) than men (mean-anxiety=4.77 ± 4.97 ; mean-depression-6=7.75 ; 53). They also have more "difficulty" identifying feelings (M=17.92 ± 5.95, P=0.01) than men (m=15.65 ± 6.00). The analysis of relationships between the different variables shows the existence of several significant connections. Among them we find a strong positive correlation (r>.50 ; P=0.01) between anxiety and depression. Moreover, these two symptoms maintain strong relationships (r>.50; P=0.01) with negative affectivity, moderate and negative with positive affectivity (r>.30; P=0.01), and moderate and low with emotional activation (r>.10; P=0.01). There are also significant relationships between affective symptoms and emotional dimensions of alexithymia: difficulty identifying feelings (r>.40; P=0.01) and difficulty describing emotions (r>.20; P=0.01). Finally, the regression analysis shows, for the anxiety factor, which only contribute significantly following dimensions: gender, negative affectivity, emotional activation and the two sub dimensions of alexithymia "difficulty identifying feelings" and "externally oriented thoughts", which explain 43% of the variance in scores (R(2)=.43, P=0.0001). Depression shares with the following dimensions: gender, negative affectivity, difficulty in identifying emotions, and includes a specific dimension, positive affectivity. This model explains 51% of the variance (R(2)=. 51, P=0.0001). However, the lack of contribution of emotional activation and "externally oriented thoughts" must be emphasized. Our study reveals the existence of a "common nucleus of vulnerability" characterized by negative affectivity associated with difficulty identifying emotions. Specific dimensions nevertheless appear to exist, and depression is strongly explained by low positive affect (anhedonia dimension); anxiety associated specifically to emotional activation and finally thought outward, marking the size limitation. The imaginary life in alexithymia, appears to operate in depression, perhaps as a mechanism of emotional repression. The involvement of alexithymia in the functioning of the affective disorder is confirmed, this helps to clarify the modalities of therapeutic care that we offer.

Costs, equity, efficiency and feasibility of identifying the poor in Ghana’s National Health Insurance Scheme: empirical analysis of various strategies

To analyse the costs and evaluate the equity, efficiency and feasibility of four strategies to identify poor households for premium exemptions in Ghana's National Health Insurance Scheme (NHIS): means testing (MT), proxy means testing (PMT), participatory wealth ranking (PWR) and geographic targeting (GT) in urban, rural and semi-urban settings in Ghana. We conducted the study in 145-147 households per setting with MT as our gold standard strategy. We estimated total costs that included costs of household surveys and cost of premiums paid to the poor, efficiency (cost per poor person identified), equity (number of true poor excluded) and the administrative feasibility of implementation. The cost of exempting one poor individual ranged from US$15.87 to US$95.44; exclusion of the poor ranged between 0% and 73%. MT was most efficient and equitable in rural and urban settings with low-poverty incidence; GT was efficient and equitable in the semi-urban setting with high-poverty incidence. PMT and PWR were less equitable and inefficient although feasible in some settings. We recommend MT as optimal strategy in low-poverty urban and rural settings and GT as optimal strategy in high-poverty semi-urban setting. The study is relevant to other social and developmental programmes that require identification and exemptions of the poor in low-income countries.

Total lymphocyte count is a good marker for HIV-related mortality and can be used as a tool for starting HIV treatment in a resource-limited setting

Total lymphocyte counts (TLC) may be used as an alternative for CD4 cell counts to monitor HIV infection in resource-limited settings, where CD4 cell counts are too expensive or not available. We used prospectively collected patient data from an urban HIV clinic in Indonesia. Predictors of mortality were identified via Cox regression, and the relation between TLC and CD4 cell counts was calculated by linear regression. Receiver operating characteristics (ROC) curves were used to choose the cut-off values of TLC corresponding with CD4 cell counts <200 and ≤350 cells/μl. Based on these analyses, we designed TLC-based treatment algorithms. Of 889 antiretroviral treatment (ART)-naïve subjects included, 66% had CD4 cell counts <200 and 81% had 350 ≤ cells/μl at baseline. TLC and CD4 cell count were equally strong predictors of mortality in our population, where ART was started based on CD4 cell count criteria. The correlation coefficient (R) between TLC and √CD4 was 0.70. Optimal cut-off values for TLC to identify patients with CD4 cell counts <200 and ≤350 cells/μl were 1500 and 1700 cells/μl, respectively. Treatment algorithms based on a combination of TLC, gender, oral thrush, anaemia and body mass index performed better in terms of predictive value than WHO staging or TLC alone. In our cohort, such an algorithm would on average have saved $14.05 per patient. Total lymphocyte counts is a good marker for HIV-associated mortality. Simple algorithms including TLC can prioritize patients for HIV treatment in a resource-limited setting, until affordable CD4 cell counts will be universally available.

Burden and outcome of HIV infection and other morbidities in health care workers attending an Occupational Health Program at the Provincial Hospital of Tete, Mozambique

To investigate the burden and outcome of HIV infection and other morbidities amongst a Mozambican hospital staff. Within an occupational health service set up in April 2008 in the provincial hospital of Tete, Mozambique, we offered to all staff members an initial clinical, laboratory and radiological screening and followed them up prospectively until April 2010. A total of 47.5% of 423 health workers attended the program. The cohort (female-to-male ratio: 2.2; mean age: 39 years) consisted mostly of auxiliary staff (43%) and nurses (29.8%). At initial screening, 71% were asymptomatic. HIV infection (28.4%) and tuberculosis (TB) (21%) were the main reported antecedent illnesses. Laboratory screening revealed anaemia (haemoglobin level <10 mg/dl) in 9% participants, abnormal liver enzymes in 23.9% and a reactive non-treponemal syphilis test in 5%. Of 145 performed chest X-rays, 13% showed abnormalities. All 113 health workers not recently tested for HIV were screened, and 31 were newly diagnosed with HIV infection (resulting in an overall HIV prevalence of 43.8%). Nine cases of TB were diagnosed at screening/during follow-up. In April 2010, all but one of the participants were alive. All HIV-infected health workers under antiretroviral therapy were actively followed-up. Serious conditions were frequently diagnosed in health workers, in particular HIV infection. Mid-term outcome was favourable within this program. Creation of screening and care services dedicated to caregivers should be of highest priority in similar African settings.

Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana

To assess whether supervision of primary health care workers improves their productivity in four districts of Northern Ghana. We conducted a time-use study during which the activities of health workers were repeatedly observed and classified. Classification included four categories: direct patient care; documentation and reporting; staff development and facility operations; and personal time. These data were supplemented by a survey of health workers during which patterns of supervision were assessed. We used logistic regression models with health facility fixed effects to test the hypothesis that supervision increases the amount of time spent providing direct patient care (productivity). We further investigated whether these effects depend on whether or not supervision is supportive. Direct patient care accounted for <25% of observations. In bivariate analyses, productivity was higher among midwives and in facilities with a high volume of care. Supervisory visits were frequent in those four districts, but only a minority of health workers felt supported by their supervisors. Having been supervised within the last month was associated with a significantly higher proportion of time spent on direct patient care (OR = 1.57). The effects of supervision on productivity further depended on whether the health workers felt supported by their supervisors. Supportive supervision was associated with increased productivity. Investments in supervision could help maximize the output of scarce human resources in primary health care facilities. Time-use studies represent an objective approach in monitoring the productivity of health workers and evaluating the impact of health-system interventions on human resources.

Hantavirus ecology in rodent populations in three protected areas of Argentina

In this study, we identified hantavirus genotypes and their reservoirs and evaluated the spatial and temporal distribution of the virus in rodent population in three protected areas of Argentina over 3 years (2007-2010). A total of 837 rodents were captured with an effort of 22 117 trap-nights. We detected the genotype Lechiguanas in Oligoryzomys nigripes and O. flavescens and Pergamino in Akodon azarae. There was no correlation between seroprevalence and trap success of the host. The proportion of seropositive males was significantly higher than the proportion of seropositive females. The total length of seropositives was higher than that of seronegatives in each host species. Seropositive individuals were observed in warm months and not in cold months, which suggests an infection cycle. This investigation confirms that protected areas of central east Argentina are places with a variety of sylvan rodents species associated with different hantavirus genotypes where reservoirs are numerically dominant. Although there was more than one known reservoir of hantavirus, only one species had antibodies in each area. This can be explained because the transmission of the virus does need not only the presence of a rodent species but also a threshold density. Longevity of even a small proportion of the host population in cold months may provide a trans-seasonal mechanism for virus persistence. The seroprevalence detected was higher than the one found before in rodent populations of Argentina, and this explains the appearance of human cases in two of these three areas.

Outpatient treatment of children with severe pneumonia with oral amoxicillin in four countries: the MASS study

A recent randomized clinical trial demonstrated home-based treatment of WHO-defined severe pneumonia with oral amoxicillin was equivalent to hospital-based therapy and parenteral antibiotics. We aimed to determine whether this finding is generalizable across four countries. Multicentre observational study in Bangladesh, Egypt, Ghana and Vietnam between November 2005 and May 2008. Children aged 3-59 months with WHO-defined severe pneumonia were enrolled at participating health centres and managed at home with oral amoxicillin (80-90 mg/kg per day) for 5 days. Children were followed up at home on days 1, 2, 3 and 6 and at a facility on day 14 to look for cumulative treatment failure through day 6 and relapse between days 6 and 14. Of 6582 children screened, 873 were included, of whom 823 had an outcome ascertained. There was substantial variation in presenting characteristics by site. Bangladesh and Ghana had fever (97%) as a more common symptom than Egypt (74%) and Vietnam (66%), while in Vietnam, audible wheeze was more common (49%) than at other sites (range 2-16%). Treatment failure by day 6 was 9.2% (95% CI: 7.3-11.2%) across all sites, varying from 6.4% (95% CI: 3.1-9.8%) in Ghana to 13.2% (95% CI: 8.4-18.0%) in Vietnam; 2.7% (95% CI: 1.5-3.9%) of the 733 children well on day 6 relapsed by day 14. The most common causes of treatment failure were persistence of lower chest wall indrawing (LCI) at day 6 (3.8%; 95% CI: 2.6-5.2%), abnormally sleepy or difficult to wake (1.3%; 95% CI: 0.7-2.3%) and central cyanosis (1.3%; 95% CI: 0.7-2.3%). All children survived and only one adverse drug reaction occurred. Treatment failure was more frequent in young infants and those presenting with rapid respiratory rates. Clinical treatment failure and adverse event rates among children with severe pneumonia treated at home with oral amoxicillin did not substantially differ across geographic areas. Thus, home-based therapy of severe pneumonia can be applied to a wide variety of settings.