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In order to switch from IS6110 and polymorphic GC-rich repetitive sequence (PGRS) restriction fragment length polymorphism (RFLP) to 24-locus variable-number tandem-repeat (VNTR) typing of Mycobacterium tuberculosis complex isolates in the national tuberculosis control program in The Netherlands, a detailed evaluation on discriminatory power and agreement with findings in a cluster investigation was performed on 3,975 tuberculosis cases during the period of 2004 to 2008. The level of discrimination of the two typing methods did not differ substantially: RFLP typing yielded 2,733 distinct patterns compared to 2,607 in VNTR typing. The global concordance, defined as isolates labeled unique or identically distributed in clusters by both methods, amounted to 78.5% (n = 3,123). Of the remaining 855 cases, 12% (n = 479) of the cases were clustered only by VNTR, 7.7% (n = 305) only by RFLP typing, and 1.8% (n = 71) revealed different cluster compositions in the two approaches. A cluster investigation was performed for 87% (n = 1,462) of the cases clustered by RFLP. For the 740 cases with confirmed or presumed epidemiological links, 92% were concordant with VNTR typing. In contrast, only 64% of the 722 cases without an epidemiological link but clustered by RFLP typing were also clustered by VNTR typing. We conclude that VNTR typing has a discriminatory power equal to IS6110 RFLP typing but is in better agreement with findings in a cluster investigation performed on an RFLP-clustering-based cluster investigation. Both aspects make VNTR typing a suitable method for tuberculosis surveillance systems.

The paper is aimed at presenting the development of the Czech historiography of psychology, which was strongly influenced by the political changes in Central and Eastern Europe. The authors deal with the historiography of psychology at the three universities offering an undergraduate program in psychology, located in Prague, Brno, and Olomouc, and at the Institute of Psychology of the Czech Academy of Sciences. Recent research, teaching, textbooks, and journal articles published in Czech and in foreign languages are showcased. The historiography of Czech psychotherapy is mentioned as a special thematic development. Contemporary problems and perspectives in the field of the history of psychology in the Czech Republic are discussed, sources of information are given.

Setting: The Rotterdam region, the Netherlands, 1995-2006., Objective: To identify factors associated with the high tuberculosis (TB) case rate in an urban area., Design: Municipalities were divided into urban and semi-urban/rural municipalities. We compared the characteristics of TB cases and stratified case rates according to age group, immigrant status and place and time of infection between the two areas., Results: The TB case rate in urban municipalities was 3.8-fold higher than in semi-urban/rural municipalities. After stratification for country of birth, the rate ratios were lower (1.7 for immigrants and 2.8 for non-immigrants). Immigrants had most frequently acquired their infection abroad (47% of urban and 62% of semi-urban/rural immigrant cases). In 40% of urban cases and 27% of semi-urban/rural cases, the infection was recently acquired in the Netherlands, translating into a 5.7-fold higher recent transmission case rate for the urban population., Conclusions: The high urban TB case rate was related to the high proportion of urban immigrants who frequently reactivated an infection acquired abroad. Recent transmission also contributed to a substantial part of the TB caseload in urban municipalities among both urban immigrants and non-immigrants. The authors propose a package of targeted interventions to address the identified factors associated with the high urban TB case rate.

We conducted a population-based study in the Rotterdam region of The Netherlands to determine the place and time of infection of tuberculosis (TB) cases using conventional epidemiological and genotyping information. In particular, we focused on the extent of misclassification if genotyping was not combined with epidemiological information. Cases were divided into those with a unique mycobacterial DNA fingerprint, a clustering fingerprint, and an unknown fingerprint. We developed transmission classification trees for each category to determine whether patients were infected in a foreign country or recently (2 years) infected in The Netherlands. Of all TB cases during the 12-year study period, 38% were infected in a foreign country, 36% resulted from recent transmission in The Netherlands, and 18% resulted from remote infection in The Netherlands, while in the remaining cases (9%) either the time or place of infection could not be determined. The conventional epidemiological data suggested that at least 29% of clustered cases were not part of recent chains of transmission. Cases with unknown fingerprints, almost all culture negative, relatively frequently had confirmed epidemiological links with a recent pulmonary TB case in The Netherlands and were more often identified by contact tracing. Our findings highlight the idea that genotyping should be combined with conventional epidemiological investigation to establish the place and time of infection of TB cases as accurately as possible. A standardized way of classifying TB into recently, remotely, and foreign-acquired disease provides indicators for surveillance and TB control program performance that can be used to decide on interventions and allocation of resources.

Human immunodeficiency virus (HIV) infection poses one of the greatest challenges to tuberculosis (TB) control, with TB killing more people with HIV infection than any other condition. The standards in this chapter cover provider-initiated HIV counselling and testing and the care of HIV-infected patients with TB. All TB patients who have not previously been diagnosed with HIV infection should be encouraged to have an HIV test. Failing to do so is to deny people access to the care and treatment they might need, especially in the context of the wider availability of treatments that prevent infections associated with HIV. A clearly defined plan of care for those found to be co-infected with TB and HIV should be in place, with procedures to ensure that the patient has access to this care before offering routine testing for HIV in persons with TB. It is acknowledged that people caring for TB patients should ensure that those who are HIV-positive are transferred for the appropriate ongoing care once their TB treatment has been completed. In some cases, referral for specialised HIV-related treatment and care may be necessary during treatment for TB. The aim of these standards is to enable patients to remain as healthy as possible, whatever their HIV status.

As the patient's treatment progresses, symptoms start to disappear and he or she becomes more familiar with the treatment. The standards in this section focus on the types of elements that need to be considered as the patient progresses from the intensive to the continuation phase of tuberculosis (TB) treatment, leading to less contact with the TB service and a resumption of 'normal' activities. Social and psychological as well as physical factors need to be assessed to plan effective care and treatment for the continuation phase. Treatment for TB takes a minimum of 6 months, during which changes to the regimen and personal changes associated with making a recovery can create barriers to continuation of treatment. Lifestyle and other changes that may occur during 6 months of anybody's life can complicate or be complicated by TB treatment. The patient may move to another location at any point during the course of treatment, in which case it may be necessary to transfer his or her care to another TB management unit. This process needs to be carefully managed to maintain contact with the patient and avoid any break in treatment; this is covered by the third standard in this chapter.

The standards in this chapter focus on maximising the patient's ability to adhere to the treatment prescribed. Many people are extremely shocked when they are told they have TB, some refuse to accept it and others are relieved to find out what is wrong and that treatment is available. The reaction depends on many factors, including cultural beliefs and values, previous experience and knowledge of the disease. Even though TB is more common among vulnerable groups, it can affect anyone and it is important for patients to be able to discuss their concerns in relation to their own individual context. The cure for TB relies on the patient receiving a full, uninterrupted course of treatment, which can only be achieved if the patient and the health service work together. A system needs to be in place to trace patients who miss their appointments for treatment (late patients). The best success will be achieved through the use of flexible, innovative and individualised approaches. The treatment and care the patient has received will inevitably have an impact on his or her willingness to attend in the future. A well-defined system of late patient tracing is mandatory in all situations. However, when the rates are high (above 10%), any tracing system will be useless without also examining the service as a whole.

The standards presented in this section focus on providing physical, social and psychological care for the patient at the point he or she is diagnosed with tuberculosis (TB) and starts treatment. Detailed guidance is included with regard to organising directly observed treatment (DOT) safely and acceptably for both the patient and the management unit. The aim is to give the patient the best possible chance of successfully completing treatment according to a regimen recommended by the World Health Organization. If the health service where the patient is diagnosed cannot offer ongoing treatment and care due to a lack of facilities, overcrowding or inaccessibility, the patient needs to be referred to a designated TB management unit (BMU) elsewhere. The patient may also receive treatment from a facility outside a BMU. However care is organised, it is essential for all patients who are diagnosed with TB to be registered at an appropriate BMU so that their progress can be routinely monitored and programme performance can be assessed. To avoid the risk of losing contact with the patient at any stage of their care, good communication is essential between all parties involved, from the patient him/herself to the person supervising their DOT to the BMU.

The best practice standards set out in chapter 2 of the Best Practice guide focus on the various aspects of identifying an active case of TB and aim to address some of the challenges associated with case detection. The importance of developing a good relationship with the patient from the start, when he or she is often most vulnerable, is emphasised. The first standard focuses on the assessment of someone who might have TB and the second gives detailed guidance about the collection of sputum for diagnosis. The standards are aimed at the health care worker, who assesses the patient when he or she presents at a health care facility and therefore needs to be familiar with the signs, symptoms and risk factors associated with TB. Having suspected TB, the health care worker then needs to ensure that the correct tests are ordered and procedures are followed so that the best quality samples possible are sent to the laboratory and all documentation is filled out clearly and correctly. The successful implementation of these standards can be measured by the accurate and prompt reporting of results, the registration of every case detected and the continued attendance of every patient who needs treatment.

The first two chapters of Best practice for the care of patients with tuberculosis: a guide for low-income countries include an introduction and guidance regarding implementation of best practice. The background to how the guide was developed is significant, as it was developed in collaboration with nurses and other health workers working in the most challenging settings. It therefore provides realistic and practical guidance for best practice where patient loads are large and resources are stretched. Guidance regarding standard setting and clinical audit is an important part of enabling people to recognise the strengths that already exist in their practice and approach those areas that require change in a systematic and practical way. The guide itself consists of a series of standards covering different aspects of patient care, from the moment they seek health care with symptoms to their diagnosis to early stages of treatment, directly observed treatment, the continuation phase and transfer of treatment. There are also standards relating specifically to HIV testing and the care of patients co-infected with tuberculosis and HIV. The standards themselves will appear in full in the subsequent chapters of this series.

Setting: The Netherlands, 1995-2000., Objectives: To describe the contribution of 6 years of nationwide DNA fingerprint surveillance to tuberculosis control in general and to conventional contact investigations in particular., Design: All Mycobacterium tuberculosis cultures are subjected to standardised IS6110-based RFLP typing, and clustered cases are systematically reported to the regional TB services involved (cluster feedback). Standardised questionnaires are used to collect information on contact investigations and epidemiological links (epi links) at regional level. Revision of the questionnaires for the period 1997-2000 allows comparison of epi linking before and after cluster feedback., Results: Among 2206 clustered cases, 462 (21%) epi links were expected before the RFLP result, whereas an additional 540 (24%) epi links were established after cluster feedback. Epi links based on documented exposure increased by 35%, from 357 to 550 (P < 0.001). Only 1% of contact investigations were extended, however, and relatively few additional persons with active or latent tuberculosis were diagnosed. Reasons for the limited impact on contact investigation outcome were 1) contact took place 1-7 years previously (51%), 2) documented contact involved a subsequent case in the cluster (21%), 3) casual contact (15.5%) and 4) different region (9%). Five per cent of epi links established by contact investigation were contradicted by RFLP data. Epi links were more frequently documented in Dutch (41%) than non-Dutch cases (19%, OR 3.0; 95%CI 1.41-1.91). Cluster monitoring permitted: 1) identification of transmission chains that could not be detected by contact investigations, 2) development and evaluation of targeted interventions, and 3) identification of professional failures and poor programme performance., Conclusions: RFLP surveillance forms the bridge between conventional contact investigation and other forms of targeted active case finding. Combining both complementary strategies in a comprehensive approach to systematic outbreak monitoring and management allows countries in the elimination phase of the disease to better target and evaluate TB control interventions.

Setting: Surveillance data from the National Tuberculosis Register for the period 1993-1997 complemented with DNA fingerprinting results of Mycobacterium tuberculosis isolates., Objective: To estimate the proportion of disease attributable to recent re-infection among Dutch tuberculosis patients with reported tuberculosis infection or disease before 1981., Design: Data from 1,547 Dutch patients diagnosed between 1994 and 1997 in the Netherlands were studied. Cases with reported tuberculosis infection or disease before 1981 were attributed to reactivation if their M. tuberculosis isolate was unclustered based on DNA fingerprinting or if they were the first case in a cluster, and to re-infection if they were clustered, but not as the first case., Results: In total, 183 Dutch tuberculosis patients (12%) had reported tuberculosis infection or disease before 1981. Tuberculosis in 29 of these patients (16%) was attributed to recent re-infection., Conclusion: In this setting with a low tuberculosis incidence, approximately one in six new disease episodes among patients with previous tuberculosis infection or disease may be attributable to recent re-infection.

Background: The diagnosis of tuberculosis in asylum seekers is followed by contact tracing, which is routinely performed by the Municipal Health Service (MHS). We investigated cases of tuberculosis whose symptoms became apparent after closure of regular contact tracing., Methods: Analysis of data from the DNA Fingerprinting Surveillance Project on all Mycobacterium tuberculosis isolates and contact tracing instances., Results: Four additional cases of tuberculosis were detected, caused by bacteria of identical DNA fingerprints. No further contacts with a bacteriologically confirmed form of tuberculosis were found around these four new patients., Conclusion: DNA fingerprinting contributed to tracing instances of late manifestations of tuberculosis transmission.

In this paper, Jungian and Freudian perspectives on the fantasy of rebirth are explored and a brief review of the literature on the theme is used to show how that the rebirth fantasy seems to be a universal fantasy in the human mind, connected with the experience of both destruction and creation. In the psychoanalytic process the rebirth fantasy is connected with initial hopes for a better life, but is also a vehicle for creating the analytic pair and for separating from the 'totalitarian object'. An account of clinical work with a patient is given to illustrate the mutual and parallel process of rebirth in both the patient and the therapist. For the patient, the therapy was experienced as an awakening or a birth. The therapist was initially doubtful about the patient's capacity to engage in the analytic process but his involvement and interest were 'born' during the early sessions, enabling the patient to rely on him to lead her out of the claustrophobic power of the totalitarian object.

To disclose risk factors for active tuberculosis transmission in the Netherlands, restriction fragment length polymorphism (RFLP) patterns of 78% of the Mycobacterium tuberculosis isolates, from the period 1993-1997, were analyzed. Of the respective 4266 cases, 46% were found in clusters of isolates with identical RFLPs, and 35% were attributed to active transmission. The clustering percentage increased strongly with the number of isolates; taking this into account, fewer cases were clustered than has been reported in other studies. Contact investigations in the five largest clusters of 23-47 patients suggested epidemiological linkage between cases. Of patients identified through contact tracing, 91% were clustered. Demographic risk factors for active transmission of tuberculosis included male sex, urban residence, Dutch and Surinamese nationality, and long-term residence in the Netherlands. Human immunodeficiency virus infection was not an independent risk factor for active transmission. Isoniazid-resistant strains were relatively less frequently clustered, suggesting that these generated fewer secondary cases.

Objective: To determine the frequency distributions of serial interval and incubation period of tuberculosis within 4 years of transmission, and to identify correlates of serial intervals and incubation periods., Methods: DNA fingerprints were obtained for all isolates from all culture-positive patients notified in The Netherlands from 1993 to 1996. Patient information was obtained from the National Tuberculosis Register. Results from contact investigations were provided by public health services. Source cases and secondary cases of tuberculosis were identified, based on 1) identical DNA fingerprints, and 2) epidemiological confirmation of contact. Under-representation of long intervals were corrected for by weighting cases., Results: A total of 69 source-secondary case couples were identified. The geometric mean serial interval was 29.5 weeks (95% confidence interval [CI] 22.8-38.2 weeks) and the geometric mean incubation period 20.8 weeks (95% CI 15.5-27.8 weeks). Serial intervals and incubation periods tended to increase with age (P > 0.05). Three secondary cases with human immunodeficiency virus infection showed very short incubation periods (P > 0.05)., Conclusion: Using a new methodology, the distribution of incubation periods of tuberculosis gave results consistent with earlier studies.

Setting: The Netherlands, May 1994 to May 1996., Objective: 1) To estimate to what extent drug-resistant tuberculosis was acquired or recently transmitted in The Netherlands, 2) to assess the relevance of drug resistance data as routinely collected, and 3) to describe case management., Design: Prospective descriptive study. Patients diagnosed with drug-resistant tuberculosis were interviewed. Information on patient management and contact tracing was collected. IS6110 restriction fragment length polymorphism (RFLP) patterns of all strains were compared with those of the National RFLP library and clusters were analyzed., Results: In total 193 cases were included in the study. Acquired drug resistance (ADR) was rare. Dutch ADR patients reported receiving treatment a long time previously (mean age 58, mean treatment interval 23 years). Most foreign ADR patients had been treated recently in their country of origin. Of 151 primary drug-resistant (PDR) cases, 129 (85%) were foreign-born, of whom few (8%-19%) had been infected in The Netherlands. Few Dutch PDR cases had been infected recently (mean age 49 years). Rifampicin resistance was more frequently observed in foreign ADR cases than in foreign PDR cases (28% vs 5%; P < 0.001). One third of cases had not been treated according to treatment guidelines., Conclusion: Only a small proportion of drug-resistant cases resulted from recent infection or treatment in The Netherlands. General rates of ADR and PDR do not reflect current Dutch programme performance. For programme monitoring, ADR/PDR rates and their trends must be reported and evaluated in Dutch and foreign patients separately.

Nosocomial transmission of multiresistant tuberculosis in the Netherlands is described for the first time in this article. It was detected by systematic country-wide DNA-fingerprinting. By the time the contact case (a man aged 35) developed disease he was residing in another part of the country. Contact-investigation by the Municipal Health Services involved revealed that the (HIV negative) contact case had been in contact with the index case (a man aged 27) during hospitalisation two years earlier. An analysis of the infection control measures applied, showed that inadequate treatment, early discharge from isolation and lack of bacteriological control (no sputum conversion documented) led to this hospital transmission.

In September 1989 50 years have elapsed since the death of one of the most distinguished personalities of science and culture in this century, Sigmund Freud. Although born in Príbor in Moravia, he spent most of his productive life in Vienna. He became the founder and pioneer of psychoanalysis--a therapeutic method of neuroses and the remarkable psychological theory which by its emphasis on unconscious, deep underlying psychic processes caused a great advance of knowledge of man of himself. Nowadays psychoanalysis is used in the world not only as a therapeutic method in neuroses, personality disorders and psychosomatic diseases but is developed further as a theoretical and scientific discipline which in many respects exceeds Freud's basic work. Modern psychoanalytic literature was not published in this country in recent decades and thus those interested in it have little opportunity to become familiar with it. Health authorities in advanced countries accept psychoanalysis and thus also in our conditions a place must be sought for psychoanalysis at least in the system of psychiatric and psychotherapeutic care.