[Disorderism: what it is and why it's a problem]. / Stoornisme: wat het is en waarom het een probleem is.

BACKGROUND: Discussion about language and psychiatry is often limited to discussion about how DSM-classifications are being used. Fundamental and more societal questions about why individual disorders (should) exist are then rarely addressed. AIM: We introduce the term disorderism to give a name to a poorly visible effect of psychiatric classification: the dominance of an individualized understanding of psychological suffering. METHOD: We substantiate the term disorderism by giving a theoretical analysis as well as providing examples of disorderistic ways of thinking. RESULTS: Our formal definition of disorderism is: the systematic decontextualization of psychological suffering by thinking about it in terms of individual disorders. At its worst disorderism brings us both failing individual treatments and (prolonged) continuation of societal problems. CONCLUSION: Only after we recognize disorderism in our language and in our way of thinking, we will be able to fight it. This could make room for alternative solutions to psychological suffering, next to the treatment of individuals. The emphasis in understanding psychological suffering could then partly shift to the societal domain: to societal and political choices.

Free-roaming dog population dynamics in Ranchi, India.

Rabies causes approximately 20,000 human deaths in India each year. Nearly all of these occur following dog bites. Large-scale, high-coverage dog rabies vaccination campaigns are the cornerstone of rabies elimination strategies in both human and dog populations, although this is particularly challenging to achieve in India as a large proportion of the dog population are free-roaming and unowned. Further, little is known about free-roaming dog ecology in India which makes defining optimum vaccination strategies difficult. In this study, data collected using a mobile phone application during three annual mass vaccination and neutering (surgical sterilisation of both males and females) campaigns of free-roaming dogs in Ranchi, India (during which a total of 43,847 vaccinations, 26,213 neuter surgeries and 28,172 re-sight observations were made) were interrogated, using two novel approaches to estimate the proportion of neutered dogs that were lost from the city (assumed due to mortality or migration) between campaign years. Analysis revealed high losses of neutered dogs each year, ranging from 25.3% (28.2-22.8) to 55.8% (57.0-54.6). We also estimated that the total population declined by 12.58% (9.89-15.03) over the three-year period. This demonstrates that there is a high turnover of free-roaming dogs and that despite neutering a large number of dogs in an annual sterilisation campaign, the decline in population size was modest over a three-year time period. These findings have significant implications for the planning of rabies vaccination campaigns and population management programmes as well as highlighting the need for further research into the demographics of free-roaming, unowned dogs in India.

Overview of rabies post-exposure prophylaxis access, procurement and distribution in selected countries in Asia and Africa, 2017-2018.

BACKGROUND: Rabies is a neglected zoonotic disease with a global burden of approximately 59,000 human deaths a year. Once clinical symptoms appear, rabies is almost invariably fatal; however, with timely and appropriate post-exposure prophylaxis (PEP) consisting of wound washing, vaccine, and in some cases rabies immunoglobulin (RIG), the disease is almost entirely preventable. Access to PEP is limited in many countries, and when available, is often very expensive. METHODS: We distributed a standardized assessment tool electronically to a convenience sample of 25 low- and middle-income countries in Asia and Africa to collect information on rabies PEP procurement, forecasting, distribution, monitoring and reporting. Information was collected from national rabies focal points, focal points at the World Health Organization (WHO) country offices, and others involved in procurement, logistics and distribution of PEP. Because RIG was limited in availability or unavailable in many countries, the assessment focused on vaccine. Data were collected between January 2017 and May 2018. RESULTS: We received responses from key informants in 23 countries: 11 countries in Asia and 12 countries in Africa. In 9 of 23 (39%) countries, rabies vaccine was provided for free in the public sector and was consistently available. In 10 (43%) countries, all or some patients were required to pay for the vaccine in the public sector, with the cost of a single dose ranging from US$ 6.60 to US$ 20/dose. The primary reason for the high cost of the vaccine for patients was a lack of funding at the central level to subsidize vaccine costs. In the remaining 4 (17%) countries, vaccine was provided for free but was often unavailable so patients were required to purchase it instead. The majority of countries used the intramuscular route for vaccine administration and only 5 countries exclusively used the dose-sparing intradermal (ID) route. Half (11/22; 50%) of all countries assessed had a standardized distribution system for PEP, separate from the systems used for routine childhood vaccines, and almost half used separate storage facilities at both central and health facility levels. Approximately half (9/22; 41%) of all countries assessed reported having regular weekly, monthly or quarterly reporting on rabies vaccination. CONCLUSIONS: While all countries in our assessment had rabies vaccines available in the public sector to some extent, barriers to access include the high cost of the vaccine to the government as well as to patients. Countries should be encouraged to use ID administration as this would provide access to rabies vaccine for many more people with the same number of vaccine vials. In addition, standardized monitoring and reporting of vaccine utilization should be encouraged, in order to improve data on PEP needs.

[Radicalization and psychiatry: a plea for a broad perspective]. / Radicalisering en psychiatrie: pleidooi voor een brede blik.

BACKGROUND: The extent to which psychiatry can, and should, contribute to the prevention of terrorism and the countering of radicalization is under debate. The political dimension of the problem raises questions about the desirability of active psychiatric involvement.
AIM: To deepen the debate by discussing the role of psychiatric disorders in terrorist activities, as well as the role of societal determinants in radicalization processes.
METHOD: Review of relevant literature and theoretical analysis.
RESULTS: Radicalization processes are heterogeneous and have determinants at individual, social and societal level. In a small minority of 'radicalizing' individuals severe psychopathology plays a role.
CONCLUSION: Knowledge of the factors relevant to radicalization at individual, social and societal level is necessary for psychiatrists to act responsibly, both at case level, and in the public and scientific debate.

Rabies control in KwaZulu-Natal, South Africa.

PROBLEM: Urbanization, large dog populations and failed control efforts have contributed to continuing endemicity of dog-mediated rabies in KwaZulu-Natal province, South Africa. APPROACH: From 2007 to 2014 we used a OneHealth approach to rabies prevention, involving both the human and animal health sectors. We implemented mass vaccination campaigns for dogs to control canine rabies, and strategies to improve rabies awareness and access to postexposure prophylaxis for people exposed to rabies. LOCAL SETTING: A rabies-endemic region, KwaZulu-Natal is one of the smallest and most populous South African provinces (estimated population 10 900 000). Canine rabies has persisted since its introduction in 1976, causing an average of 9.2 human rabies cases per annum in KwaZulu-Natal from 1976 to 2007, when the project started. RELEVANT CHANGES: Between 2007 and 2014, the numbers of dog vaccinations rose from 358 611 to 395 000 and human vaccines purchased increased form 100 046 to 156 996. Strategic dog vaccination successfully reduced rabies transmission within dog populations, reducing canine rabies cases from 473 in 2007 to 37 in 2014. Actions taken to reduce the incidence of canine rabies, increase public awareness of rabies and improve delivery of postexposure prophylaxis contributed to reaching zero human rabies cases in KwaZulu-Natal in 2014. LESSONS LEARNT: Starting small and scaling up enabled us to build strategies that fitted various local settings and to successfully apply a OneHealth approach. Important to the success of the project were employing competent, motivated staff, and providing resources, training and support for field workers.

Global rabies control: the role of international organisations and the Global Strategic Plan to eliminate dog-mediated human rabies.

International partners are united to reach the shared goal of zero dog-mediated human rabies deaths by 2030, worldwide. Under the Tripartite collaboration, the World Health Organization, the World Organisation for Animal Health and the Food and Agriculture Organization of the United Nations are prioritising rabies as a model for 'One Health' in action. In 2015, the Global Rabies Conference led to the development of the Global Framework for the Elimination of Dog-Mediated Human Rabies. This long-term strategy centres around five pillars of rabies elimination (STOP-R): i) Sociocultural; ii) Technical; iii) Organisational; iv) Political; and v) Resources. Together with their partners, the Tripartite are working to operationalise the Framework through: i) engaging communities to build rabies awareness; ii) strengthening human and animal health systems, surveillance, and providing proof of concept that rabies elimination is feasible; iii) promoting intersectoral and regional collaboration; iv) advocating for political engagement and support; and v) building the case for investment through public-private partnerships and a Global Strategic Plan to end human deaths from dog-mediated rabies. By creating an enabling environment for countries to prioritise rabies and implement existing tools, the Tripartite are committed to catalysing change, empowering nations and providing the necessary support to consign rabies to the history books.

Les partenaires internationaux agissent de concert afin d'atteindre l'objectif de réduire à zéro le nombre de décès dus à la rage humaine transmise par les chiens dans le monde d'ici 2030. Dans le cadre de leur collaboration tripartite, l'Organisation mondiale de la santé, l'Organisation mondiale de la santé animale et l'Organisation des Nations Unies pour l'alimentation et l'agriculture ont fait de la rage la maladie phare de leur action gouvernée par le principe « Une seule santé ¼. En 2015, la Conférence mondiale sur la rage a abouti à la création du Cadre stratégique mondial d'élimination de la rage humaine transmise par les chiens. Cette stratégie à long terme repose sur cinq piliers visant l'élimination de la rage (STOP-R) : i) aspects socioculturels ; ii) aspects techniques ; iii) aspects organisationnels ; iv) aspects politiques ; v) ressources. Avec ses partenaires, la Tripartite met tout en oeuvre pour rendre ce cadre opérationnel, notamment à travers i) la participation des communautés à des activités de sensibilisation sur la rage ; ii) le renforcement des systèmes de santé humaine et animale, l'application de la surveillance et la démonstration de la faisabilité de l'élimination de la rage ; iii) la promotion de la collaboration intersectorielle et régionale ; iv) l'appel actif en faveur d'un engagement et d'un soutien politiques ; v) la justification de la rentabilité des investissements à travers des partenariats public-privé et un plan d'activités pour l'élimination mondiale de la rage. En créant un environnement propice permettant aux pays de prioriser la rage et de mettre en application les instruments existants, la Tripartite s'est engagée à dynamiser le changement, à donner aux pays les capacités d'agir et à fournir le soutien nécessaire pour que le rage soit un jour reléguée dans les livres d'histoire.

Una serie de asociados internacionales trabajan codo a codo para alcanzar el objetivo común de que para 2030 no haya en el mundo ninguna persona que muera de rabia transmitida por perros. Como parte de una alianza tripartita, la Organización Mundial de la Salud (OMS), la Organización Mundial de Sanidad Animal (OIE) y la Organización de las Naciones Unidas para la Alimentación y la Agricultura (FAO) están otorgando prioridad a la lucha antirrábica como modelo para poner en práctica los postulados de «Una sola salud¼. En 2015, la conferencia mundial dedicada a la lucha contra la rabia culminó con la elaboración de un marco estratégico mundial para eliminar la rabia humana transmitida por perros. Se trata de una estrategia a largo plazo (STOP-R) edificada en torno a cinco grandes pilares: i) aspectos socioculturales; ii) aspectos técnicos; iii) aspectos organizativos; iv) políticas; y v) recursos. Junto con sus colaboradores, la alianza tripartita trabaja para llevar ese marco a la práctica: i) haciendo participar a las comunidades en la sensibilización respecto de la rabia; ii) fortaleciendo los sistemas sanitarios y zoosanitarios, efectuando labores de vigilancia y demostrando empíricamente que la eliminación de la rabia es un objetivo factible; iii) promoviendo la colaboración intersectorial y regional; iv) presionando para lograr el compromiso y apoyo políticos; y v) aportando argumentos en defensa de la inversión por la vía de alianzas publicoprivadas y elaborando un plan de trabajo para la eliminación de la rabia a escala mundial. La alianza tripartita, al crear condiciones propicias para que los países otorguen prioridad a la rabia y apliquen las herramientas existentes, está impulsando el cambio, dotando a las naciones de capacidad de acción y prestando el apoyo necesario para conseguir que un día la rabia quede relegada a los libros de historia.

One Health contributions towards more effective and equitable approaches to health in low- and middle-income countries.

Emerging zoonoses with pandemic potential are a stated priority for the global health security agenda, but endemic zoonoses also have a major societal impact in low-resource settings. Although many endemic zoonoses can be treated, timely diagnosis and appropriate clinical management of human cases is often challenging. Preventive 'One Health' interventions, e.g. interventions in animal populations that generate human health benefits, may provide a useful approach to overcoming some of these challenges. Effective strategies, such as animal vaccination, already exist for the prevention, control and elimination of many endemic zoonoses, including rabies, and several livestock zoonoses (e.g. brucellosis, leptospirosis, Q fever) that are important causes of human febrile illness and livestock productivity losses in low- and middle-income countries. We make the case that, for these diseases, One Health interventions have the potential to be more effective and generate more equitable benefits for human health and livelihoods, particularly in rural areas, than approaches that rely exclusively on treatment of human cases. We hypothesize that applying One Health interventions to tackle these health challenges will help to build trust, community engagement and cross-sectoral collaboration, which will in turn strengthen the capacity of fragile health systems to respond to the threat of emerging zoonoses and other future health challenges. One Health interventions thus have the potential to align the ongoing needs of disadvantaged communities with the concerns of the broader global community, providing a pragmatic and equitable approach to meeting the global goals for sustainable development and supporting the global health security agenda.This article is part of the themed issue 'One Health for a changing world: zoonoses, ecosystems and human well-being'.

Peptide array functionalization via the Ugi four-component reaction.

The Ugi four-component reaction was investigated as a tool for the functionalization of peptide arrays via post-synthetic side-chain modification, mimicking post-translational processes. Additionally, as a proof of concept for the synthesis of peptidomimetics on arrays, the integration of an Ugi unit into a growing peptide chain was demonstrated.

Monitoring the outcomes of interventions against Taenia solium: options and suggestions.

There is an increasing interest in reducing the incidence of human neurocysticercosis, caused by infection with the larval stage of Taenia solium. Several intervention trials are currently assessing various options for control of T. solium transmission. A critical aspect of these trials will be the evaluation of whether the interventions have been successful. However, there is no consensus about the most appropriate or valuable methods that should be used. Here, we undertake a critical assessment of the diagnostic tests which are currently available for human T. solium taeniasis and human and porcine cysticercosis, as well as their suitability for evaluation of intervention trial outcomes. Suggestions are made about which of the measures that are available for evaluation of T. solium interventions would be most suitable, and which methodologies are the most appropriate given currently available technologies. Suggestions are also made in relation to the most urgent research needs in order to address deficiencies in current diagnostic methods.

World Health Organization initiative to estimate the global burden of foodborne diseases.

Foodborne diseases are a multi-sectoral public health risk closely linked with the agricultural and animal health sectors. Many foodborne diseases are zoonotic in nature. The World Health Organization (WHO) seeks to measure for the first time the real impact of foodborne diseases through the advice of its independent expert body, the Foodborne Disease Burden Epidemiology Reference Group (FERG). Through the FERG, the WHO works on both assembling and appraising existing data as well as supporting countries in conducting their own studies into the national burden of foodborne disease. This is complemented by efforts to ensure thatthe findings are meaningful and useable to policy-makers and other research end-users to implement informed policy and interventions. For the Initiative to operate effectively and achieve its objectives, linkages and collaboration at all levels, especially at the human-animal interface, need to be fostered.

Planning for rapid response to outbreaks of animal diseases transmissible to humans via food.

Planning for rapid response to outbreaks of foodborne zoonoses requires coordination and intersectoral collaboration, making the process inherently complex. Guidance documents have been published by the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) on the topics of foodborne outbreak investigation, establishing food safety emergency response plans, applying risk analysis principles during food safety emergencies, and developing national food recall systems. These guides should be used as resources by national authorities to develop national plans which should each reference the other in order to maintain consistency at the country level. FAO and WHO, together with the World Organisation for Animal Health (O1E), are the international organisations responsible at the global level for the health of people and animals and for food safety and security. As such, these organisations need to continue to work together to develop an intersectoral mechanism to conduct robust and timely joint risk assessments in the face of foodborne outbreaks and other food safety emergencies. Three international instruments have the potential to aid countries in their preparedness to face outbreaks of foodborne zoonoses and organise subsequent response efforts: the International Food Safety Authorities Network (INFOSAN), the newly enhanced Global Early Warning System for Major Animal Diseases, including Zoonoses (GLEWS+), and the FAO Emergency Prevention System for Food Safety (EMPRES Food Safety).

Local anaesthesia and propofol-fentanyl sedation for carotid artery surgery.

BACKGROUND: In patients undergoing carotid artery surgery with local anaesthesia (LA), a sedative/analgesic pharmacological supplement is appropriate in most cases in order to provide comfort. This adjunct should not preclude continuous clinical neurological monitoring. The aim was to investigate if a combination of fentanyl and propofol to supplement LA would provide comfort for the patient, allow continuous clinical neurological monitoring and absence of difficulties for the anaesthetist, and good conditions for surgery, including insertion of a shunt if this should become necessary. METHODS: During a 1-year period low doses of propofol and fentanyl were used to supplement LA in 36 cases of carotid artery surgery in 34 consecutive patients. A shunt was only used if neurological dysfunction occurred. Data on haemodynamics, pulmonary gas exchange, clinical neurological monitoring, and subjective opinions from patients, surgeons and anaesthetists were obtained. Morbidity within 30 days was documented. RESULTS: Conversion to general anaesthesia was undertaken in one patient, previously operated on the same artery, who became unconscious due to a stroke during manipulation of the artery before arteriotomy. No other adverse outcome was found within 30 days. In the remaining 35 cases the procedures were carried out under LA. Stump pressures below 50 mmHg were found in 17/35 cases. Intraoperative neurological dysfunction was detected in 10/35 cases (stump pressures between 23 and 60 mmHg). Shunting was easily performed, and rapidly relieved the neurologic symptoms in all these patients. Intraoperative respiratory and haemodynamic control was satisfactory. Ease of performance, including clinical neurological monitoring, was acknowledged by both anaesthetists and surgeons, and all 33 patients (35 operations) who were accessible for a postoperative interview stated that they would prefer the same regimen in the case of further surgery. CONCLUSION: The number of cases in this open, uncontrolled study does not permit an evaluation of this anaesthetic and sedative technique in terms of neurological and cardiac outcome. Thus, we simply want to inform about our positive experiences regarding patient acceptance and ease of performance in all relevant respects when fentanyl and propofol are used to supplement LA for carotid artery surgery.

[Value of computer tomographic determination of spleen size for the elucidation of splenic involvement within the framework of primary lymph node neoplasms]. / Wertigkeit der computertomographischen Milzgrössenbestimmung zur Abklärung eines Milzbefalls im Rahmen primärer Lymphknotenneoplasien.

The splenic index was determined in 155 persons, without evidence of splenic disease, in order to obtain a simple measure of splenic size. Subsequently 36 patients with malignant lymphomas and who then had their spleens removed were examined by CT. A comparison of the CT and pathological-anatomical findings showed that it is a valuable non-invasive method for diagnosing splenic involvement, having a specificity of 86%, sensitivity of 77% and accuracy of 83%.