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After an initial wave of coronavirus disease 2019 (COVID-19) in Haiti in summer 2020 (primarily lineage B.1), seropositivity for anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) was ~40%. Variant P.1 (gamma) was introduced in February 2021, with an initially limited introduction followed by exponential local dissemination within this unvaccinated population with prior exposure to earlier SARS-CoV-2 lineages.

BACKGROUND: A retrospective study was performed to evaluate factors associated with 30-d re-intubation following surgical aortic valve repair. We hypothesized a significant increase in the odds of re-intubation among patients with preoperative comorbidities. METHODS: The American College of Surgery National Surgical Quality Improvement Program database from 2007 to 2016 was used to evaluate demographic and clinical factors associated with 30-d re-intubation following surgical aortic valve repair. Multivariable logistic regression was used to report factors associated with 30-d re-intubation while controlling for various patient characteristics. RESULTS: The study population consisted of 5,766 adult subjects who underwent surgical aortic valve repair, of whom 258 (4.47%) were re-intubated within 30 d of surgery. The mean ± SD age was 69 ± 12.98 y, and 3,668 (63.6%) were male. The prevalence of diabetes mellitus, shortness of breath, poor functional status, COPD, congestive heart failure, hypertension, and bleeding disorder was higher among subjects who were re-intubated compared to those who were not (P < .05). Age, severe COPD, congestive heart failure, and bleeding disorder were associated with this outcome. CONCLUSIONS: Age, COPD, congestive heart failure, and bleeding disorder were associated with 30-d re-intubation in this surgical cohort. If surgical aortic valve repair is deemed non-emergent, patients should be optimized preoperatively and receive careful postoperative planning to reduce the risk of postoperative complications.

Anhedonia-diminished interest and pleasure in response to rewards-may be a symptom of tobacco withdrawal that is understudied in priority populations. This experiment investigated the magnitude and correlates of various dimensions of anhedonia during tobacco withdrawal among African-American (AA) smokers-a population subject to health disparities. AA smokers (N = 607; ≥ 10 cigarettes/day, 37.8% female, M[SD] age = 50.0[10.6] years) completed self-report measures assessing expected pleasure from (i.e., consummatory anhedonia) and desire to engage in (i.e., anticipatory anhedonia) various types of hypothetically experienced rewards at counterbalanced 16-hr tobacco deprived and nondeprived lab visits. Other tobacco withdrawal symptom measures (e.g., craving, negative affect, hunger) were also assessed. Tobacco deprivation most robustly increased scores on a composite measure of consummatory anhedonia directed toward various reward domains (i.e., hobbies, sensory experiences, social activities; d = .32, p < .001). Deprivation modestly increased consummatory and anticipatory anhedonia directed toward sexual rewards (ds = .09-.12, ps < .02), did not significantly change anhedonia toward food rewards, and decreased anhedonia directed toward psychoactive drug rewards (i.e., increased desire for and pleasure from drugs; ds = -.21 to -.19, ps < .001). Deprivation-induced changes in anhedonia were modestly correlated with other withdrawal symptoms (average |r|s = .04-.23) and were amplified among participants with higher nicotine dependence and lower positive affect-related traits (|β|s = .10-.12, ps < .01). Some dimensions of anhedonia may be genuine expressions of acute tobacco withdrawal in AA smokers. Applying multi-dimensional anhedonia conceptualizations might advance basic knowledge and treatment of tobacco use disorder, improve smoking cessation outcomes, and address tobacco-related health disparities facing AA smokers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Theoretically, anxiety sensitivity-fear of anxiety symptoms-enhances perception of and emotional reactivity to autonomic arousal and mental distress, thereby increasing negative affect and motivation to use substances for negative reinforcement. Because no prior study of adolescents has tested if anxiety sensitivity is indirectly associated with substance use problems through symptoms of emotional disorders (i.e., disorders involving high levels of negative affect), the current cross-sectional study examined this theoretical pathway. Participants included ninth-grade students from 10 different high schools in the Los Angeles metropolitan area (N = 3005; 54.3% female). Self-report measures of anxiety sensitivity, emotional disorder symptoms, tobacco dependence, and alcohol and other drug problems were administered. Controlling for sex, race/ethnicity, parental education, school, and impulsiveness, we tested the associations of anxiety sensitivity with tobacco, alcohol, and other drug use problems as well as the indirect effects of anxiety sensitivity on each domain of substance use problems through emotional disorder symptoms. Anxiety sensitivity was associated with more severe tobacco dependence and greater alcohol problems and other drug problems, and anxiety sensitivity further was indirectly associated with all three domains of substance use problems through emotional disorder symptoms. Current findings suggest that adolescents high in anxiety sensitivity tend to experience emotional disorder symptoms, which may increase risk for substance use problems. Interventions that target anxiety sensitivity and enhance negative-affect coping skills may assist in preventing and reducing adolescent substance use problems.

Background and aimsFrequent experiences of discrimination could increase vulnerability to tobacco withdrawal and smoking lapse in populations subject to tobacco-related health disparities. This laboratory study (2013-17) examined whether individual differences in perceived exposure to discrimination in one's daily life predicted tobacco withdrawal symptoms and smoking lapse behavior following acute tobacco deprivation in African American smokers.DesignMixed design with the between-subjects continuous variable of perceived discrimination crossed with the within-subject variable of tobacco deprivation status (deprived versus non-deprived).SettingAcademic medical center in Los Angeles, CA, USA.ParticipantsAfrican American non-treatment seeking daily cigarette smokers (n=607, ≥10 cig/day).MeasurementsAt a baseline visit, self-reported frequency of perceived exposure to discrimination in one's daily life was measured [everyday discrimination scale (EDDS)]. At two subsequent counterbalanced experimental visits (16-hour tobacco deprivation versus ad-libitum smoking), self-report assessments of various tobacco withdrawal symptom domains [Brief Questionnaire of Smoking Urges), Wisconsin Smoking Withdrawal Scale (WSWS), Profile of Mood States (POMS), Snaith-Hamilton Pleasure Scale (SHAPS) and Current Impulsivity Scale (CIS)) and a behavioral smoking lapse analogue task were measured.FindingsAdjusted models demonstrated that greater frequency of perceived exposure to discrimination was associated with larger deprivation-induced increases in acute urges to smoke to alleviate negative mood, several negative mood states and subjective cognitive functioning-effect sizes were small in magnitude (βs=0.09-0.13; Ps&nbsp

Highlights • E-cigarettes were the most commonly used product across the lifetime. • Bisexual (vs. straight, lesbian/gay) individuals had higher odds of cigarette, e-cigarette, and cannabis use. • Bisexual (vs. straight) females had higher odds of lifetime cigarette use., Purpose Sexual minority young adults report greater cigarette and cannabis use. Emerging evidence suggests this trend may extend to e-cigarettes. The current study evaluated the relationship between sexual identity and prevalence of e-cigarette, cigarette, and cannabis use and whether such associations differ by gender. Methods Cross-sectional, regionally representative data of young adults (M[SD]age = 20.02 [0.60] years; nheterosexual = 1314; nbisexual = 77; nlesbian/gay = 28) from Wave III (2016) of the Southern California Children’s Health Study were analyzed in 2019. Logistic regression analyses were conducted with sexual identity as the predictor and product use (never, prior, infrequent past 30-day [1-2 days], frequent past 30-day [3-5+ days]) as the outcome in separate models by substance (e-cigarettes, cigarettes, cannabis). Results Bisexual individuals were the highest-risk sub-group for nearly all outcomes, with over five times the odds of reporting frequent past 30-day use for e-cigarettes (Odds Ratio [OR]: 6.68; 95% Confidence Interval [CI]: 2.80, 15.9), cigarettes (OR: 5.42; 95% CI: 2.37, 12.4), and cannabis (OR: 8.43; 95% CI: 4.40, 16.1) compared to heterosexual individuals. Although the sample size for lesbian/gay participants was small, bisexual (vs. lesbian/gay) participants also had greater odds of reporting prior use of nicotine products and frequent past 30-day cannabis use. A significant sexual identity × gender interaction emerged for lifetime cigarette use, wherein bisexual (vs. heterosexual) identity was only associated with greater odds of use for females (p

Multiple digital data streams forecast COVID-19 activity weeks before traditional epidemiological surveillance., Given still-high levels of coronavirus disease 2019 (COVID-19) susceptibility and inconsistent transmission-containing strategies, outbreaks have continued to emerge across the United States. Until effective vaccines are widely deployed, curbing COVID-19 will require carefully timed nonpharmaceutical interventions (NPIs). A COVID-19 early warning system is vital for this. Here, we evaluate digital data streams as early indicators of state-level COVID-19 activity from 1 March to 30 September 2020. We observe that increases in digital data stream activity anticipate increases in confirmed cases and deaths by 2 to 3 weeks. Confirmed cases and deaths also decrease 2 to 4 weeks after NPI implementation, as measured by anonymized, phone-derived human mobility data. We propose a means of harmonizing these data streams to identify future COVID-19 outbreaks. Our results suggest that combining disparate health and behavioral data may help identify disease activity changes weeks before observation using traditional epidemiological monitoring.

Covid-19 Notes: Facing the Monster in Haiti Lacking international support, clinicians in Haiti have implemented practical solutions to coordinate laboratory testing for Covid-19, provide education ...

Tobacco addiction and obsessive-compulsive symptoms (OCS; intrusive thoughts or impulses that cause distress and rituals) are both mediated by compulsivity and negative reinforcement. Little evidence exists to guide theory, research, treatment, and population-based prevention of this co-occurrence. We propose a conceptual model of OCS-smoking co-occurrence in which smokers with elevated OCS capitalize on smoking to assuage OCS. This secondary analysis examined associations between OCS levels and self-reported smoking motives that are model-concordant: i) negative reinforcement—smoking for relief; ii) sensorimotor—benefits of behaviors and sensations of the tobacco self-administration ritual; and iii) habitual—smoking without conscious control. A community sample of cigarette smokers enrolled in a cessation trial (N=458; 47.2% female; M(age)=36.9; SD=13.6) completed pre-quit self-report measures of OCS levels and smoking motives. Regression models adjusted for sociodemographic covariates and non-OCS psychopathologies indicated that OCS level was positively associated with each model-concordant motive. OCS level was also correlated with tobacco dependence severity and greater withdrawal symptom severity experienced during previous quit attempts. Those with higher OCS report greater motivation to smoke for negative reinforcement, sensorimotor behavioral-ritualistic, habit/automaticity, and stimulation reasons. Further examination of the proposed model of OCS-smoking co-occurrence is warranted to guide theory and intervention for this population.

Background: Insufficient training in infection control and occupational health among healthcare workers (HCWs) in countries with high human immunodeficiency virus (HIV) and tuberculosis (TB) burdens requires attention. We examined the effectiveness of a 1-year Certificate Program in Occupational Health and Infection Control conducted in Free State Province, South Africa in an international partnership to empower HCWs to become change agents to promote workplace-based HIV and TB prevention. Methods: Questionnaires assessing reactions to the program and Knowledge, Attitudes, Skills, and Practices were collected pre-, mid-, and postprogram. Individual interviews, group project evaluations, and participant observation were also conducted. Quantitative data were analyzed using Wilcoxon signed-rank test. Qualitative data were thematically coded and analyzed using the Kirkpatrick framework. Results: Participants recruited (n = 32) were mostly female (81%) and nurses (56%). Pre-to-post-program mean scores improved in knowledge (+12%, p = 0.002) and skills/practices (+14%, p = 0.002). Pre-program attitude scores were high but did not change. Participants felt empowered and demonstrated attitudinal improvements regarding HIV, TB, infection control, and occupational health. Successful projects were indeed implemented. However, participants encountered considerable difficulties in trying to sustain improvement, due largely to lack of pre-existing knowledge and experience, combined with inadequate staffing and insufficient management support. Conclusion: Training is essential to strengthen HCWs' occupational health and infection control knowledge, attitudes, skills, and practices, and workplace-based training programs such as this can yield impressive results. However, the considerable mentorship resources required for such programs and the substantial infrastructural supports needed for implementation and sustainability of improvements in settings without pre-existing experience in such endeavors should not be underestimated. Keywords: capacity building, healthcare workers, HIV infection control, occupational health, tuberculosis

The 1st cigarette of the day is strongly tied to tobacco dependence. However, prior research has not investigated whether within-subject (WS) day-to-day fluctuations in prefirst-cigarette affect are associated with the subjective effects from the 1st cigarette of the day or whether these associations differ by smokers' average prefirst-cigarette affect. In the current study, 85 premenopausal female daily smokers completed baseline measures and 35 days of ecological momentary assessment. Prefirst-cigarette positive affect (PA) and negative affect (NA) were assessed prior to the 1st cigarette of the day and were partitioned into between-subjects (BS) and WS variables. Pleasurable and NA relief effects were assessed following the 1st cigarette of the day. On days when women reported higher than their usual prefirst-cigarette PA (WS-PA), they reported more pleasurable effects. On days when women reported higher than their usual prefirst-cigarette WS-NA, they reported greater pleasurable effects and NA relief effects. Women with higher average prefirst-cigarette NA relative to others (BS-NA), reported greater NA relief effects. Women with higher average prefirst-cigarette PA relative to others (BS-PA) reported greater pleasurable and NA relief effects from smoking. The association of within-subject affect (i.e., that day's level of NA or PA) with NA relief effects is attenuated in female smokers with higher average prefirst-cigarette NA (i.e., Prefirst-Cigarette WS Affect × Prefirst-Cigarette BS-NA interaction). Results suggest that prefirst-cigarette affect may impact the subjective effects from the 1st cigarette of the day and that the association between prefirst-cigarette affect and NA relief effects may be dampened in women with greater average precigarette NA. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Introduction Prior studies have found heightened negative affect following tobacco abstinence in women compared to men. However, experimental work addressing whether these findings generalize across racial groups is scarce. This study investigated whether race (non-Hispanic White vs. non-Hispanic African American) moderated gender differences in abstinence-induced negative affect and smoking behavior. Methods Data were collected from 2010 to 2017 from two separate laboratory studies investigating experimentally manipulated tobacco abstinence. Following a baseline session, adult daily smokers (≥10 cigarettes/day; women: n = 297, 83.8% non-Hispanic African American; men: n = 492, 86.2% non-Hispanic African American) attended two counterbalanced lab sessions (16 hours abstinent vs. non-abstinent) and completed self-report measures of negative affect followed by a laboratory analogue smoking reinstatement task. Results We found a gender × race interaction for several negative affect states and composite negative affect (βs = −.12 to −.16, Ps < .05). Analyses stratified by race showed that non-Hispanic White women compared to non-Hispanic White men exhibited greater abstinence-induced increases in anger, anxiety, and composite negative affect (βs = −.20 to −.29, Ps < .05). No significant gender differences in abstinence-induced negative affect were found for non-Hispanic African American smokers (βs = .00 to − .04, Ps > .05). Conclusion These findings suggest that negative affect during acute tobacco abstinence may be a clinically important and intervenable factor that can inform cessation interventions specifically for non-Hispanic White women smokers. Further empirical exploration of mechanisms underlying interactions of gender and race in tobacco addiction may benefit smoking cessation efforts in non-Hispanic African American women smokers. Implications This study contributes to a scant body of research examining the intersectional influence of race and gender on abstinence-induced negative affect—a central, motivationally prepotent feature of tobacco withdrawal. Using a laboratory-based design to experimentally manipulate abstinence, we provide evidence of a gender × race interaction on negative affect–related withdrawal. Our findings suggest that gender differences in abstinence-induced negative affect observed among non-Hispanic White smokers may not generalize to non-Hispanic African American smokers, highlighting the need for future work to address potential mechanisms underlying the racially discrepant impact of gender on affective tobacco withdrawal.

Modeling intra-individual fluctuations in estradiol and progesterone may provide unique insight into the effects of ovarian hormones on the etiology and treatment of nicotine dependence. This randomized placebo-controlled laboratory study tested the independent and interactive effects of intra-individual ovarian hormone variation and nicotine on suppression of tobacco withdrawal symptoms and smoking behavior. Female smokers randomized to 21 mg nicotine (TNP; n=37) or placebo (PBO; n=43) transdermal patch following overnight abstinence completed three sessions occurring during hormonally distinct menstrual cycle phases. At each session, participants provided saliva for hormone assays and completed repeated self-report measures (ie, tobacco withdrawal symptoms, smoking urge, and negative affect (NA)) followed by an analog smoking reinstatement task for which participants could earn money to delay smoking and subsequently purchase cigarettes to smoke. Higher (vs lower) progesterone levels were associated with greater reductions in NA. Higher (vs lower) progesterone levels and progesterone to estradiol ratios were associated with reducing smoking urges over time to a greater extent with TNP compared to PBO. There was an interaction between Patch and estradiol on NA. With TNP, higher-than-usual estradiol was associated with greater decreases in NA. However with PBO, lower-than-usual estradiol was associated with greater decreases in NA. These results suggest that the effects of TNP on mood- and smoking-related outcomes may vary depending on the ovarian hormone levels.

Author(s): Liautaud, Madalyn M; Leventhal, Adam M; Pang, Raina D | Abstract: Introduction:African American (AA) smokers are at disproportionate risk of tobacco dependence, utilizing smoking to regulate stress, and poor cessation outcomes. Positive emotional traits may function as coping factors that buffer the extent to which dependence increases vulnerability to adverse responses to acute tobacco abstinence (ie, tobacco withdrawal). This laboratory study examined subjective happiness (SH; dispositional orientation towards frequent and intense positive affect [PA] and life satisfaction) as a moderator of the relation between tobacco dependence and subjective and behavioral abstinence effects among AA smokers. Methods:AA smokers (N = 420, 39.0% female) completed self-report measures of tobacco dependence and SH followed by two counterbalanced experimental sessions (nonabstinent vs. 16-hour abstinent) involving self-report measures of composite withdrawal, urge to smoke, and mood, and a behavioral smoking task in which participants could: (1) earn money to delay smoking reinstatement, and (2) subsequently purchase cigarettes to smoke. Results:Tobacco dependence was positively associated with increased abstinence effects in composite withdrawal, urge to smoke, PA, and latency to smoking reinstatement (ps l .04). SH significantly moderated the relation between dependence and abstinence-induced increases in composite withdrawal (β = -.17, p l .001), such that the predictive power of dependence on withdrawal severity grew proportionately weaker as levels of SH increased. Conclusions:SH may insulate against adverse effects of dependence on withdrawal during acute smoking abstinence, particularly withdrawal symptom clusters that are craving- and mood-based. Consideration of positive emotional traits as stress-coping factors in the dependence-withdrawal link may be warranted in research and practice with AA smokers. Implications:The current study contributes to a growing body of literature examining the potentially advantageous role of positive emotional traits to smokers. We do so by identifying a relatively understudied psychological construct within tobacco research-subjective happiness-that may suppress the extent to which more severe tobacco dependence increases risk for subjective withdrawal-related distress during acute smoking abstinence in AA smokers. In doing so, the study provides a primer for future targeting of subjective happiness and other positive emotional traits as means to understand and treat acute tobacco abstinence effects among dependent AA smokers.

Objectives There is a paucity of information on environmental risk factors for prostate cancer. We conducted a case–control study in Montreal to estimate associations with exposure to ground-level nitrogen dioxide (NO 2 ), a marker for traffic-related air pollution. Methods Cases were 803 men with incident prostate cancer, ≤75 years of age, and diagnosed across all French hospitals in Montreal. Concurrently, 969 controls were drawn from electoral lists of French-speaking individuals residing in the same electoral districts as the cases and frequency-matched by age. Concentrations of NO 2 were measured across Montreal in 2005–2006. We developed a land use regression model to predict concentrations of NO 2 across Montreal for 2006. These estimates were back-extrapolated to 1996. Estimates were linked to residential addresses at the time of diagnosis or interview. Unconditional logistic regression was used, adjusting for potential confounding variables. Results For each increase of 5 parts per billion of NO 2 , as estimated from the original land use regression model in 2006, the OR 5ppb adjusted for personal factors was 1.44 (95% CI 1.21 to 1.73). Adding in contextual factors attenuated the OR 5ppb to 1.27 (95% CI 1.03 to 1.58). One method for back-extrapolating concentrations of NO 2 to 1996 (about 10 years before the index date) gave the following OR 5ppb : 1.41 (95% CI 1.24 to 1.62) when personal factors were included, and 1.30 (95% CI 1.11 to 1.52) when contextual factors were added. Conclusions Exposure to ambient concentrations of NO 2 at the current address was associated with an increased risk of prostate cancer. This novel finding requires replication.

Syphilis reemerged in Martinique in 2004 and initially affected 3 HIV-infected patients. By March 2008, syphilis was diagnosed for 37 men and 18 women. As of October 31, 2009, this outbreak had not yet been brought under control. It initially affected mainly men who had sex with men before it spread to heterosexual persons, minority group members, and crack cocaine users.

Objective: To describe physical symptoms in those local residents, local workers, and cleanup workers who were enrolled in a treatment program and had reported symptoms and exposure to the dust, gas, and fumes released with the destruction of the World Trade Center (WTC) on September 11, 2001. Methods: Symptomatic individuals underwent standardized evaluation and subsequent treatment. Results: One thousand eight hundred ninety-eight individuals participated in the WTC Environmental Health Center between September 2005 and May 2008. Upper and lower respiratory symptoms that began after September 11, 2001 and persisted at the time of examination were common in each exposure population. Many (31%) had spirometry measurements below the lower limit of normal. Conclusions: Residents and local workers as well as those with work-associated exposure to WTC dust have new and persistent respiratory symptoms with lung function abnormalities 5 or more years after the WTC destruction.

In Martinique, among 9 HIV carriers recently diagnosed with early syphilis, 7 had biologic cholestasis. Less than half of the patients had been diagnosed on clinical grounds for syphilis (cutaneous eruption or syphilis in partner), whereas most of them were diagnosed on a systematic screening of HIV infected patients.

International audience; We report the first case of visceral leishmaniasis (VL) caused by Leishmania martiniquensis in the Caribbean, which until now, was known only to cause cutaneous leishmaniasis. The disease presented with fatigue, anemia, and hepatosplenomegaly in a 61-year-old man with human immunodeficiency virus (HIV) infection who was receiving antiretroviral therapy. Diagnosis was made by bone marrow biopsy. VL is life-threatening, and its emergence in the Caribbean is of concern.

Background: HIV voluntary counseling and testing (VCT) may be an effective strategy to prevent transmission of HIV in developing countries. Hypothesizing that primary care services and HIV VCT have synergistic benefits, we examine the feasibility, the demand, and the effect of integrating on-site primary care services into VCT at a stand-alone VCT center in Port an Prince, Haiti. Methods: Through a retrospective review of patient records, we describe the integration of primary care services at the Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) VCT center between 1985 and 2000. Results: Between 1985 and 1999, services for HIV care, tuberculosis care, treatment of sexually transmitted diseases, and reproductive health were sequentially integrated into HIV VCT at GHESKIO. The number of new people seeking voluntary counseling and testing at GHESKIO increased from 142 in 1985 to 8175 in 1999, with an increasing percentage of women, adolescents, symptom-free clients, and self-referred clients. Of new adults seeking VCT in 1999, the center was able to provide AIDS care to 17%, tuberculosis treatment to 6%, sexually transmitted infection management to 18%, and family planning to 19%. HIV transmission between discordant couples was 0 infection%s/100 follow-up years (95% CI, 0-3.2); vertical transmission from mother to child was I 1 infections/100 live births (95% CI, 4.6-21.9); These rates are significantly lower than expected rates of transmission in Haiti. Conclusions: This report demonstrates the feasibility, demand, and effective synergy of integrating on-site primary care services into HIV VCT in Haiti. VCT is a good entry point for people in need of services for communicable diseases and reproductive health, and, reciprocally, services attract more people to VCT, including populations that are at high risk for HIV infection. This program is being duplicated elsewhere in Haiti and can serve as a model for other countries.

International audience; A cluster of 21 cases of watery diarrhea suspected to be cholera that involved French military policemen and young volunteers occurring in the context of the Haiti cholera outbreak is described. The attack rate (AR) was higher among young volunteers (71.4%) than among policemen (15.3%) (p < 0.0001). There was a significant association between raw vegetables consumption and watery diarrhea in the young volunteer group. If we consider the raw vegetables consumers only, AR was lower among doxycycline-exposed subjects (relative risk: 0.2; 95% confidence interval: 0.1–0.4). The main aspect that is of scientific interest is the potential prophylactic effect of doxycycline used for malaria prophylaxis on the watery diarrhea AR.

The development of evidence-based mental health interventions for refugees is complicated by the cultural and linguistic diversity of the participants, and the need to balance treatment of past traumatic experiences with ongoing support during the process of acculturation. In an effort to gather "practice-based evidence" from existing mental health services for refugees, a collaborative study of International Family, Adult, and Child Enhancement Services (FACES), a comprehensive, community-based mental health program working with refugee children, was conducted to describe the program participants and service delivery model and to assess whether participants improved over time as a function of services. Results showed that participants improved, but that the improvement was not related to dosage of services. Implications of these findings for refugee mental health services are discussed and suggestions are made for future evaluation research of mental health services with refugees.

Rationale Following collapse of the World Trade Center (WTC), individuals reported new-onset respiratory symptoms. Despite symptoms, spirometry often revealed normal airway function. However, bronchial wall thickening and air trapping were seen radiographically in some subjects. We hypothesized that symptomatic individuals following exposure to WTC dust may have functional abnormalities in distal airways not detectable with routine spirometry. Methods One hundred seventy-four subjects with respiratory symptoms and normal spirometry results were evaluated. Impedance oscillometry (IOS) was performed to determine resistance at 5 Hz, 5 to 20 Hz, and reactance area. Forty-three subjects were also tested for frequency dependence of compliance (FDC). Testing was repeated after bronchodilation. Results Predominant symptoms included cough (67%) and dyspnea (65%). Despite normal spirometry results, mean resistance at 5 Hz, 5 to 20 Hz, and reactance area were elevated (4.36 ± 0.12 cm H 2 O/L/s, 0.86 ± 0.05 cm H 2 O/L/s, and 6.12 ± 0.50 cm H 2 O/L, respectively) [mean ± SE]. Resistance and reactance normalized after bronchodilation. FDC was present in 37 of 43 individuals with improvement after bronchodilation. Conclusions Symptomatic individuals with presumed WTC dust/fume exposure and normal spirometry results displayed airway dysfunction based on the following: (1) elevated airway resistance and frequency dependence of resistance determined by IOS; (2) heterogeneity of distal airway function demonstrated by elevated reactance area on oscillometry and FDC; and (3) reversibility of these functional abnormalities to or toward normal following administration of a bronchodilator. Since spirometry results were normal in all subjects, these abnormalities likely reflect dysfunction in airways more distal to those evaluated by spirometry. Examination of distal airway function when spirometry results are normal may be important in the evaluation of subjects exposed to occupational and environmental hazards. Clinical trials registration number NCT00395330. http://www.clinicaltrials.gov .

Contamination by water-born infectious diseases is closely linked to urban slums conditions such as overcrowding and high level of faecal pollution by animal and human excreta. In this environment, cryptosporidiosis is a major cause of acute diarrhoea in children and chronic persistent diarrhoea in AIDS patients, resulting in increased morbidity and mortality in both populations. The aims of this study conducted in Port-au-Prince, Haiti were to: (i) determine the frequency of Cryptosporidium infection in two populations of patients with diarrhoea, children and AIDS patients, and the existence of Cryptosporidium carriage in healthy adults living in close contact with them; (ii) identify by molecular genotyping the Cryptosporidium species involved; and (iii) evaluate the viability of Cryptosporidium oocysts isolated from human stools. From January 2000 to January 2001, 158 of 1529 diarrhoea stool samples collected from 93 patients with diarrhoea, 57 adults followed at Centres GHESKIO and 36 children admitted at the University Hospital in Port-au-Prince contained Cryptosporidium oocysts (10.3%). The majority of adult patients (98%) were HIV-infected whereas the majority of children (81%) tested negative for HIV. Cryptosporidium was documented in only 1/102 healthy persons living in contact with Cryptosporidium infected patients and infection was with the same genotype as that of the contact patient. Among the 69 Cryptosporidium isolates studied for genotyping, three species were identified: C. hominis (59%), C. parvum (38%) and C. felis (3%). The two C. felis cases are the first reported from AIDS patients in the Caribbean. Most of the children regardless of their HIV status were infected with C. hominis (72%), whereas AIDS patients were more likely to be infected by either human or animal genotypes. These data confirm that immunocompromised individuals are susceptible to a wide range of Cryptosporidium spp. Viability of Cryptosporidium oocysts were determined in an experimental mouse model for 17/18 specimen studied including in 12/13 C. hominis, 4/4 C. parvum and 1/1 C. felis. Infectivity in newborn mice was found to be dose-dependent and more effective with C. parvum than the other two genotypes. Cryptosporidiosis remains a frequent hazard for both AIDS patients and young children in Haiti because of poor hygiene, particularly contaminated water and overcrowded conditions associated with urban slums.

We investigated a phase III randomized trial to compare efficacy and tolerance of CDDP + 5-FU to CDDP + VP16, both given intravenously in patients with unresectable advanced head and neck cancer. The 197 eligible patients were paired off successively on the basis of tumor sites and UICC stage. Comparisons were made through sequential closed plans. In 179 patients, tumor beds and cervical lymph nodes were irradiated, and 20 patients underwent salvage surgical procedures. Cisplatin plus 5-fluorouracil showed a response (CR + PR) rate of 15% greater than that observed with cisplatin plus etoposide (alpha=0.05, power 70%). Complete responses played a major role in the CDDP + 5-FU regimen. Furthermore, we noted a higher cervical node regression with this chemotherapy combination. Because radiotherapy was administered after chemotherapy, we could not analyze the mean duration response for each protocol. No significant difference in survival existed between the two groups. Myelosuppression was the most frequent sign of toxicity observed, especially with the CDDP + VP16 regimen. Mucositis was rare with allopurinol protection. In the CDDP + 5-FU group, one patient had grade 4 cardiac dysfunction, and 3 patients exhibited unconsciousness that may be related to cerebral vascular damage. Thirteen patients died, with 8 cases related to septic shock (5 CPPP + VP16 and 3 CDDP + 5-FU). Cisplatin plus 5-FU chemotherapy showed a satisfactory efficacy and acceptable toxicity profile compared with CDDP + VP16, with caution to patients with a cardiac or vascular history. Although we could not show a benefit in survival with the CDDP + 5-FU protocol, this trial supports literature data and confirms that this regimen may be proposed as a first-line therapy in advanced cancer of the head and neck.

The prospects for antiretroviral therapy in resource-poor settings have changed recently and considerably with the availability of generic drugs, the drastic price reduction of brand-name drugs, and the simplification of treatment. However, such cost reductions, although allowing the implementation of large-scale donor programs, have yet to render treatment accessible and possible in the general population. Successfully providing HIV treatment in high-prevalence/high-caseload countries may require that we redefine the problem as a public health mass therapy program rather than a multiplication of clinical situations. The public health goal cannot simply be the reduction of morbidity and mortality for those treated but must be the reduction in morbidity and mortality for the many, that is, at a population level.

AIDS is inexorably involving all parts of the country and all strata of society with 10% of the urban and 3% of the rural population infected with HIV. It is increasingly a disease of women and children. The major cofactors for transmission are also sexually transmitted. For most developing countries in spite of all education efforts the "silent epidemic" of AIDS continues. AIDS is known but not understood: counseling modifies behavior in only 10-20% of at-risk persons. Under optimal conditions HIV discordant females have seroconversion rates of 4.7%/per year and pregnancy rates of 10.4%/per year. The recent political unrest in Zaire and Haiti will further enhance the spread of AIDS in these countries. Despite these difficult periods the work can and must continue. After all during the authors 10th year of collaboration with a Haitian private research group the Haitian government and Cornell University Haiti had known 7 different political rulers. Finally the author wants to make a pledge on behalf of the millions of people who face a certain death from HIV infection and AIDS and who will never make the front page of any newspaper. For these people one can make a difference. The author requests the tools to carry on the fight. The clinical trials must be done where they are most needed: the developing countries. Vaccines represent the only viable alternative despite the recognized obstacles of viral heterogeneity immunogenicity and delivery. (authors)

This retrospective study concerning patients with a carcinomatous meningitis (CM) associated with solid tumour aimed at identifying risk markers of CM which could be used in the future in order to prevent from this neurological complication. From 1976 to 1996, the patients whose CSF sampling was positive cytologically, were registered recording base-line clinical data, tumour histology with grade, tumour dissemination, treatments and follow-up, Simultaneously to the recruitment of the patients the incidence of CM was derived at each 5-year period. The variables were analysed by uni- and multivariate statistics. Among the 41 cases, the first three sites of the primary were breast, lung, essentially small cell lung cancer, and urinary tumours. At their initial presentation, 22 patients revealed an M1 dissemination and 22 tumours were undifferentiated Over the 20 years, the incidence of CM has significantly increased for urinary cancers, decreased for breast cancer while the administration of neoadjuvant chemotherapy was increasing, and remained unchanged for lung cancer. M1 and/or undifferentiated tumours shortened the time-to-CM whereas bone metastases, that were the most frequent site for secondary deposits, did not. Breast, lung and urinary cancers produced 80% of the CM in the series. Neoadjuvant chemotherapy possibly could save patients from the meningeal dissemination. M1 and undifferentiated tumours appeared to be independent risk factors, as well as osseous metastases. Other risk factors of CM should be identified in prospective trials.

This letter presents a study conducted in Port-au-Price Haiti on the seroprevalence of HIV in patients referred for sexually transmitted disease (STD) and the HIV seroconversion rate in those who returned with new signs and symptoms of STDs after treatment for initial infection.

The WHO grading system for breast cancer is based on the subjective, poorly reproducible evaluation of two cytological criteria (Mitotic Activity: MA and Nuclear Pleiomorphism: NP) and one histological criterion (Tubular Differentiation: TD). In order to improve the reproducibility of the assessment of tumour differentiation, we have looked for nuclear cytophotometric parameters (densitometry, geometry and texture) that could be measured objectively on smears stained by the Feulgen method. Tumour cell populations from 36 breast cancers were investigated by nuclear image analysis according to NP scores, MA scores, TD scores ( ie for each variable, three categories), WHO total scores (3 to 9 or 7 categories) and WHO grades (grade 1: 13 patients, whereas 13 and 10 for grade II and III respectively). Discrimination between each score or grade could be displayed by the average profiles of the nuclear cytophotometric parameters provided by multivariate analysis. Discrimination between TD scores was based on two parameters of nuclear texture. All these data suggest that WHO grading could be obtained in an objective manner by nuclear image analysis.

During July 1983 to December 1984, we observed that 62 (46%) of 134 Haitian patients with acquired immunodeficiency syndrome had intensely pruritic eruptions for which neither specific causative nor categoric diagnoses could be established. These lesions were a presenting manifestation of acquired immunodeficiency syndrome in 79% of the patients and appeared a mean of 8 months before the diagnosis of either Kaposi's sarcoma or opportunistic infection. Lesions included erythematous round macules, papules, or nodules that first appeared on the extensor surface of the arms, but subsequently involved the legs, trunk, and face. Histologically, the lesions were characterized by varying degrees of mixed (predominantly eosinophilic) perivascular and perifollicular inflammatory cell infiltrates of the dermis. The lesions did not respond to any therapeutic regimens used and usually persisted throughout the acquired immunodeficiency syndrome illness. Demographic and laboratory data did not distinguish these patients from those without pruritic skin lesions.

A total of 121 acquired immunodeficiency syndrome (AIDS) patients diagnosed in Haiti were studied between June 1979 and December 1983. Risk factors were identified in 65% of 34 patients evaluated in a standardized manner since July 1983 and included: bisexuality, 38%; blood transfusion, 21%; and intravenous drug abuse or a spouse with AIDS, 6%. These risk factors were reported by only 20% of the 85 patients studied between June 1979 and June 1983. AIDS patients also reported more frequent parenteral injections prior to the onset of their illness than control subjects (e.g., siblings, friends, sexual partners). Heterosexual activity among female AIDS patients was also greater than in their female controls. It was concluded that, in contrast to the experience reported among Haitians with AIDS in the USA, risk factors are present among most patients with AIDS in Haiti.

To identify the characteristics of the acquired immunodeficiency syndrome (AIDS) as it occurs in Haiti, we studied 61 previously healthy Haitians who had diagnoses of either Kaposi's sarcoma (15), opportunistic infections (45), or both (1) established in Haiti between June 1979 and October 1982. The first cases of Kaposi's sarcoma and opportunistic infections in Haiti were recognized in 1978-1979, a period that coincides with the earliest reports of AIDS in the United States. We do not believe that AIDS existed in Haiti before this period. The types of opportunistic infections and the clinical course in Haitians with Kaposi's sarcoma and opportunistic infections were similar in most aspects to those in patients with AIDS in the United States. The median age of Haitians with Kaposi's sarcoma and opportunistic infections was 32 years, and 85 per cent were men. The interval between diagnosis and death was six months in 80 per cent of the patients. Diarrhea was the most common reason for seeking medical attention in patients with opportunistic infections. Lymphopenia and skin-test anergy were observed in 86 and 100 per cent of patients, respectively. Potential risk factors (bisexual activity or blood transfusions) were identified in 17 per cent of male and 22 per cent of female patients. Demographic information suggests that patients belonged to all socioeconomic strata of Haitian society.

Cotrimoxazole (trimethoprim/sulfamethoxazole [TMP-SMX]) is an alternative treatment for toxoplasmic encephalitis because it is inexpensive, well-tolerated, and as effective as pyrimethamine-sulfadiazine, which is the first-line drug regimen). We report results of a large cohort study of patients with acquired immunodeficiency syndrome who were treated for toxoplasmic encephalitis with cotrimoxazole. The mean follow-up period was more than three years. Our results confirm that cotrimoxazole is effective (85.5%), with a relatively low incidence of side effects (22%; 7.4% requiring treatment interruption). Relapse occurred in 30.1% of the patients at a mean +/- SD of 7.8 +/- 16.2 months after the first episode. The only risk factor for relapse was poor treatment and/or prophylaxis adherence. Mortality was significantly higher (P < 0.05) before 1996 than after 1996 (the era of highly active antiretroviral therapy). There was a non-significant trend towards a higher rate of relapse among patients treated before 1996 (P = 0.06). Consequently, cotrimoxazole could be a first-line drug regimen for curative treatment and prophylaxis of toxoplasmic encephalitis.

Two hundred twenty-nine patients in Haiti with the acquired immunodeficiency syndrome were studied between 1979 and 1984. The clinical spectrum of the syndrome in Haitians was similar in most aspects to that in patients with the disease in the United States. However, in contrast to findings in the United States, accepted risk factors (bisexuality, blood transfusions, intravenous drug abuse) were identified in only 43% of Haitian patients. Patients in Haiti with and without these risk factors were similar to each other but differed from age- and sex-matched siblings and friends in the number of heterosexual contacts and receipt of intramuscular injections. These latter activities were commoner in patients than in their siblings and friends, and represent potential modes of transmission of infection with the human T-lymphotropic virus type III.