Psychiatric disorders, suicidality, and personality among young men by sexual orientation.

Personality and its potential role in mediating risk of psychiatric disorders and suicidality are assessed by sexual orientation, using data collected among young Swiss men (n=5875) recruited while presenting for mandatory military conscription. Mental health outcomes were analyzed by sexual attraction using logistic regression, controlling for five-factor model personality traits and socio-demographics. Homo/bisexual men demonstrated the highest scores for neuroticism-anxiety but the lowest for sociability and sensation seeking, with no differences for aggression-hostility. Among homo/bisexual men, 10.2% fulfilled diagnostic criteria for major depression in the past 2weeks, 10.8% for ADHD in the past 12months, 13.8% for lifetime anti-social personality disorder (ASPD), and 6.0% attempted suicide in the past 12months. Upon adjusting (AOR) for personality traits, their odds ratios (OR) for major depression (OR=4.78, 95% CI 2.81-8.14; AOR=1.46, 95% CI 0.80-2.65) and ADHD (OR=2.17, 95% CI=1.31-3.58; AOR=1.00, 95% CI 0.58-1.75) lost statistical significance, and the odds ratio for suicide attempt was halved (OR=5.10, 95% CI 2.57-10.1; AOR=2.42, 95% CI 1.16-5.02). There are noteworthy differences in personality traits by sexual orientation, and much of the increased mental morbidity appears to be accounted for by such underlying differences, with important implications for etiology and treatment.

Sociocultural context of suicidal behaviour in the sundarban region of India.

The role of mental illness in nonfatal deliberate self-harm (DSH) is controversial, especially in Asian countries. This prospective study examined the role of psychiatric disorders, underlying social and situational problems, and triggers of DSH in a sample of 89 patients hospitalised in primary care hospitals of the Sundarban Delta, India. Data were collected by using a specially designed DSH register, Explanatory Model Interview Catalogue (EMIC), and clinical interview. Psychiatric diagnosis was made following the DSM-IV guidelines. The majority of subjects were young females (74.2%) and married (65.2%). Most of them (69.7%) were uncertain about their "intention to die," and pesticide poisoning was the commonest method (95.5%). Significant male-female differences were found with respect to education level, occupation, and venue of the DSH attempt. Typical stressors were conflict with spouse, guardians, or in-laws, extramarital affairs, chronic physical illness, and failed love affairs. The major depressive disorder (14.6%) was the commonest psychiatric diagnosis followed by adjustment disorder (6.7%); however 60.7% of the cases had no psychiatric illness. Stressful life situations coupled with easy access to lethal pesticides stood as the risk factor. The sociocultural dynamics behind suicidal behaviour and community-specific social stressors merit detailed assessment and timely psychosocial intervention. These findings will be helpful to design community-based mental health clinical services and community action in the region.

Socio-cultural determinants of anticipated acceptance of an oral cholera vaccine in Western Kenya.

Determinants of anticipated acceptance of an oral cholera vaccine (OCV) were studied in urban and rural communities of Western Kenya. An explanatory model interview administered to 379 community residents assessed anticipated vaccine acceptance at various prices from no cost to full-cost recovery, socio-cultural features of cholera and social characteristics. Nearly all (99%) residents indicated willingness to accept a no-cost OCV, 95% at a price of US$ 0·8, 73% at US$ 4·2 and 59% at US$ 8·4. Logistic regression models analysed socio-cultural determinants of anticipated OCV acceptance. Prominence of non-specific symptoms for cholera was negatively associated with acceptance. A cholera-specific symptom (thirst), self-help referring to prayer, income and education were positively associated. In the high-cost model, education was no longer significant and reliance on herbal treatment was a significant determinant of vaccine non-acceptance. Findings suggest high motivation for OCVs, if affordable. Socio-cultural determinants are better predictors of anticipated acceptance than socio-demographic factors alone.

Stakeholders perspectives on perceived needs and priorities for leprosy control and care, Tamil Nadu, India.

Although leprosy has been declared as eliminated in India, treated patients with persisting disabilities still require care. With the shift from vertical to integrated services, questions remain about case detection and maintaining the quality of patient care. We conducted a qualitative study to clarify the perceived status of elimination, patient care and other aspects of leprosy control from the perspective of various stakeholders. We interviewed leprosy programme managers, Non-governmental organization directors, healthcare providers, patients and community leaders from Kanchipuram district, Tamil Nadu. Consensus endorsed the current approach to integration of leprosy in primary healthcare, but healthcare personnel acknowledged problems from shortage of medicines and failure to fill key positions. Patients were concerned about limited clinic hours, long waits and delayed treatment. Disabled patients indicated how they were troubled by stigmatization of their condition. Programme managers mentioned limited support for needed research and some emphasized the potential threat of emerging drug resistance. Although consensus supports an integrated approach for leprosy services in primary care, the relative priority of different aspects of leprosy control vary among stakeholders. Perspectivist approaches to methodologically sound operational research could guide planning for effective case detection and patient care during the post-elimination era.

Gender and community views of stigma and tuberculosis in rural Maharashtra, India.

Stigma associated with tuberculosis (TB) is often regarded as a barrier to health seeking and a cause of social suffering. Stigma studies are typically patient-centred, and less is known about the views of communities where patients reside. This study examined community perceptions of TB-related stigma. A total of 160 respondents (80 men and 80 women) without TB in the general population of Western Maharashtra, India, were interviewed using Explanatory Model Interview Catalogue interviews with same-sex and cross-sex vignettes depicting a person with typical features of TB. The study clarified features of TB-related stigma. Concealment of disease was explained as fear of losing social status, marital problems and hurtful behaviour by the community. For the female vignette, heredity was perceived as a cause for stigmatising behaviour. Marital problems were anticipated more for the male vignette. Anticipation of spouse support, however, was more definite for men and conditional for women, indicating the vulnerability of women. Community views acknowledged that both men and women with TB share a psychological burden of unfulfilled social responsibilities. The distinction between public health risks of infection and unjustified social isolation (stigma) was ambiguous. Such a distinction is important for effective community-based interventions for early diagnosis of TB and successful treatment.

Rocuronium for nonemergent intubation of term and preterm infants.

OBJECTIVE: The aim of this study was to analyze clinical characteristics of rocuronium as premedication for nonemergent intubation in infants. STUDY DESIGN: Preterm infants requiring nonemergent intubation were randomized to receive atropine and fentanyl with or without rocuronium. Outcomes, patient characteristics and intubator's experience were noted. Onset, duration and degree of clinical paralysis were recorded for rocuronium group and for older infants receiving rocuronium per unit protocol. RESULT: Forty-four intubations were randomized (20 rocuronium, 24 control). Groups were similar in chronological and corrected gestational age, weight and intubator's experience. Successful intubation on first attempt was achieved in 35% of intubations under rocuronium vs 8% of controls; rocuronium was the only significant variable by logistic regression (odds ratio=0.052, P=0.029). Complete paralysis was reported in 80% of 57 rocuronium intubations; onset ranged from 14 to 178 s (65.9±43.4), and duration from 1 to 60 min (16.3±13.5). CONCLUSION: Rocuronium facilitated successful intubation and provided clinical paralysis quickly in most infants.

Validity and reliability of the N-PASS assessment tool with acute pain.

OBJECTIVE: To establish evidence of clinical validity and reliability of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) in neonates with acute heelstick pain. STUDY DESIGN: Prospective psychometric evaluation, randomized crossover design. Two nurses administered the N-PASS simultaneously and independently during an actual and sham heelstick done in randomized order. One nurse also administered the Premature Infant Pain Profile (PIPP) concurrently with the N-PASS. Heelsticks were videotaped for repeat analysis. RESULT: Construct (discriminate) validity was established through the Wilcoxon Signed-ranks test, comparing the distribution of the heelstick and sham N-PASS scores. The mean pain scores were 3.93 (2.30) and 0.81 (1.21) for the heelstick and sham procedures, respectively (Z=-6.429, P<0.0001). Convergent validity was demonstrated by correlation with the PIPP scores (Spearman rank correlation coefficient of 0.75 and 0.72 for raters 1 and 2, respectively). Inter-rater reliability was high, measured by intra-class coefficients; the ICC estimates (95% CI) of the pain scale were 0.86 (0.78, 0.92) and 0.93 (0.88, 0.96) for a single rating and average of two independent ratings, respectively (P<0.0001). Internal consistency, measured by Cronbach's alpha, was evident (0.84 to 0.89). Test-retest reliability was demonstrated by repeat scoring of videotaped heelsticks, measured by Spearman's rho correlation (0.874, P<0.0001). CONCLUSION: This research provides beginning evidence that the N-PASS is a valid and reliable tool for assessing acute heelstick pain in infants 0 to 30 days of age, 23 to 40 weeks gestation.

Cultural epidemiology of TB with reference to gender in Bangladesh, India and Malawi.

SETTING: TB control programmes in Bangladesh, India and Malawi. OBJECTIVE: To identify and compare socio-cultural features of tuberculosis (TB) and the distribution of TB-related experiences, meanings and behaviours with reference to gender across cultures in three high-endemic low-income countries. DESIGN: Approximately 100 patients at three sites were interviewed with in-depth semi-structured Explanatory Model Interview Catalogue (EMIC) interviews inquiring about patterns of distress, perceived causes and help-seeking behaviours in the context of illness narratives. RESULTS: Female patients reported more diverse symptoms and men more frequently focused on financial concerns. Most patients reported psychological and emotional distress. Men emphasised smoking and drinking alcohol as causes of TB, and women in Malawi reported sexual causes associated with HIV/AIDS. In Bangladesh, exaggerated concerns about the risk of spread despite treatment contributed to social isolation of women. Public health services were preferred in Malawi, and private doctors in India and Bangladesh. CONCLUSION: Cross-site analysis of these studies has identified features of TB that influence the burden of disease and are likely to affect timely help seeking and adherence to treatment. Health systems benefit from sex-disaggregated epidemiological data complemented by cultural epidemiological study, which together clarify the role of gender and contribute to the knowledge base for TB control at various levels.

Gender and socio-cultural determinants of delay to diagnosis of TB in Bangladesh, India and Malawi.

SETTING: Tuberculosis (TB) control programmes in Bangladesh, India and Malawi. OBJECTIVE: To compare the interval from symptom onset to diagnosis of TB for men and women, and to assess socio-cultural and gender-related features of illness explaining diagnostic delay. DESIGN: Semi-structured Explanatory Model Interview Catalogue (EMIC) interviews were administered to 100 or more patients at each site, assessing categories of distress, perceived causes and help seeking. Based on time from initial symptoms to diagnosis of TB, patients were classified with problem delay (>90 days), timely diagnosis (< or =30 days) or moderate delay. EMIC interview data were analysed to explain problem delay. RESULTS: The median interval from symptom onset to diagnosis was longest in India and shortest in Malawi. With adjustment for confounding, female sex (Bangladesh), and status of married woman (India) and housewife (Malawi) were associated with problem delay. Prominent non-specific symptoms--chest pain (Bangladesh) and breathlessness (Malawi)--were also significant. Cough in India, widely associated with TB, was associated with timely diagnosis. Sanitation as a perceived cause linked to poor urban conditions was associated with delayed diagnosis in India. Specific prior help seeking with circuitous referral patterns was identified. CONCLUSION: The study identified gender- and illness-related features of diagnostic delay. Further research distinguishing patient and provider delay is needed.

Gender and socio-cultural determinants of TB-related stigma in Bangladesh, India, Malawi and Colombia.

SETTING: Tuberculosis (TB) control programmes in Bangladesh, India, Malawi and Colombia. OBJECTIVE: Assess indicators of TB-related stigma and socio-cultural and gender-related features of illness associated with stigma. DESIGN: Semi-structured Explanatory Model Interview Catalogue (EMIC) interviews were administered to 100 or more patients at each site, assessing categories of distress, perceived causes and help seeking. Indicators of self-perceived stigma were analysed individually and in a validated index, which was compared across sites and between men and women at each site. Cultural epidemiological explanatory variables for stigma and interactions with female sex were analysed at each site. Qualitative illness narratives were examined to explain the role and context of explanatory variables. RESULTS: The overall stigma index was highest in India, lowest in Malawi and greater for women in Bangladesh. In India and Malawi, women were more likely to be concerned about impact on marital prospects. Associations with HIV/AIDS were linked to TB stigma in Malawi, where sexual contact as a perceived cause was more associated with stigma for men and less for women. CONCLUSION: Stigma both influences and indicates the effectiveness of TB control. Cultural epidemiological methods clarify cross-cutting and local features of stigma and gender for TB control.

Clinical reliability and validity of the N-PASS: neonatal pain, agitation and sedation scale with prolonged pain.

OBJECTIVE: To establish beginning evidence of clinical validity and reliability of the Neonatal Pain, Agitation and Sedation Scale (N-PASS) in neonates with prolonged pain postoperatively and during mechanical ventilation. STUDY DESIGN: Prospective psychometric evaluation. Two nurses administered the N-PASS simultaneously and independently before and after pharmacologic interventions for pain or sedation. One nurse also administered the premature infant pain profile (PIPP) concurrently with the N-PASS. The setting consisted of 50-bed level III neonatal intensive care unit. Convenience sample of 72 observations of 46 ventilated and/or postoperative infants, 0 to 100 days of age, gestational age 23 to 40 weeks was used. Outcome measures comprised convergent and construct validity, interrater reliability and internal consistency. RESULT: Interrater reliability measured by intraclass coefficients of 0.85 to 0.95 was high (P<0.001 to 0.0001). Convergent validity was demonstrated by correlation with the PIPP scores (Spearman's rank correlation coefficient of 0.83 at high pain scores, 0.61 at low pain scores). Internal consistency, measured by Cronbach's alpha, was evident with pain scores (0.82), and with sedation scores (0.87). Construct validity was established via the Wilcoxon signed-rank test, comparing the distribution of N-PASS scores before and after pharmacologic intervention showing pain scores of 4.86 (3.38) and 1.81 (1.53) (mean (s.d.), P<0.0001) and sedation scores of 0.85 (1.66) and -2.78 (2.81) (P<0.0001) for pre- and postintervention assessments, respectively. CONCLUSIONS: This research provides beginning evidence that the N-PASS is a valid and reliable tool for assessing pain/agitation and sedation in ventilated and/or postoperative infants 0 to 100 days of age, and 23 weeks gestation and above.

Biomedical markers and psychiatric morbidity of neurasthenia spectrum disorders in four outpatient clinics in India.

CONTEXT: Disorders of unexplained fatigue are researched globally and debated prominently concerning their biomedical and psychiatric comorbidity. Such studies are needed in India. AIMS: To identify biomedical markers and psychiatric morbidity of disorders of severe unexplained fatigue or weakness with disability, designated neurasthenia spectrum disorders (NSDs). To compare biomedical markers of patients with controls. To study correlation between biomedical markers and psychiatric morbidity. SETTINGS: Four specialty outpatient clinics of Psychiatry, Medicine, Dermatology, and Ayurved of an urban general hospital. DESIGN: Case-control study for biomedical markers. Diagnostic interviews for assessment of psychiatric morbidity. MATERIALS AND METHODS: Patients (N = 352) were recruited using screening criteria and Structured Clinical Interview for DSM-IV screening module. They were compared with controls (N = 38) for relevant biomedical markers. Psychiatric morbidity was assessed with SCID-I interviews, Hamilton scales, and Symptom Check List-90 (SCL-90). Correlations between a nutritional index and axis I morbidity were studied. STATISTICAL ANALYSES: Frequencies and means of biomedical markers and psychiatric diagnoses were compared and associations assessed with regression analysis. RESULTS: Corrected arm muscle area (CAMA) was significantly lower among patients (P < 0.001), but not anemia. Anxiety (73.0%) and somatoform (61.4%) disorders, especially nonspecific diagnoses, were more frequent than depressive disorders (55.4%). Generally, Hamilton and SCL scores were lowest in Ayurved clinic, and highest in Psychiatry clinic. Presence of Generalized Anxiety Disorder (GAD) and adjustment disorders correlated with low nutritional index. CONCLUSIONS: Malnutrition or de-conditioning that may explain weakness need to be considered in the management of NSDs in India, particularly with comorbid GAD or adjustment disorders. Weakness and anxiety, rather than fatigue and depression, are distinct features of Indian patients. SCL may be more useful than categorical diagnoses in NSDs. NSDs are an independent entity with nonspecific psychiatric comorbidity. Cross clinic differences among patients with similar complaints highlight need for idiographic studies.

Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol.

OBJECTIVE: Respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) are frequent complications of prematurity. To decrease ventilator-induced lung injury, we evaluated the safety, efficacy and neonatal outcomes of a heated humidified high-flow nasal cannula (HFNC) system and an early extubation protocol (EEP) designed for preterm infants 25 to 29 weeks' gestational age (GA). STUDY DESIGN: The Vapotherm (VT) high-flow humidification system was introduced to our unit in March 2004. After 10 months of VT use, an EEP was developed to begin January 2005. Infants 25 to 29 weeks of GA, intubated for RDS, were enrolled in January-December 2005 to extubate to VT following the EEP. Exclusion criteria were: major congenital anomalies, asphyxia and a 5 min Apgar score <5. Variables examined included BPD, growth and infection. Subjects were compared to historical controls, admitted January to December 2003, prior to the use of VT. RESULT: Inclusion criteria were met by 49/57 infants in the control group and 65/75 infants in the HFNC group. The groups had similar demographics, perinatal conditions, birthweight, GA, timing and total doses of surfactant. There were no differences in rates of extubation failure, patent ductus arteriosus, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, laser eye surgery, sepsis, BPD at 28 days and 36 weeks and death. The groups did not differ in oxygen use, i.v. steroid days, or parenteral nutrition days. Days to reach full feeds were similar. Infants in the HFNC group were extubated from a higher ventilator rate (32.6+/-8.5 vs 28+/-7.5, P=0.003) and spent fewer days on the ventilator (11.4+/-12.8 vs 18.5+/-21, P=0.028). Rates of ventilator-associated pneumonia were higher in the control group (P=0.018). Discharge weights were greater in the HFNC group (P=0.016) despite similar length of stay and GA at discharge. CONCLUSION: High-flow nasal cannula use appears safe and well-tolerated. Infants extubated to HFNC spent fewer days on the ventilator. Additional benefits may include a decreased rate of ventilator associated with pneumonia and improved growth.

Pesticide practices and suicide among farmers of the sundarban region in India.

BACKGROUND: Deliberate self-poisoning by ingesting pesticides is a serious health problem among farmers, especially in low- and middle-income countries. Preventing these suicides is a priority for a public mental health agenda. OBJECTIVE: To examine the role of pesticide poisoning in suicide and nonfatal deliberate self-harm, and clarify awareness of risks, safe practices concerning storage and use of pesticides, and associated self-injury, both unintentional and intentional, within farmer households of the Sundarban region, India. METHODS: Retrospective record review of adult cases of deliberate self-poisoning at the Block Primary Health Centres of 13 Sundarban Blocks was performed to analyze the relative roles of various methods of self-harm and their lethality. Focus group discussions, questionnaires, and in-depth interviews were undertaken in a community study of farmer households to examine pesticide-related views and practices, with particular attention to storage, use, and health impact. RESULTS: Pesticide poisoning was the most common method of deliberate self-harm in both men and women. Pesticide storage in most households was unsafe and knowledge was inadequate concerning adverse effects of pesticides on health, crops, and the environment. CONCLUSIONS: An intersectoral approach linking the interests of public health, mental health, and agriculture is well suited to serve the collective interests of all three agendas better than each in isolation. Such an approach is needed to reduce morbidity and mortality from unintentional and intentional self-injury in low-income agricultural communities like those of the Sundarban region.

Use of army weapons and private firearms for suicide and homicide in the region of Basel, Switzerland.

OBJECTIVES: Switzerland has one of the highest rates of firearm suicides in the world. International studies show a positive correlation between the rate of households with guns and femicides with guns. Because its defense system requires a militia to keep personal firearms at home, Switzerland has a high rate of households with a gun. METHODS: Records of suicides in the region of Basel between 1992 and 1996 were reviewed. Suicides with either army weapons or private firearms and suicides by other means were compared. Methods and types of homicides that occurred in the region at the same time were also analyzed. FINDINGS: Firearm suicides were clearly the most frequent means of suicide. They were also used in 30.0% of domestic homicides, although other means were used at similar rates. Firearms for suicide were mainly used by men, especially army weapons. These men were younger, professionally better qualified, and fewer had ever been treated in one of the local state psychiatric services. DISCUSSION: The use of firearms for suicide, rather than homicide, and particularly of army weapons by young, well-educated men, requires more attention in debates and informed policy regarding access to firearms and suicide prevention in Switzerland.

Impact of migration on illness experience and help-seeking strategies of patients from Turkey and Bosnia in primary health care in Basel.

Migration, particularly among refugees and asylum seekers, poses many challenges to the health system of host countries. This study examined the impact of migration history on illness experience, its meaning and help-seeking strategies of migrant patients from Bosnia and Turkey with a range of common health problems in general practice in Basel, Switzerland. The Explanatory Model Interview Catalogue, a data collection instrument for cross-cultural research which combines epidemiological and ethnographic research approaches, was used in semi-structured one-to-one patient interviews. Bosnian patients (n=36) who had more traumatic migration experiences than Turkish/Kurdish (n=62) or Swiss internal migrants (n=48) reported a larger number of health problems than the other groups. Psychological distress was reported most frequently by all three groups in response to focussed queries, but spontaneously reported symptoms indicated the prominence of somatic, rather than psychological or psychosocial, problems. Among Bosnians, 78% identified traumatic migration experiences as a cause of their illness, in addition to a range of psychological and biomedical causes. Help-seeking strategies for the current illness included a wide range of treatments, such as basic medical care at private surgeries, outpatients department in hospitals as well as alternative medical treatments among all groups. Findings provide a useful guide to clinicians who work with migrants and should inform policy in medical care, information and health promotion for migrants in Switzerland as well as further education of health professionals on issues concerning migrants health.

Community Psychiatry Clinics at Sundarban: a clinical and cultural experience.

A series of Community Psychiatric Clinics were conducted in different blocks of Sundarban region of West Bengal. One of the primary objectives of this was to collect clinical epidemiological data on psychiatric morbidity in the region. A total of 26 clinics were conducted in Sagar, Kakdwip, Canning and Gosaba block of the Sundarban region during the period from end 1998 to end 2000. A total of 451 psychiatric cases with diagnostic categories (male 239, female 212) and 215 non-psychiatric cases (male 107 and female 108) were seen in these clinics. Diagnostic Interview Schedules (SCID) and Clinical rating scales like Hamilton Depression Rating Scale and Brief Psychiatric Rating Scales were used to ascertain clinical diagnosis quantitatively. Special emphasis was given on common psychiatric disorders.

Bovine tuberculosis: an old disease but a new threat to Africa.

Bovine tuberculosis (TB) is a disease characterised by progressive development of specific granulomatous lesions or tubercles in lung tissue, lymph nodes or other organs. Mycobacterium bovis is the causative agent of the disease. Bovine species, including bison and buffaloes, are susceptible to the disease, but nearly all warm-blooded animals can be affected. All species are not equally susceptible to the disease; some are spill-over (end) hosts and others maintenance hosts. In Africa, bovine TB primarily affects cattle; however, infection in other farm and domestic animals, such as sheep, goats, pigs, dogs and cats, is not uncommon. Wild ruminants and carnivores are also affected and are the natural reservoirs of the infectious agent in the wild. Man is also susceptible to the disease, the highest risk groups being individuals with concomitant HIV/AIDS infection. In Africa, human TB is widely known to be caused by M. tuberculosis; however, an unknown proportion of cases are due to M. bovis. This infection in humans is under-reported as a result of the diagnostic limitations of many laboratories in distinguishing M. bovis from M. tuberculosis. None of the national reports submitted to the OIE and WHO by African member states mention the importance of M. bovis in human TB cases. Consumption of unpasteurised milk and poorly heat-treated meat and close contact with infected animals represent the main sources of infection for humans. This review attempts to examine the impact of bovine TB on the health of animals and humans.