To test the ‘Liverpool Osteoarthritis in Dogs’ (LOAD) questionnaire for construct and criterion validity, and to similarly test the Helsinki Chronic Pain Index (HCPI) and the Canine Brief Pain Inventory (CBPI).Prospective Study.222 dogs with osteoarthritis.Osteoarthritis was diagnosed in a cohort of dogs on the basis of clinical history and orthopedic examination. Force-platform analysis was performed and a “symmetry index” for peak vertical force (PVF) was calculated. Owners completed LOAD, CBPI and HCPI instruments. As a test of construct validity, inter-instrument correlations were calculated. As a test of criterion validity, the correlations between instrument scores and PVF symmetry scores were calculated. Additionally, internal consistency of all instruments was calculated and compared to those previously reported. Factor analysis is reported for the first time for LOAD, and is compared to that previously reported for CBPI and HCPI.Significant moderate correlations were found between all instruments, implying construct validity for all instruments. Significant weak correlations were found between LOAD scores and PVF symmetry index, and between CBPI scores and PVF symmetry index.LOAD is an owner-completed clinical metrology instrument that can be recommended for the measurement of canine osteoarthritis. It is convenient to use, validated and, as demonstrated here for the first time, has a correlation with force-platform data. Osteoarthritis (OA) is estimated to affect approximately 20% of the adult dog population A “construct” is a term borrowed from clinical psychology and refers to any theoretical framework. The construct of OA is complex: that is, the clinical picture of an affected dog will include changes in limb function, ability to perform activities, overall activity, and demeanor, amongst other dimensions. Measurement of ground reaction forces (GRFs) using a force platform, or a pressure sensitive walkway, is generally considered the ‘gold standard’ for quantifying canine limb function In the field of human medicine, the standard methods for assessing chronic pain are validated, patient-completed, clinical metrology instruments (CMIs) The design and testing of metrology instruments is well described Face validity answers the question “Is this instrument measuring what it is designed to measure?” and is usually tested through review by experts in the field, and/or review by the intended audience. Content validity answers the question “Is there anything missing that would add value?” and is also tested via a review process. Construct validity is a test of how well the instrument’s authors’ theorized construct matches the true construct of what is being measured. It can be tested by administering the instrument to groups of known and differing clinical status (e.g. those with OA and those without); by comparing the results of the instrument with those of other, similar measures; and by factor analysis. Criterion validity is a test of how well an instrument correlates with a standard, external measure of the disease. The validity of an instrument also depends on its reliability and its responsiveness. Reliability is a test of how well the instrument returns the same score for a given level of disease. It is also sub-divided into repeatability and internal consistency. Repeatability is examined in a test-retest scenario, over a period when it is assumed there is no change in the underlying level of disease Validity is sub-divided in to four major categories. There are at least six CMIs reported for measuring the severity of OA in dogs Our primary objective was to test LOAD against other similar measures to provide evidence of construct validity, and against the results of force platform analysis to provide evidence of criterion validity. Secondarily, we wished to report factor analysis of LOAD, to repeat factor analysis of CBPI and HCPI, to repeat internal consistency testing for LOAD, CBPI and HCPI, and to test CBPI and HCPI for criterion validity. For dogs for which we had longitudinal data, we also wished to compare changes in instrument scores with changes in activity data, as collected using accelerometer-based monitors.Our hypotheses were that there would be correlation between the three CMIs, and that there would be correlation between the CMIs and the objective measures.The study protocol was approved by the University of Liverpool Research Ethics Committee. A public awareness campaign was run targeting the hinterlands of the University of Liverpool Small Animal Teaching Hospital (SATH) in the Northwest of England, a region with a human population in the region of five million. This included press advertisements and editorials, local radio coverage, poster campaigns, and a letter-drop to previous clients of the SATH’s orthopedic service. Interested pet owners then contacted study personnel and completed a preliminary telephone screening interview. Primary care veterinarians of potential participants were then contacted in writing to request referral for inclusion in the study, in a process approved by the Professional Conduct Department of the Royal College of Veterinary Surgeons. Prospective participants then attended the SATH for a screening visit.At the screening visit, clinical history was collected and a clinical examination was completed by a veterinarian with experience in orthopedics, and recorded in a standardized data-capture form (DCF). For this study, data from two cohorts, one cross sectional and one longitudinal, were used. The longitudinal cohort is a sub-population of the cross-sectional cohort. Inclusion criteria for the cross-sectional cohort were different than those for the longitudinal cohort. Both are summarized in Owners received the instructions, as published for each CMI, before being given ample time in a quiet space to complete the CMIs. For the longitudinal cohort, the same person completed the CMIs at each subsequent assessment.Force-platform analysis was performed in a dedicated canine gait analysis laboratory. This consisted of a force-platform  set in a low-level runway constructed of hard foam. The force platform and runway were covered with the same non-slip surface. Four high-speed, infra-red motion capture cameras  were arranged in an arc around the force platform, creating a calibrated motion capture volume approximately four meters long with the force platform at the center. A digital video camera  was directed at the force platform to record each trial for validation purposes. At each session, dogs were allowed a minimum of five minutes to familiarize with the space, and several “practice” trials were performed. Reflective markers were placed bilaterally at the dorsoventral midpoint of the tenth rib of each dog to facilitate velocity measurement of each trial. For each trial, four seconds of force data, motion capture data, and digital video footage were collected simultaneously. Video footage was examined to confirm satisfactory foot placement and motion data were used to measure forward velocity and acceleration: these were both performed using proprietary software . Force data were analyzed using dedicated software . Dogs were allowed to move at the gait and velocity that was most comfortable for them and which allowed for most consistent foot placement on the force platform. Once this gait and velocity were identified, it was recorded and kept constant for every trial and, for dogs in the longitudinal cohort, for all subsequent sessions.For dogs recruited to the longitudinal study, an accelerometer-based activity monitor (AM)  was attached at the ventral aspect of the collar using nylon cable ties at the end of the screening visit.For each longitudinal-cohort participant, the study began with a fourteen-day “baseline period”. During this time, no NSAID medication was administered. Owners were provided with a supply of veterinary-licensed paracetamol/codeine tablets  to use as “rescue analgesia” if they felt necessary. After this baseline period, participants attended “Visit 1″. At this visit, and all subsequent visits, CMI and force platform data were collected as described above, and activity data were downloaded from the AM. Data collected at this visit were used as the ‘off-treatment’, or baseline, data. At Visit 1, dogs were randomly allocated to receive one of two NSAIDs, both licensed in Europe for the long-term treatment of canine OA. Dogs received the allocated NSAID for the next 12 weeks, administered on-label. Data were collected after six weeks of treatment at “Visit 2″, and at the end of the treatment period at “Visit 3”.R is the PVF for the right limb and PVFL is the PVF for the left limb. If the index joint was an elbow, for example, then the SI for the thoracic limbs was calculated. If the index joint was a hip or stifle (knee), the SI for the pelvic limbs was calculated. Negative values (i.e. produced for right limb lameness) were made positive. Total CMI scores were compared against SI. Further to this, following factor analysis, a LOAD “lameness index” was generated and also compared against SI. Secondarily, criterion validity was tested in the longitudinal cohort by comparing change in CMI scores against change in PVF for the index limb, and against change in activity parameters from the AMs, from Visit 1 (baseline) to Visit 2 (six weeks of treatment). Activity parameters used were total weekly count (TWC), and weekly average counts for four quarters of the day: Q1 = 12 am to 6 am, Q2 = 6 am to 12 pm, Q3 = 12 pm to 6 pm, and Q4 = 6 pm to 12 am.Criterion validity was tested in two ways. Primarily, CMI scores were compared against the left-right symmetry index (SI) for the worst affected limb. Symmetry index for PVF was calculated thus:Construct validity was tested, primarily, by comparing LOAD, CBPI and HCPI scores against each other. Additionally, factor analysis was performed for all CMIs and reported for the first time for LOAD, and was compared against that previously reported for CBPI and HCPI. For factor analysis, data from the cross-sectional cohort was used and a Kaiser-Meyer-Olin measure of sampling adequacy >0.6 was used as an indicator for sampling adequacy. Extracted factors were assessed by Eigenvalue, scree-plot analysis and theoretical interpretability. Item loading on extracted components was based on a varimax-rotated model of the factor analysis, with a communality cut-off value of 0.4.For all comparisons, Spearman’s rank correlation was used and significance was set at p≤0.05 (two-tailed). Internal consistency for all CMIs was tested for the cross-sectional cohort, using Cronbach’sα.It should be noted that CBPI is reported as a three factor CMI, made up of a Pain Severity Score (CBPI PSS), Pain Interference Score (CBPI PIS), and an Overall Quality of Life Score (CBPI QOL). For all analyses except factor analysis, each CBPI factor was tested individually.525 enquiries from interested dog owners were received. 508 telephone interviews were performed, resulting in 362 screening examinations. Of these, 222 dogs met the inclusion criteria for the cross-sectional cohort. Of these dogs, longitudinal data were available for 79 that fulfilled the inclusion criteria for the longitudinal cohort. Demographic data of the cross-sectional cohort are summarized in s = 0.232, p<0.01), CBPI PSS , and CBPI PIS . s = 0.297, p<0.01, n = 224). Kaiser-Meyer-Olin values for factor analyses of LOAD, HCPI and CBPI were 0.83, 0.81 and 0.90 respectively, indicating suitability of data for factor analysis. Here, for the first time, we report evidence of criterion validity for LOAD and CBPI. Criterion validity for LOAD was previously investigated, but not demonstrated, in a small cohort of Labrador retrievers The correlations between LOAD and SI PVF and the CBPI factors and SI PVF were significant but weak. However, left-right asymmetry constitutes only one aspect of impaired limb function. Dogs with bilateral disease, for instance, may have severely impaired function but be relatively symmetrical with respect to load bearing. Diametrically, a dog with severe OA in a single joint but three other healthy limbs might have reasonable mobility overall, but marked asymmetry. Likewise, impaired limb function is only part of the construct that these CMIs aim to capture. Therefore, it is not surprising that correlations are only weak.We chose this symmetry index as our primary criterion variable as it is applicable across all sizes and shapes of dog, across different gaits and velocities, and for thoracic and pelvic limbs. To use simply PVF would mean sub-dividing the cohort by index joint, and normalizing at least to bodyweight, but also arguably to other biometric values. Asymmetry of ground reaction forces has previously been used as a criterion reference for CMI validity testing We also tested for criterion validity by comparing change in CMI scores with change in PVF for the index limb, and with changes in activity as measured using an accelerometer-based AM. No significant correlations were found in these analyses. There were, however, statistically significant correlations between changes in all CMIs. The longitudinal cohort was smaller than the cross-sectional one, and it is possible that the lack of significant correlations is due to insufficient statistical power. It is also possible that NSAID treatment affects different components of the OA construct to different degrees, possibly even differently across individual dogs. Change in PVF will only detect a treatment effect on load-bearing through an individual limb: it may not detect an overall improvement in mobility, and would not detect a change in demeanor or activity. Furthermore, the use of AMs as an outcome measure for canine OA remains exploratory. We decided to use TWC and weekly averages for daily quartiles as our activity parameters as these have been previously reported Construct validity was tested by comparing CMI scores against each other. For the cross-sectional cohort, significant moderate correlations were found between all instruments. These CMIs have been developed in similar ways, but by different authors in different geographical territories. Item selection and reduction has been based on preliminary testing that has occurred on different cohorts of dogs, belonging to owners from different cultural backgrounds. Furthermore, the scaling of items is similar for HCPI and LOAD  but is different for CBPI, which is based on 11-point numerical rating scales. It is likely that each CMI captures different components of the OA construct to variable degrees, therefore correlations are only moderate, and not strong.Construct validity was also explored using factor analysis. Factor analysis is similar to principal component analysis and is performed in the same way. One difference between the two is that factor analysis assumes that there are underlying factors (latent variables) that have causal influence on the observed variables. The aim of factor analysis in construct validation is not necessarily to reduce the data to simplified components for further analysis, but to determine if extracted components can be reasonably explained by the theoretical construct underlying the instrument. Component extraction based on factor analysis is somewhat subjective, although several recommendations are reported. One such recommendation is to extract only components with an Eigenvalue greater than or equal to one Factor analysis of LOAD data extracted 3 components with Eigenvalues >1. Based on the items loading on these components, they could reasonably be identified as 1) an “activity/exercise” component, 2) a “stiffness/lameness” component and 3) an “effect of weather” component.Factor analysis of HCPI data extracted 2 components with eigenvalues >1, but a third, with an eigenvalue of 0.99 was also evaluated. Based on the items loading on these components, they could reasonably be identified as 1) a “willingness to be active/exercise” component, 2) a “stiffness/ease of movement” component and 3) a “painful vocalization” component. These results are very similar to those previously reported Overall, the data presented here demonstrate significant overlap in the theoretical constructs that underpin these three CMIs, and that the components extracted by factor analysis can be reasonably explained by theorized components of the constructs. This is evidence that the constructs on which these CMIs are based are reasonable approximations of what constitutes canine OA in the clinical sense.Correlation of LOAD and CBPI with SI-PVF is the first reported evidence of criterion validity for these CMIs. It is not certain why HCPI did not correlate with SI-PVF, but it may related to the observation that factor analysis did not extract a component that could reasonably described as “lameness” based on the wording of the loading items. CBPI PSS and CBPI PIS had the highest correlation coefficients, and it is reasonable to assume that “pain” as captured by this instrument might correlate with lameness. However, the LOAD “lameness index”, as identified by factor analysis, had a higher correlation coefficient still.Based on these analyses, and those previously published, LOAD can be recommended as a valid measurement tool for canine OA.


Knowledge about the acquisition of “Immunity” to recurrent pathogens is cultural heritage of mankind. The Greek writer Thucydides in 400nowledge . This knnowledge , and latnowledge .When Behring and Kitasato demonstrated the specific protection of rabbits by serum from infected animals in 1890 , it becaThe nature of this reactive memory and its role in “immunity” is a matter of debate even today. The nature of “protective memory” became less controversial recently, since it has been shown in the past 15 years that plasma cells can survive as “memory” plasma cells in the bone marrow, secondary lymphoid organs and inflamed tissues, in dedicated “survival niches” organized by specialized stromal cells –9. This In the first essay, Zehn and colleagues discuss how the original activation of T cells by antigen impacts their activation and development into long-lived cells. Yamane and Paul then provide a look into the T cells themselves, in particular their functional polarization and imprinting, and their developmental plasticity. This is also discussed by Buchholz and colleagues, for CD8+ T cells, in particular with respect to the question whether effector and memory cells are distinct lineages or not?Boyman and colleagues then discuss the maintenance of long-lived T cell and NK cell populations of the periphery by “homeostatic” proliferation, in the apparent absence of antigen. The recently identified memory T helper cells from bone marrow, described by Tokoyoda and Radbruch, are resting in terms of proliferation. While we poorly understand their relation to peripheral effector memory cells, they provide a new model of organization and maintenance of memory by stromal cells. This may be a general principle of organization of memory, since it has recently been shown that also long-lived memory plasma cells are organized by bone marrow stromal cells. In a final view on T cell memory, Goronzy and Weyand draw our attention to the aging memory and its potential for a break of tolerance and induction of autoimmune diseases.The discourse is closed by two provocative essays. Reynaud and colleagues discuss B cell memory, in particular the controversial facet of IgM memory B cells, which are a remarkable population in humans, and not so in mice. This raises the general question of how to model long-lasting memory in short-lived mice. Not to forget the memento of Rolf Zinkernagel, to put memory in its biological context, and to understand it with respect to its protective value, which brings us back to Thucydides.


In this issue of the Journal, Belcastro and associates review terminology and classification issues for migralepsy, hemicrania epileptica, post-ictal and ictal headache . They raMisdiagnosis between epilepsy and migraine is considerable though their differentiation should not be difficult on clinical grounds . The proAccording to the ICHD-II 1.5.5, “migraine-triggered seizure ” denotes an epileptic seizure that occurs “during or within one hour after a migraine aura” . HoweverMigralepsy is an old term derived from migra(ine) and (epi)lepsy, coined by Dr Douglas Davidson, but mainly attributed to Lennox and Lennox, which we quote, “a given seizure may be a composite of symptoms encountered in epilepsy and migraine. Such cases are more common in children than in adults. In our experience, the migraine-like symptoms appear first−the characteristics of ophthalmic migraine with perhaps nausea and vomiting, followed by symptoms−characteristic of epilepsy, impairment or loss of consciousness and involuntary muscle movement. Dr Douglas Davidson calls such hybrid phenomena as ‘migralepsy’” .There should be no reason why epileptic seizures, which are so vulnerable to precipitating factors, could not be susceptible to cortical changes induced by migraine , 3. HoweHeadache as a symptom of an epileptic seizure is well documented in many publications. However, this ictal headache manifests with multiple and diverse symptomatology, such as a sensation of bifrontal pressure, vague ache in the head, sharp stabbing retro-orbital pains or a sensation of electricity passing through the head of varying intensity, discomfort and localisation. These are often cephalic sensations with or without true ache and may occur at the onset or in the progression of a seizure. As a rule, ictal headache is associated with other seizure symptomatology emanating from the affected epileptogenic zone. It may be exceptional to have headache as a sole manifestation of a seizure and this is more unlikely to be consistent in all seizures of the same patient. Ictal headache is unlikely to be confused with migraine though this may be the case in some exceptional patients and circumstances referred to as hemicrania epileptica and status epilepticus migrainosusThe ICHD-II includes ictal headache amongst a broad group of “headache attributed to epileptic seizure” (7.6), which may be ictal, periictal, postictal, interictal or comorbid, without specifying characteristics of these headaches . Of ictaPostictal headache occurs in 10–40% of patients with partial or generalised seizures and may be indistinguishable from migraine particularly if associated with vomiting and photophobia (ICHD-II 7.6.2) . AnotherPostictal headache is particularly common in occipital epilepsy occurring in more than half of patients even after brief simple visual seizures , 3. ThisBased on these findings, it is reasonable to propose that occipital seizures often generate a true migraine attack. This “occipital seizure-migraine” sequence appears to be much commoner than the previously prevailing view of migraine visual aura triggering epileptic seizures , 3.In view of the above uncertainties and the high prevalence of misdiagnosis, there is a need for collaboration between the relevant headache and the epilepsy classification committees to critically re-assess these matters, which are of significant diagnostic, management and pathophysiological importance. Achieving clarity and consensus in this area may be challenging but with the ICHD-III on the horizon, now is the time for this to happen.


They are therefore well suited for studying complex exposures such as diet and traffic emissions. “I think that’s a strength for this study,” Pedersen says.The researchers categorized adduct levels as low, moderate, or high and considered several statistical models for various birth outcomes and numerous confounding factors. Analyses were conducted for the entire study population, by country, and by groupings of southern (Greece and Spain) versus northern  countries.For the entire study population, newborns in the high-adduct group had an average birth weight of 129 g less than newborns in the low-adduct group. The southern countries had, on average, higher adduct levels and lower birth weights than the northern group, but high adduct levels were associated with high, not low, birth weight.  In women with low intakes of fruits and vegetables, there was a stronger association between high adduct levels and low birth weight (an estimated 248-g reduction for high versus low adduct levels) than there was among women with high fruit and vegetable intakes (an estimated 58-g decrease for high versus low adduct levels).Radim J. Šrám, head of the Department of Genetic Ecotoxicology at the Institute of Experimental Medicine AS CR in Czech Republic, who was not involved with the study, says of his own research on PAHs and human health, “According to our experience, you get better information about the quality of fruits and vegetables intake when you measure vitamin C and E in the plasma, than when you calculate it according to the answers in questionnaires.” Pedersen and her colleagues indicate that further study is needed to test and possibly expand on their findings. “I’m already doing the analysis for the next study, and I can see that there are many modifiable factors that we can work on,” says Pedersen.


The re-emergence of tuberculosis (TB) in low-incidence countries and its disproportionate burden on immigrants is a public health concern posing specific social and ethical challenges. This review explores perceptions, knowledge, attitudes and treatment adherence behaviour relating to TB and their social implications as reported in the qualitative literature.Systematic review in four electronic databases. Findings from thirty selected studies extracted, tabulated, compared and synthesized. TB was attributed to many non-exclusive causes including air-born transmission of bacteria, genetics, malnutrition, excessive work, irresponsible lifestyles, casual contact with infected persons or objects; and exposure to low temperatures, dirt, stress and witchcraft. Perceived as curable but potentially lethal and highly contagious, there was confusion around a condition surrounded by fears. A range of economic, legislative, cultural, social and health system barriers could delay treatment seeking. Fears of deportation and having contacts traced could prevent individuals from seeking medical assistance. Once on treatment, family support and “the personal touch” of health providers emerged as key factors facilitating adherence. The concept of latent infection was difficult to comprehend and while TB screening was often seen as a socially responsible act, it could be perceived as discriminatory. Immigration and the infectiousness of TB mutually reinforced each another exacerbating stigma. This was further aggravated by indirect costs such as losing a job, being evicted by a landlord or not being able to attend school.Understanding immigrants’ views of TB and the obstacles that they face when accessing the health system and adhering to a treatment programme-taking into consideration their previous experiences at countries of origin as well as the social, economic and legislative context in which they live at host countries- has an important role and should be considered in the design, evaluation and adaptation of programmes.  Declared a global health emergency by the World Health Organization (WHO) in 1993, tuberculosis (TB) remains an important cause of mortality and morbidity worldwide. In spite of the gradual decline during the 1990s and 2000s, there were around nine million incident cases of TB in 2010, which translates into a global incidence of 128 per 100,000. In the same year, 1.4 million persons died as a result of the disease [Caused by Mycobacterium tuberculosis, TB is an air-borne disease transmitted when a person with the active pulmonary disease coughs, sneezes, speaks or spits. The main symptoms are a persistent cough (sometimes producing blood), fever, sweating, weakness and weight loss. In some cases, TB can affect other organs. Although it is estimated that one third of the world’s population might be infected with TB, not all infected individuals develop the disease. For many years, the infection can remain latent, asymptomatic and non-infectious. However, the infection can reactivate at any time and this occurs in up to 10% of cases. Clinically suspected TB is mainly confirmed with a chest X-ray and the identification of the bacterium in blood/sputum samples. A cutaneous Tuberculin test can also be used for diagnose . TreatmeThe re-emergence of TB in low-prevalence industrialized countries is a public health challenge. Multiple antibiotic resistance and TB’s interaction with HIV/AIDS are however only part of this ; TB is sMultiple socio-economic, cultural, environment and political factors underpin the recent increases in human migration that have contributed to changes in patterns of TB infection . Indeed,In industrialized low-incidence countries with high levels of immigration from less-developed countries, the basic TB control strategy consists of minimizing transmission through identifying and curing a high proportion of cases . The fundamental elements of this strategy are: a) early TB detection, mainly in most vulnerable groups; b) adequate treatment adherence for active infections; and c) in certain circumstances, detection and prophylactic treatment of latent asymptomatic infections –11. There are notable differences between countries with regard to their TB screening programmes for immigrants, in terms of screening location, the programmes’ administrative and financial autonomy and the procedures followed. In general, because of the ease with which at-risk groups can be reached, migrants are screened on arrival or during the processing of temporary residence applications in the host country. In some instances, for diagnosis and to complete treatment over several months, referrals to specialized clinics are given. However, patients can be repatriated or deported prior to completing treatment. Many treatment programmes involve Directly Observed Treatment (DOT) policies, by specially trained health personal, which seeks to ensure that patients follow the necessary treatment regimen. Although often unnoticed, reactivation of latent infection is common amongst immigrants and is responsible for many of the TB cases that occur up to several years after arrival in the host country . An asymIn general, screening for latent TB is only cost-effective amongst particularly vulnerable groups, such as immuno-compromised individuals or those who have had recent contact with an active TB infection . In spitMigrants’ social, legal and economic circumstances can have a detrimental effect on TB’s disease progression, its diagnosis and treatment. However, TB can also exacerbate many of these factors. Although migration is a highly heterogeneous process, it is often highly stressful  and the Currently, TB control and treatment programmes in low-incidence countries that host large numbers of migrants face challenges brought about by changing patterns of TB. The general aim of this review is to explore immigrants’ perceptions of TB and TB control programmes. Understanding these perceptions has an important role to play in evaluating and adapting current programmes. Specific objectives include: a) to examine their knowledge of, attitudes towards and beliefs about TB; b) to analyze factors related to seeking TB care; c) to analyze factors influencing treatment adherence; and d) to describe the social repercussions of a positive TB diagnosis. A systematic review of qualitative studies was carried out following a meta-ethnographic approach . Using rSearches were carried out in the following databases: MEDLINE, SCOPUS, JSTOR and EMBASE. Search topics included “Tuberculosis”, “immigrants” and “qualitative research” using the search terms and MeSH descriptions described in A hand search was also undertaken of the bibliographies of the selected articles. A final internet search was conducted using Google Scholar, in order to minimize the potential loss of relevant sources. The search and article screening process was reviewed by a second researcher.We included qualitative studies, as well as studies that combined both qualitative and quantitative methods in which qualitative results were reported and described clearly. The search was limited to studies in English, French or Spanish. There were no limits regarding place of study or publication date. The initial search identified 3,150 articles, which were reduced to 2,501 after eliminating duplicates. After reviewing titles and abstracts 2,301 more were excluded as irrelevant for the research topic. Of the 200 remaining, by reading the abstracts and the full text versions, 23 articles were selected as meeting inclusion criteria. Reviewing the bibliographies of these articles and the additional Google Scholar search identified seven further articles that met inclusion criteria –28. A toFour categories were developed for the analysis of findings: a) knowledge of, attitudes towards and beliefs around TB; b) seeking healthcare and TB diagnosis; c) TB treatment and prophylaxis; and d) social repercussions of TB. Published between 1997 and 2011, as Various studies showed a generally low level of knowledge about TB and widespread misconceptions about TB transmission. Some respondents had basic notions of bacteria and infection with regard to air-borne transmission ,29–31 buFor many respondents, the modes of TB transmission, or preventive methods were unclear, and different explanations of disease aetiology sometimes co-existed . The bel“ (You can get TB) just being around someone who has it, or drinking out of their glass, or eating off of their plate, or by having relations with a woman who has TB”Mexican migrant farmworker in the US .Thought of as an important but treatable disease ,29 that “If you get TB, you die.”Male Mexican immigrant in the US, with latent TB . “Nobody knows, except my family… But they (the doctors) said that it isn’t like the TB that we used to have that was very contagious and very bad.”Female Samoan TB patient in New Zealand .“...I don’t think Somalis here, in America, have it. Maybe people in Africa...”Male Somali immigrant in the US .Tuberculosis was mainly perceived as a disease of the lungs, with respiratory symptoms including cough and coughing up blood, but also non-respiratory symptoms like fever, weight loss and general tiredness ,28,30,35“People were mixing TB up with lung cancer, asthma, so the term, particularly the formal term of TB is not very well understood. It’s sort of lumped in with other lung conditions... There is a lot of miscommunication within the community. Not only some fears about this, but a whole lot of muddle around the condition.” Male Chinese immigrant in Canada .Many study participants had never heard of latent TB before being diagnosed ,25,38 an “Latent TB has no symptoms and the one who has cannot infect others, then why call it a disease?”Male Somali immigrant in Sweden .In other cases, the positive result of a Tuberculin skin test was perceived as a very serious clinical diagnosis . “When my son was diagnosed with latent TB infection, I thought he was going to die.”Male Mexican immigrant in the US .Respondents generally understood that the vaccination helped to prevent TB , though Many participants in numerous studies talked of how their situation as immigrants could negatively influence their health or increase their exposure to TB. A weak social network , illiterFactors encouraging immigrants to seek healthcare included the desire to receive a negative result to avoid stigma associated with suspected TB infection; the right to stay legally in the host country until completing treatment ; wantingBarriers to accessing healthcare services and therefore TB diagnosis, treatment or prophylaxis included lack of knowledge of existing free TB diagnosis and screening services at specifically designed centres ,44; illiDelays in diagnosis or seeking healthcare were common and sometimes serious ranging from days to months since the onset of symptoms ,25,26,46“At the beginning, I thought it might just be a cold, so after three or four days, I went twice to a pharmacy to buy some drugs. But I felt I was coughing more heavily after taking the medicine, so I decided to go to see a doctor in a private clinic.”Rural-born female Chinese migrant who suspected TB .‘‘If they’re talking about something where it’s preventive (TB screening), you know they’re not sick, then you know, there’s little motivation to do it…’’ Immigrant in a literacy centre in the US .January that I was referred to hospital for chest X-ray.”“I started coughing in November and it wasn’t until mid-Male Nigerian immigrant receiving TB treatment in the UK .Experiences of diagnostic processes and settings were varied. In some cases, the norm was to pass through many health centres and see many health professionals prior to receiving a TB test, which led to high patient costs . ParticiAs for the screening process, it was generally well received by study participants and seen as a socially responsible act in terms of helping to prevent further cases . There w“Actually it is a good idea because if you do it (get screened for TB), you know you have it then you can cure it. If you don’t cure it you can carry on giving it to other people and then that is another problem to the country.”Male Ghanaian immigrant with suspected TB in the UK .“She only say me I have to take my blood pressure and my urine from me, she haven’t mentioned the tuberculosis test but when I came and she saw perhaps I am a black person, or something like that, I am not saying she is racist or something like that, I don’t say that, but I think it is because I am African.”Male African immigrant with suspected TB in the UK .Some respondents expressed anxiety with regard to diagnostic procedures and others feared the lack of privacy, worrying particularly about the presence of non-medical administrative staff and health professionals from their own country .TB control often involves collection of epidemiological data and tracing the contacts of diagnosed persons in order to administer prophylactic antibiotics. In some studies, due to fears about deportation, immigrants with irregular residence status would not be willing to reveal details of their migratory route ,22 and t“Once Smittskydds people put you in their books (records), they follow not only the patient but the whole family and this puts fear and suspicion in peoples’ minds. . . so people see themselves as “marked” and not see the advantage of controlling infection. Nevertheless, they feel pursued by authority.”Male Somali immigrant, ill with TB in Sweden .Problems of accessibility can constitute a barrier to health seeking and early diagnosis, and can also present obstacles to prophylaxis and the periodic visits that adequate TB treatment necessitates. At times, the need to travel , difficuFactors facilitating adherence to treatment included family support , receivi“We do know that tuberculosis is not difficult to treat. The problem is that health care services have to give the medication but they have no control if people will take it. How do we deal with this problem? You must have a strategic plan. First, the education is too mechanical... you need the personal touch.”Male Vietnamese community leader and immigrant in the US . The length of TB treatment and prophylaxis caused changes in migrants’ lives  and thisEven though in most countries TB screening, prophylaxis and treatment is free, two studies carried out in China reported problems associated with the overall costs ,46. This“The free treatment policy means I need to pay all the medical costs first. It does little to release my current financial burden in treating TB.”Male Chinese rural-to-urban migrant, diagnosed with TB .In two US studies, respondents regarded traditional remedies as complementary to modern treatments, which were considered as the most effective against TB ,28. Howe‘‘(Treat with) not generic medicine, good medicine… Generic’s no good medicine.’’Somali immigrant in the US .Adverse effects of TB medication could also lead to poor treatment adherence ,37,45. TThere was a variety of expectations about antibiotic treatment or preventive therapy for latent TB. Some studies suggested that preventive therapy would be accepted if a full explanation were given, whereas others were more sceptical . In some“It will kill the germs... stop the virus from continuing... the infection will disappear... I will feel better, not to be contagious especially for my children...”Latin American immigrant, ill with TB in the US .Experiences of TB-related stigmatization were reported in most of the studies. Feelings of stigmatization derived from being labelled as an “at-risk group” began within the health system when some participants perceived that health staff treated immigrants differently ,37,43,48“...don’t splash all over the mainstream media that immigrants have TBit will just make the discrimination that might exist, even higher.” Immigrant and interview facilitator in Canada .Feelings of stigma influenced immigrants’ attitudes towards prevention, diagnosis and treatment ,37,41,46“I do not want community doctors to visit me regularly. Others will know that I am sick and have TB. My landlord will expel me if he knows (I have TB).”Chinese rural to urban immigrant, ill with TB .In a Spanish study, immigrants feared getting sick again when noticing minor symptoms or seeing someone close to them cough, which had a negative psychological effect even after they were cured . The ass“These days, if you have TB, they say it’s AIDS. If you have pneumonia, they say it’s AIDS. If you have common fever, make sure you stay inside your house! Once you lose one kilogram, you’re finished. Some won’t even shake your hands or eat with you. The stigma is too much. So people prefer to die.”Male Nigerian immigrant, ill with TB, in the UK .Fear of being infected ,33, anti“I remember in our family, one of our relatives had TB, and we isolated him. It used to scare the heck out of me. We would talk to him from a distance.”Philippine immigrant in the US .With few economic resources and savings to start with, a TB diagnosis entailed a range of direct costs associated with the illness and medical procedures as well as indirect costs such as losing a job , being eWhen analyzing immigrants’ experiences and views of TB, many authors highlighted the influence of misconceptions about the disease, its aetiology and its prognosis. In many cases, past TB-related experiences of family members and in the country of origin – where the prevalence and severity of TB tends to be more pronounced – were the first contact with and source of information about the disease ,35. The Misconceptions were accentuated by contradictions in the information received from health professionals in migrants’ home and host countries . In theiDelayed TB diagnosis is frequent amongst migrants ,41,44,46Although there are different screening strategies, screening that is carried out with coercion or linked to entry or legalizing residence reaches more immigrants ,54. HoweThere were not many references to compulsory screening and treatment policies at borders or entry point in the literature reviewed. Acceptability of screening and opinions of TB patients identified in these settings may differ.In spite of the fear that TB provokes, there was also a false sense protection, both amongst immigrants, who assume that they have left behind the hazardous circumstances, and the health professionals, who do not suspect TB if they do not recognize the risk of reactivation of latent TB, are not familiar with diagnostic procedures or symptoms are unclear. In market-orientated health systems, financial incentives for health professionals can increase the number of appointments and diagnostic tests carried out prior to a TB diagnosis . Interactions with health professionals – initially and during the follow up that treatment requires – were highlighted as a fundamental element of treatment adherence. Cultural understanding, personal closeness and immigrants’ trust in health professionals, whether of the same background or not, was a key factor for adherence and encouraged diagnosis. Programme design and assessment of adherence should also be reassessed. For example, the use of indicators linked to periodic collection of medication from health centres or the absence of adequate treatment surveillance, could lead to false image of success. Similarly, prescribing medication but providing partial information combined with coercion led to treatment initiation but did not guarantee long-term adherence. Moreover, although programmes of TB diagnosis and treatment might be free, the most marginalized immigrant populations often lacked awareness regarding these programmes and at times they faced other, often unnecessary, indirect costs.The use of “traditional” remedies did not present an obvious threat to biomedical treatments, even if at times immigrants found it difficult to adopt them. In turn, traditional knowledge about diet or natural remedies could help patients to deal with common adverse effects of treatment.Although TB-related stigma has been widely discussed elsewhere , it has Immigrants’ fear of TB was based on previous experiences in their home countries and was sometimes translated into community and personal marginalization weakening the patients’ closest social networks, often key to providing the long-term support required for a successful completion of TB treatment. The social and economic consequences of TB extended beyond perceptions of stigma. The marginalization of the patient was often described, and the costs associated with the disease and the physical weakness, unemployment, or reduced employment capacity could have serious repercussions for a patient’s economic situation, social support and mental health. These problems, together with prevailing misconceptions about the disease and its prognosis, should be taken into consideration and addressed in TB treatment and control programmes. Compared to the general population, immigrants are more vulnerable to TB and disproportionally affected by the disease ,36,42,43This review is limited by the difficulty of synthesising and comparing results of studies conducted in a wide diversity of contexts, with a variety of respondents and using different approaches. Not all studies included easily-comparable information on relevant issues, such as migrants’ legal and socio-economic economic circumstances, religion, or length of residence in the host country. The lack of information in many studies regarding the sex and age of study participants did not allow us to disaggregate the analysis by these variables despite its possible relevance. On the other hand, strengths of the review included a systematic search in four databases, supplemented by a hand search of the bibliography in the articles identified and an additional search in Google Scholar. Having no limits to the inclusion of articles regarding place of study or publication date also allowed for a broader perspective, and a comprehensive analysis of immigrants’ perceptions of TB and TB control programmes.The results of this review indicate that immigrants’ knowledge of and attitudes towards TB are largely built on their previous experiences. Even though the immigrant populations were heterogeneous, there were common challenges amongst groups, such as the perception of TB as being highly contagious and severe, frequent lack of treatment adherence, obstacles to effective communication with health providers and/or anticipated and enacted stigma that hindered treatment and isolated the patient. However, these similarities should not obscure the needs of specific groups – defined in terms of cultural references and socio-economic factors including social networks and living conditions at host countries. Immigrants require appropriate information on TB aetiology and transmission tailored to different language abilities, levels of knowledge and beliefs systems, in addition to screening strategies and health care provision that are adapted to their particular traditions, values and social relationships, in order to guarantee information, screening, diagnosis and adherence to treatment. Beyond escalating current interventions and increasing monitoring of TB incidence and prevalence in immigrant populations it is crucial to understand immigrants’ perceptions of TB and the specific obstacles that they face when accessing the health system, seeking a diagnosis and adhering to a treatment programme. Checklist S1PRISMA checklist.(DOCX)Click here for additional data file.


We intended to analyse which aspects of spirituality are of relevance for medical doctors in a mostly secular society and how their spiritual/religious attitudes are related to specific views of illness, their dealing with patients' individual situation, and finally physicians' life satisfaction. Data from an anonymous survey enrolling 237 medical doctors from Germany  indicated that secular forms of spirituality scored highest, while specific religious orientation had the lowest scores. Physicians with a specific specialization in complementary/alternative medicine (CAM) or anthroposophic medicine differed from their conventional counterparts with respect to specific aspects of spirituality; however, the specific views associated with these specialisations were only weakly to moderately correlated with physicians' view on the meaning of illness and how they assume that they would deal with their patients' individual situation. Of interest, the specific aspects of spirituality were negatively correlated with the view of “illness as a meaningless interruption” of life, indicating that physicians with a spiritual attitude would see illness also as a chance for an “individual development” and associated with a “biographical meaning” rather than just a “useless interruption” of life. Physicians exercise a profession which contains many intrinsic and extrinsic gratifications: intrinsic gratifications like feeling medically competent by acting accordingly, “flow” experiences in being absorbed in their medical activities, achieving good results of treatments, being able to help people in need, being a point of reference, of authority, and of trustworthiness for the patients; as for extrinsic gratifications, we consider social prestige due to their role, financial gains and profits, and positions of superiority. All of these gratifications may in one way or another, in idiosyncratic constellations, help to compensate for the manifold demands and high levels of stress they deal with on a daily scale, both in practice and administration, and also, though less so, in professional politics. “Enough” intrinsic gratifications seem to be more consistent with, and useful for, their satisfaction with their work (and with themselves) rather than a too strong dependence on compensations by extrinsic gratifications , 2.Much research has been done on what motivates people to become doctors , how medAmong a sample of 1,144 US physicians, 55% would agree that their religious beliefs may influence their practice of medicine . NeverthWhat might be true for the US must not necessarily be true for the more secular Europe. Research has just started in European countries which addresses physicians' spiritual/religious convictions, and how these may influence their practice of medicine.We thus intended to analyse (1) which aspects of spirituality are of relevance for medical doctors in a mostly secular society and (2) whether and how these spiritual/religious attitudes are related to specific views of illness, their dealing with patients' individual situation, and finally physicians' life satisfaction. In particular, we intended to know whether physicians with a specific focus on complementary and alternative medicine (CAM) approaches differ from conventional physicians. For this purpose, we decided to choose a more open approach to address a wide variety of important aspects of spirituality, both religious and secular forms.In this anonymous survey, we enrolled 237 medical doctors recruited via the university's network of family practitioners, in different hospitals and wards with which medical students were in contact (convenience sample with a response rate of 59%). Because we intended to compare physicians with a specific focus on complementary and alternative medicine (CAM) approaches with conventional physicians, we specifically recruited physicians also in hospitals known to offer CAM treatments on the one hand, and physicians in conventional hospitals and wards.All were assured of confidentiality, consented to participate, and completed the questionnaire, which neither requested names nor initials, by themselves. We had neither inclusion nor exclusion criteria (just the will to participate).prayer, trust in God, and shelter; insight, awareness, and wisdom; transcendence conviction; compassion, generosity, and patience; conscious interactions; gratitude, reverence, and respect; and equanimity. For this analysis, we used a shortened version with 25 items (ASP 2.1) which differentiates 6 factors [religious orientation , that is, praying, feeling guided and sheltered, trust in and turn to God, spiritual orientation in life, distinct rituals, reading spiritual/religious books, and so forth, search for insight/wisdom  with two subconstructs:aspiring beauty/insight , that is, developing wisdom, aspiring to insight and truth, aspiring to beauty and goodness, and aspiring to broad awareness,quest orientation , that is, life is a search and question for answers, search for deep insight in fabric of life, and achieve of frankness/wideness of the spirit;conscious interactions    with two sub-constructs:conscious interaction , that is, with others, self, and environment,compassion/generosity , that is, developing compassion and practicing generosity;transcendence conviction , that is, belief in the existence of higher beings, rebirth of man/soul, soul origins in “higher” dimensions, and man is a spiritual being.All items were scored on a 5-point scale from disagreement to agreement ; 3—applies quite a bit; 4—applies very much). The scores are referred to a 100% level (4 “applied very much” = 100%).To measure a wide variety of important aspects of spirituality beyond conventional conceptual boundaries, we developed a questionnaire on the basis of the answers of expert representatives of various spiritual orientations which aspects of spirituality are relevant to them  . We cond factors , that isBrief Multidimensional Life Satisfaction Scale (BMLSS) [Myself, Overall life), social dimensions , external dimensions , and the prospective dimension . The internal consistency of the instrument was good  [Life satisfaction was measured with the  (BMLSS)  which re (BMLSS) , 18. Thea = .87) . Each itSingle Items Addressing Physicians' Dealing with Their Patients and Meaning of Illness. To address physicians' self-perceived dealing with their patients' individual situation and their view about how illness may impact patients' life in terms of “meaning,” we used 10 single statements (see [nts (see ), that iAll items were scored on a 5-point scale from disagreement to agreement ; 3—applies quite a bit; 4—applies very much).P < 0.05 when mean scores were compared and at P < 0.01 when correlations between the respective variables were analysed. With respect to classifying the strength of the observed correlations, we regarded r > .5 as a strong correlation, an r between .3 and .5 as a moderate correlation, an r between .2 and .3 as a weak correlation, and r < .2 as no or a negligible correlation.Descriptive and analyses of variance and first-order correlations and regression analyses were computed with SPSS 20.0. Given the exploratory character of this study, significance level was set at Among the 237 medical doctors with a mean age of 45.7 ± 9.6, 58% were male and 42% female, 81% were living with a partner and 19% alone, and a Christian denomination was predominating .With respect to their academic status, 61% had a doctoral graduation, 3% had a postdoctoral lecture qualification, and 36% had a medical diploma. As shown in conscious interactions and compassion/generosity, followed by aspiring beauty/wisdom, quest orientation, and transcendence convictions, while religious orientation had the lowest scores indicating indecisiveness , and 37% are praying for themselves ; 46% are reading spiritual texts/scriptures , and 32% are meditating .conscious interactions  or family status . Those with a Christian denomination had significantly higher scores for religious orientation , transcendence conviction , aspiring beauty/wisdom (F = 7.0: P = 0.001), and quest orientation , and in trend also for compassion/generosity , but not for conscious interactions .Women had significantly higher scores only for ractions , while aractions . MoreoveF values range from 0.0 to 1.3; n.s.). However, within the field of the medical profession, religious orientation  and also transcendence conviction  showed significant differences, which could be explained in part by the underlying specialisations .Also the academic grade had no significant impact on the spirituality scores , while the statement that “patients' own opinion about what may have caused their illness is not of importance for diagnosis and finding an adequate treatment” (ÄS18) was commented positively by a minority of physicians . This means that most have an implicit perception that patients' individual perspectives should be included in the process of diagnosis and treatment. However, the more fatalistic statement that it is often “a matter of fate or chance whether a patient becomes healthy again or not” (SK8) showed the strongest variance; that is, 45% rejected this statement, while 27% agreed, and 28% were undecided.Particularly medical doctors with a specialisation in AM and psychotherapy rejected the statement that “illness is nothing more than a useless interruption of the course of life” (SK3) more strictly than conventional physicians. Due to their specific spiritual orientation and worldview, AM doctors clearly rejected the statement that “illness prevents patients' individual development” (SK4) or that it is “completely incomprehensible that illness may have a biographical meaning” (SK2); conventional physicians would reject these statements too but in a less clear-cut manner.All other statements did not show significant differences with respect to medical doctors' professional specialisation or underlying orientation .Next we intended to analyse associations between aspects of spirituality, life satisfaction, and statements towards illness, treatment and recovery Tables  and 5.transcendence conviction and religious orientation and the scales conscious interactions and search for insight/wisdom with their subconstructs. Interestingly, conscious interactions and religious orientation were only weakly associated. However, life satisfaction was associated weakly and negatively only with conscious interactions and aspiring beauty/wisdom  and that “illness is nothing more than a useless interruption of course of life” (SK3). The opposite statement that illness “may have a biographical meaning” (SK2) was thus positively associated particularly with ituality . The resituality .conscious interactions). Of particular interest, there were no significant correlations between physicians' specific aspects of spirituality and the conviction that patients' process of recovery is a matter of fate or chance (SK8) and the time physicians' think they have to invest in their patients' individual situation (SK9).The specific statements addressing physicians' dealing with their patients' individual situation were in most cases either not at all or only weakly associated with their spirituality. However, particularly the strict statement “if I had also to deal with patients' individual situation, it would unnecessarily cost time and nerves” (SK10) was negatively associated with the relational forms of spirituality , while the more specific religious forms were of the lowest relevance. This is in line with the findings among adolescents/young adults with a high-school education in secular society such as that of Germany [Among the recruited medical doctors, particularly secular and relational forms of spirituality were of relevance  either an influence on the way they care for their patients and (2) how they would interpret illness and its impact on patients' course of life.While the majority of physicians regard illness as a patients' chance to deal more consciously with life (92%), and only a minority would have a negative or indecisive perception of illness (up to 18%), it was of interest that the specific aspects of spirituality were negatively correlated with the view of “illness as a meaningless interruption” of life. This means that physicians with a spiritual attitude would see illness also as a chance for an “individual development” and associated with a “biographical meaning” rather than just a “useless interruption” of life which was rejected by 88%. However, particularly those with an AM background rejected the point of view that “illness is nothing more than a meaningless interruption of life's course” and that “illness prevents patients' individual development” very strongly. This strict and unique point of view can be explained by the conviction that illness and other forms of hardship in life can (but do not have to) be “tasks in life,” the experience of which may even contribute to the inner development of an individual .With respect to the physicians' perception how they think they are dealing with patients' individual situation, only the relational and existential forms of secular spirituality were negatively and only weakly associated with the cynical statement that dealing with patients' individual situation “would unnecessarily cost time and nerves” and that patients' individual points of view in regard of the suggested causes of illness “is irrelevant for the process of recovery”. With respect to these patient-oriented views, physicians with a CAM or AM specialisation and those with a conventional specialisation did not differ significantly.While psychosomatic medicine has already called for a medical ethos of physicians which overcomes the so-called value neutrality of the 19th century The development of “spiritual care,” in consequence, is still mainly restricted to the end of life medicine , 30, altHowever, a limitation of the study is the fact that the data are not representative for German physicians. This was not our intention because we aimed to oversample medical doctors with a specific specialisation in CAM (including AM) to compare their data with conventional medical doctors. Moreover, we are aware that particularly the items addressing the suggested meaning of illness may be answered with social desirability, and thus the focus of attention should be on the undecided and those who agreed to the respective statement (8–18%). The same is true for two items addressing their perceptions and how they deal with patients' individual situation .While the physicians with a specific CAM or AM specialisation differ from their conventional counterparts with respect to specific aspects of spirituality, the specific views associated with these specialisations were only weakly to moderately associated with their view on the meaning of illness and how they assume that they would deal with their patients' individual situation. On the other hand, physicians' spirituality was either not at all or only weakly associated with their life satisfaction, particularly their conscious interactions with others, self, and environment (which is not a specific religious issue), and their aspiration to develop wisdom, insight and truth, beauty and goodness, and broad awareness is of relevance (which is at least moderately associated with a religious orientation). Nevertheless, it was of interest that the specific aspects of spirituality were negatively correlated with the view of “illness as a meaningless interruption” of life, indicating that physicians with a spiritual attitude would see illness also as a chance for an “individual development” and associated with a “biographical meaning” rather than just a “useless interruption” of life.


This study aimed to evaluate the potential contribution of informal community initiatives and formal interventions in support of former child soldiers' resilience in the wake of armed conflict. Using a cross-sectional survey design, a stratified random sample of 330 formerly recruited and 677 nonrecruited young people was consulted about their perspective on desirable support for former child soldiers provided by close support figures, communities, humanitarian organizations, and governments. Data analysis occurred by conducting qualitative thematic analysis and statistical chi-square analysis to explore clusters, similarities, and variations in reported support across the different “agents,” hereby comparing the perspectives of formerly recruited and non-recruited participants. The results indicated that formerly recruited and non-recruited participants had comparable perspectives that call for the contribution of various informal and formal support systems to former child soldiers' human capacities and the communal sociocultural fabric of war-affected societies. This highlights the importance of community-based, collective, and comprehensive support of formerly recruited young people and their surroundings in the aftermath of armed conflict. Contemporary warfare increasingly inflicts military strategies on civilians and sometimes particularly victimizes children minor 18s) [8s [1]. AThese implications have been incorporated into the Psychosocial Working Group (PWG)'s conceptual framework for psychosocial intervention in complex emergencies . This frAll this raises questions concerning the role that formal support systems, such as governmental agencies and non-governmental organizations, must fulfill and the necessity and complementarity of their services in conjunction with those already provided by informal support systems. The initiation of formal support in (post-)conflict settings often follows the assumption that the informal support systems have insufficient resources or engage insufficiently in resource exchange processes to deal with the formidable harm inflicted on them , 20. By This study is part of a larger mixed-method research project conducted between October and December 2010 in the Lira district of northern Uganda. This area is currently in transition after two decades of a complex armed conflict in which the Lord's Resistance Army (LRA) forcibly recruited thousands of minors as child soldiers . The aimTo create a stratified random sample, the District Education Office's overview of schools in Lira district was used to select six secondary schools and for each school two adjacent villages in urban, periurban, and rural areas. The age range of 12–25 years was determined to include youth that were at the time of the LRA insurgency most likely to be among the young people that the LRA targeted for recruitment. In the villages, the out-of-school youth in this age bracket was invited to participate. In the schools, the students of classes Senior 2 and 3 of the O-level were considered to be the best age-match, given that in the lower level a diversity of ages was represented and that the higher level showed a considerable frequency of drop-outs. This resulted in a sample of 1008 Ugandan youths, of whom about a third had formerly been recruited by the LRA (one participant did not disclose his status). In cooperation with community leaders and school principals, a plenary meeting was organized in each village and school to disperse information necessary to make an informed decision on participating in this study. This information mainly included the purpose and procedure of the study, the possibilities and consequences of refusal or withdrawal from the study, and the availability of psychosocial support during or subsequently to the study. The written informed assent or consent was obtained from all participants. Collecting consent of legal guardians of minors was hindered by them living separately and often far apart. The participants did not receive any compensation for their participation in this study. A cross-sectional survey questionnaire with mainly open-ended questions was administered. This questionnaire firstly consisted of sociodemographics of the participants, including age, gender, district and location of residence, occupation, religion, household composition, and former child soldiering experiences. Secondly, it contained open-ended questions on what different agents could do to support formerly recruited young people in their transition from military to civilian life. The questions were carefully designed by the bicultural research team to ensure inclusion of the most relevant informal and formal agents  and ease of understanding . “Family” referred to the nuclear and extended family members; “friends” consisted of intimate friends, age mates and classmates; “community” referred to the people who are linked by social ties and the geographical location, including neighbors, social groups and local cultural, religious and political leaders; “organizations” included charitable, non-governmental and United Nations agencies; and “government” referred to national and international government bodies. Rules were made concerning how to communicate and translate this additional information, which was orally disseminated to the participants. The in-school participants and out-of-school participants with sufficient literacy skills individually administered a written version of the questionnaire in English , while the researcher and a trained bilingual research assistant remained available. For out-of-school participants with limited literacy skills, the questionnaire was in interview format administered orally by the researcher and simultaneously translated on-site into Lango (the native language of the region) by trained bilingual research assistants. These interviews took place individually in a confidential setting. The answers were analyzed and divided into meaning units, whereby those that were conceptually identical were merged and each unique meaning unit received a different numerical code. This procedure resulted in composite lists of the reported unique items per agent. The analysis of these items was based on the Psychosocial Working Group (PWG)'s conceptual framework for psychosocial intervention in complex emergencies, which incorporates an integration of the original conceptual framework discerning the main domains of resources   and empisd = 2.31, range = 12–25) years. The median duration of their recruitment in the LRA was 348.50  days. The greater part of them had escaped  on average 5.57  years ago. A majority of 225 (68.2%) participants originated from Lira district, others resided here for familial, economic, or educational reasons. Most of them lived in a rural  or periurban  village, while the minority lived in town  or in a camp . Most participants were attending school . Of the out-of-school participants, the greater part engaged in farming activities  or declared to have no occupation . The subsample of 677 non-recruited participants consisted of 346 (51.18%) males and 331 (48.89%) females, with the average age of 16.54  years. They either lived in the same village or attended the same class as the formerly recruited participants in this study. The subsample of 330 formerly recruited participants comprised 201 (60.91%) males and 129 (39.09%) females, with an average age of 17.04 (J = 1.00). The items allocated to organizations were situated in between the items of family and friends on the one hand and the items of community and government on the other hand. However, the similarity metric shows that there was high similarity between the sample sets of all agents (range = 0.80–1.00). The cluster dendogram  shows a This table and figure also show that formerly recruited adolescents were primarily recommended to strengthen their own “human capacity”, by developing their “knowledge and skills”, adhering to “religious beliefs”, applying “mental health” strategies, and strengthening their “livelihood”. To a lesser extent, they were also expected to contribute to the “culture and values” and the “social ecology” of their environment. The table and figure further seem to indicate that support expected from families, friends and communities diminished steadily from resources in “human capacities” to the “periphery”. Families' largest contribution lies in the support of “human capacities”—specifically their children's “knowledge and skills”, “livelihood”, and “physical health”—and in the provision and promotion of “social support”. Friends were mainly expected to contribute to “human capacities” by supporting the “knowledge and skills” and “mental health” of their friends, and also to the “social ecology” by facilitating their “social connectedness” and delivering “social support”. The community's assignments were equally divided over the three core domains, and were more specifically oriented to support the “knowledge and skills” and “livelihood” of formerly recruited young people, as well as “social support” and “human rights” issues in the community. The support functions assigned to organizations and the government mainly pertained to the “human capacities” and “social ecology” domains, but then diminished markedly for “culture and values” and the “periphery”. Organizations were reported to make the largest contributions to “human capacities” by supporting the “livelihood”, “mental health”, and “knowledge and skills” of formerly recruited young people, and also to the “social ecology” by initiating “social services and infrastructure' and promoting “social support”. The government's responsibilities were mostly defined in relation to the “social ecology”, including the initiation of “social services and infrastructure” as well as “law and order”, and in relation to the “human capacities”, mainly the “knowledge and skills” and “livelihood” of formerly recruited youth. This study examined formerly recruited young people's perspectives on the potential contributions that diverse informal and formal support systems can make to their well-being in the wake of child soldiering. The results revealed that formerly recruited young people call for support on a variety of resource domains to which both informal and formal agents can make significant contributions. Required supports seemingly diminished from resources endowed to individuals to resources in the periphery. A plausible explanation is that those challenges and resources that are most directly related to one's well-being are often considered salient and therefore are more reported , 22. HenIn addition, there is a great deal of recommendations that represent nonspecific and communal support, given that these pertain to the social and cultural fabric. The need for support of the social ecology might be explained by the fact that the impact of war is in part influenced by the extent to which social networks, public facilities, and customary practices are affected and hence limited in their supportive capacities , 19. To Support for culture and values was less reported, though still requires considerable attention from informal and formal agents. Support in this domain should mainly be oriented to human rights issues and cultural practices. During and following warfare, grave abuses may occur that defy basic human rights, and formerly recruited young people may in particular experience subjugation and discrimination, which possibly explains their need for support in this area . War alsInfluences of the broader context are still relevant to the formerly recruited youth, albeit apparently to a lesser extent. These peripheral factors are mainly considered to be an issue of the government that bears a duty with regard to the economic and political climate of the country. The latter should be supported by organizations . The empIn addition, the study explored similarities and differences between the perception of formerly recruited and non-recruited participants concerning the contribution that various informal and formal agents can make to these resource domains. The aim of this comparison was to obtain a preliminary insight into whether former child soldiers' perspectives are endorsed by agents in their environment. The results showed some significant differences that suggest that the participants who were recruited situate more supports outside themselves and their families than is acknowledged or supported by their non-recruited age mates. Nonetheless, the overall distribution patterns of resources showed that formerly recruited and non-recruited young people generally shared the same perspective on support for former child soldiers. This reveals that the age mates acknowledge the important supportive role to be played by environmental agents, and that they are willing to invest and exchange their own and communal resources in support of formerly recruited young people. However, formerly recruited young people themselves are also expected to not only invest in their own capacities, but to make a contribution to their social ecology and to the culture and values of their community. Such investment in the socio-cultural fabric may be warranted when they aim to obtain access to the rich reservoir of communal resources in their environment, that can help to deal with loss brought forth by child soldiering and to offset ensuing challenges that may occur in the aftermath . VariousThe high similarity of items across informal and formal agents indicates that all agents are supposed to work toward similar goals and largely must support the same resource domains. This recommends collaborative initiatives, whereby local informal support systems within the community report to formal agents about the resources at their disposal and about their ongoing initiatives to deliver the required support. Formal support systems may in turn strengthen the local capacities by revitalizing, augmenting or formalizing the support offered by communities , 35, 40.These findings should be interpreted in the light of the methodological limitations of this study. To begin with, when asked to share perspectives on desirable support, people are likely to favor direct needs satisfaction to compensate direct resource loss , 22. As


I never like to give my background and, anyway, I make it all up different every time I’m asked,” Andy Warhol said. “It’s not just that it’s part of my image not to tell anything, it’s just that I forget what I said the day before, and I have to make it all up over again.” The man described as “a serious artist whose posture was unseriousness” called himself “a deeply superficial person.” He frustrated those who wanted to know more about him: “Just look at the surface of my paintings and films and me, and there I am. There’s nothing behind it.”Though he claimed to “come from nowhere,” he was born Andrew Warhola in Pittsburgh, Pennsylvania, to Czech immigrant parents. He lost his father early and grew up in a modest household during the Depression, shy and frail and plagued by childhood diseases, among them Sydenham chorea, a movement disorder that occurs with rheumatic fever, which interfered with his early formal education. As he lay bedridden for months, he listened to the radio; discovered magazines, which he read avidly; and started to draw, entering his artistic career in tune with the popular culture of his generation.His talent was recognized early. He attended the then Carnegie Institute of Technology in his hometown, to study pictorial design and soon moved to New York to work as commercial illustrator. His first assignment for Glamour magazine was titled “Success Is a Job in New York.” He found such success quickly with other magazines. He designed window displays for major retailers and promotional materials for record labels. Much of this work, which received many accolades, relied on photographs and other existing images, a process he would continue to use throughout his life.The 1960s saw Warhol’s debut in the fine arts, his Pop paintings, depicting celebrities, dollar bills, and supermarket products. Pop Art, a movement of the 1950s and 1960s, trampled tradition by embracing mass-produced elements of popular culture. Drawn from advertising, comic books, and the mass media and examined in a different light, these mundane elements were transformed into icons of contemplation―product labels and all. The controversial images were created by mechanical techniques of reproduction and established new boundaries for originality and aesthetic legibility. “What about your transformation from being a commercial artist to a real artist?” Warhol was asked in an interview. “I’m still a commercial artist,” he retorted. “I was always a commercial artist.”Campbell’s Soup Cans in 1962, along with his depictions of cartons used for shipping and his sculptures Brillo Soap Box, started him on the way to fame. Unlike other Pop artists, who injected their works with irony or parody, he treated them with detachment, emphasizing, even idealizing, mass production. When asked why he painted cans of soup, he said, “I used to drink it. I used to have the same lunch every day for 20 years, I guess, the same thing over and over again.” As for the dollar bills, he explained, “A teacher once told me to paint what I like.”Warhol’s He opened a studio, dubbed the Factory, and surrounded himself with artists, writers, musicians, and the avant-garde. There he perfected the two-layer screen-printing technique for his portraits. Also called silk-screening, this technique generated a precise image that could mass produce prints—a most appropriate goal considering the duplicative nature of his subjects, who existed not only in life but also on film, in magazines, newspapers, and billboards. Clips from these sources were transferred photographically to the silk or other fine mesh. The canvas was painted, completely or in part, and the screened image, which was slightly larger or smaller than the canvas, was printed on top of the painted designs, allowing some variation in each image.At the Factory, Warhol created sculptures; published a magazine, The Interview; and managed an electronic rock band called the Velvet Underground. “Your work as an artist has always been so varied, like Leonardo. You’re a painter, a filmmaker, a publisher …. Do you think that’s what an artist is?” He was once asked. “No,” he said, “I think an artist is anybody who does something well, like if you cook well.” At the time of his death he was host of an MTV cable program called “Andy Warhol’s Fifteen Minutes”―a reference to his famous comment that in the future everyone will be world famous for 15 minutes. In the 1960s, 1970s, and 1980s, he produced more than 1,000 portraits, among them, of Marilyn Monroe, Nelson Rockefeller, Elvis Presley, Jackie Kennedy, Brigitte Bardot, and Mao Zedong.Warhol, always cognizant of the cinematic and telegraphic nature of life, became interested in death and created portraits of people grieving, deceased public figures, the electric chair, car wrecks, race riots. This obsession with death ironically collided with an attempt on his own life inside his studio when a disgruntled disciple shot him and he nearly died. “Before I was shot, I always thought that I was more half-there than all-there. I always suspected that I was watching TV instead of living life. People sometimes say that the way things happen in movies is unreal, but actually it’s the way things happen in life that’s unreal. The movies make emotions look so strong and real, whereas when things really do happen to you, it’s like watching television―you don’t feel anything.”The philosophical issues surrounding life and death permeated Warhol’s work. “Isn’t life a series of images that change as they repeat themselves?” he said about image repetition in series and within individual works. When he painted soup cans or Coca-Cola bottles, he filled the canvas with them in every direction, suggesting that the line-up did not end at the edge. He insisted that all images are portraits. When he painted a portrait, it was a series.Repetition, present at many levels in Warhol’s work, is not unique in the history of art. He was aware of its use by Giorgio de Chirico (1888–1978): “He repeated the same images over and over again …. What he repeated regularly, year after year, I repeat the same day in the same painting. All my images are the same, but very different at the same time.” Warhol also cited Edvard Munch: “We see with different eyes at different times. We see things one way in the morning and another in the evening, and the way we view things also depends on the mood we are in. That is why one subject can be seen in so many ways and that is what makes art so interesting.”Ten Portraits of Jews of the 20th Century, the artist used archival photos over patches of color. He outlined the features in graphite, enlarged the source image on paper, and transferred both onto acetate transparencies. Against convention, the prints preceded the paintings by several months. The same silk-screens were used for multiple prints and paintings, further challenging the divide between painted original and printed reproduction. One of the 10 portraits was Albert Einstein, on this month’s cover. Like the others, this is less a portrait and more an icon; the icon of intelligence.In ad infinitum, “the most burdensome thought.” Yet each icon reflects the moment of its creation and is original. Thus the artist challenges the nature of seriality as described in antiquity and more recently in the work of Nietzsche and others, who attributed meaning to life by suggesting it was cyclical—the snake bites its tail. The artist was closer to those who disagreed, among them novelist Milan Kundera, who considered the “unbearable” possibility of no recurrence at all. At death, each person, each copy is gone.Further repetition and simulacra exist beyond these portraits and other Warhol works. His paintings are a sequence of recurrences already preceded by many and to be followed by many, like the eternal paths encountered by Friedrich Nietzsche’s famed Zarathustra on the mountainside, embodying the philosopher’s discussion of eternal recurrence: the universe and all in it have already occurred and will recur Warhol understood how the media shape our view of the world by appropriating and projecting icons, a process he adopted and used to great advantage. Along with another media favorite, repetition, this “deeply superficial” artist captured and held up for us to see, as in a mirror, the media’s fragmented version of reality. His technique fit perfectly the portrait of Einstein, whose expansive vision also allowed more than one version of reality.With characteristic unseriousness, Warhol proposed a more contemporary view of eternal recurrence: originality in duplication. This approach has a parallel in nature, which in this issue of Emerging Infectious Diseases relates to virus replication. A virus inserts itself into the cellular machinery, which produces and reassembles new viral particles—an age-old serial activity that will continue to recur. Like Warhol’s portraits, the replication is not always completely true, so some copies are not identical. The next virus, even though a replica, is not the same. The defining differences can be beneficial for virus replication and survival and may favor the emergence of infectious disease.


Dear Editor,It is with great interest that we recently read the article by Rostami et al. titled “Health Related Quality of Life in Iranian Hemodialysis Patients With Viral Hepatitis: Changing Epidemiology”  publisheHowever, there are few studies about this important issue it is excellent that Rostami et al. worked about this important topic. They showed that not only general health and physical activity were preserved but also health perception may be better among HD patients with viral hepatitis , while oFirst) it is important to note that in the current study , treatmeSecond) a number of studies have shown that many confounder factors such as age, educational level, gender, marital state, sex function, work status and other socioeconomic factors can influence HRQoL , 7. It iThird) in a previous study, Bianchi and coworkers  evaluateFinally, although this was a great study about HRQoL in a huge number of HD patients with chronic hepatitis, it still requires more studies to evaluate different factors that can affect on HRQoL.