Acute stress disorder modifies cerebral activity of amygdala and prefrontal cortex.

The diagnosis constraint of acute stress disorder (ASD), consisting of testing individuals in the month following trauma exposure, limits research on the very early and initial stage of the disease. In this regard, this work aims to explore the cerebral mechanism of ASD in a population of fire-fighters before and after trauma exposure. Thirty-six healthy non-traumatized male fire-fighters were explored by an fMRI emotional face-matching task to evaluate the cerebral substrate of emotional recognition. During the two years of the follow-up, two subjects were traumatized, and thus retested, as were 10 non-traumatized subjects among the initial non-exposed ones. In comparison to non-exposed subjects, fire-fighters with ASD had enhanced amygdala, orbitofrontal, and dorsolateral prefrontal BOLD responses to fearful and angry faces (p < .05, FDR-corrected). These results shed new light on the cerebral mechanism associated with ASD. We observed for the first time the existence of an altered fear processing pathway in ASD that is mediated by amygdala and prefrontal cortex hyperactivity, which might be at the core of the disorder.

Relationship between emotional experience and resilience: an fMRI study in fire-fighters.

Resilience refers to the capacity to cope effectively in stressful situations or adversity. It may involve the ability to experience emotions matching the demands of environmental circumstances. The brain mechanisms underlying resilience remain unclear. In this study, we aim to investigate the relationship between the neural basis of emotional experience and resilience. Thirty-six fire-fighters were included. They performed an fMRI script-driven paradigm comprising relaxing and trauma-related scripts to evaluate the cerebral substrate of emotional experience (p<0.05, FDR-corrected). Correlations were examined between fMRI activations and the resilience DRS15 scale (p<0.05). Resilience was positively correlated with the right amygdala and left orbitofrontal activations when performing the contrast of trauma vs. relaxing script. The present study provides neural data on the mechanisms underlying resilience and their relationship with emotional reactivity, suggesting that appropriate emotional response in stressful situations is essential for coping with aversive events in daily life.

Use of imaging in the follow-up of workers exposed to lung carcinogens: practices in occupational medicine and its determinants.

We studied occupational physicians' (OPs) practices of referrals for imaging of workers occupationally exposed to lung/pleural carcinogens and the factors associated with them. This cross-sectional telephone survey of 379 OPs practicing in Southeastern France showed that 81% of them referred exposed patients for chest radiographs, 33.5% for computed tomography (CT), and 16.1% for neither. Making no referral was positively associated with believing cancer risks are lower in one's own geographic sector than elsewhere and negatively associated with keeping employee risk records up-to-date. Referrals for CT were positively associated with work at in-house occupational health services (OHS), and completing employee exposure histories often/always. Both the OHS type and factors that may shape OPs' awareness of cancer risks in their sector appear to influence imaging referral practices. Occupational physicians would benefit from guidelines clarifying benefits and risks associated with imaging in such patients. An effort to harmonize regulatory provisions and guidelines also appears necessary.

Occupational physicians' attitudes and practices in relation to occupational cancer prevention: a qualitative study in southeastern France.

We conducted a qualitative survey of 20 occupational physicians (OPs) in southeastern France in 2008 to study their attitudes and practices regarding the prevention of occupational cancers. Occupational physicians' practices regarding occupational cancers centered mainly on prevention. Numerous difficulties impeded these activities: attitudes that minimized the carcinogenic risks by employers and employees, the absence or inadequacy of mandatory risk assessment to identify health hazards, and difficulties in obtaining individual exposure forms, which employers are supposed to complete to identify employees exposed to carcinogens. Other problems were related to the resources available to OPs and the constraints on their time. Finally, some OPs reported that they lacked self-efficacy. The results of this study suggested the need to strengthen OPs' initial training, draft and adopt good practice guidelines for various aspects of their practices, and improve collaborations between OPs and other professionals specialized in the prevention of occupational risks.

[What barriers hinder the reporting of work related sciatic pain by GPs and rheumatologists?]. / Quels freins à la déclaration d'une lombosciatique en maladie professionnelle pour les médecins généralistes et les rhumatologues?

Despite an epidemic of muscular-skeletal disorders (MSD), they are underreported. We carried out a telephone survey of 391 general practitioners (GPs) and 96 rheumatologists in south-eastern France to study the barriers to physicians' reporting of occupational diseases (OD). We presented them with a case-study of a patient with work-related sciatica. 72% of GPs and 84% of rheumatologists did not recommend to report this OD, for the following reasons, respectively: hesitation due to the possible role of extraprofessional activities as the root cause (77%, 74%), preferably should be reported as an occupational accident (67%, 42%), acknowledgement that the reporting of this is the role of occupational physicians (60% et 60%) and fear of risk of loosing one's job (47%, 36%). Results of multiple regression analyses suggest that the lack of awareness of reporting procedures and the presumption of causality principle may be main barriers to reporting.

Barriers to physician reporting of workers' compensation cases in France.

Studies suggest strong underreporting of occupational diseases in industrialized countries. We studied physician-related barriers to reporting of occupational sciatica (with herniated disk). We conducted a telephone survey of 391 general practitioners (GPs) and 96 rheumatologists in southeastern France with a standardized questionnaire and case-vignette of a patient with occupational sciatica. Our results show that 71% of GPs and 78% of rheumatologists would not recommend that the case-vignette patient file a workers' compensation claim, for the following reasons: possible role of nonwork-related activities (77%, 74%), should be reported as an occupational accident (67%, 42%), recommendation should be made by occupational physicians (60%, 60%), and risk of patient's losing his job (47%, 38%). Our results suggest that occupational sciatica is underreported in France. Physicians' lack of knowledge of reporting principles and procedures and their ethical dilemma regarding job loss may be barriers to reporting.

[Factors associated with physicians' under-reporting of asbestos-related bronchopulmonary cancers. Telephone survey conducted among general practitioners and pulmonologists randomly selected in the French region of Provence-Alpes-Côte-d'Azur]. / Facteurs associés à la sous-déclaration par les médecins des cancers bronchopulmonaires liés à l'amiante. Enquête téléphonique auprès d'un échantillon représentatif de médecins généralistes et de pneumologues de la région Provence-Alpes-Côte-d'Azur.

OBJECTIVES: To study the difficulties faced by general practitioners to detect and report asbestos-related cancers, focusing on the influence of patients' tobacco use, physicians' training and role perception. METHOD: Telephone survey conducted among 486 general practitioners and pulmonologists randomly selected in the French region of Provence-Alpes-Côte d'Azur, with: 1) a standardized questionnaire on their behaviors, attitudes and practices in the field of occupational health; 2) a clinical case (case vignette) about a lung cancer patient with occupational asbestos exposure. Two alternative versions of the clinical case varying only in the patient's smoking status were presented randomly to two subgroups of general practitioners and pulmonologists. The primary variable examined was the physician recommendation that the patient described in the vignette file an occupational disease claim. RESULTS: The response rate was 64.4% among general practitioners and 62.5% among pulmonologists. In multiple logistic regressions, the recommendation to file an occupational disease claim was significantly associated with specialty (OR = 4,46; 95% CI: 2.38-8.37 for pulmonologists versus general practitioners), patient's smoking status (OR = 3.15; 95% CI: 2.11-4.70, for non-smokers versus smokers), physician's workload (OR =1,8; 95% CI:1.17-2.88, for physicians examining less than 25 patients per day versus those examining more than 25) and role perception (OR = 2.00; 95% CI:1.22-3.27, for those who considered completing occupational disease medical certificates to be part of their role versus those who did not). CONCLUSION: For a certain number of physicians, tobacco use often over-shadows the role of environmental carcinogens in the development of cancers. Those responsible for initial and continuing medical education should give occupational health higher priority in their programs. Tools designed to help physicians detecting and managing occupational diseases should be developed and disseminated.

Intensive physical activity and alexithymia: results from swimmers' discourse analysis.

The aim of this study was to describe and understand the relationship of swimmers' practice intensity and alexithymia features in discourse. This study investigated psychological processes in two groups of male swimmers training at different intensities. The first group was composed of 10 Expert amateurs (M age = 19.5 yr., SD = 1.9), who were competing at the national or international level and trained 22 hours per week. The second group was composed of 10 Amateur swimmers (M age = 20.5 yr., SD = 1.4), who competed at the regional level and trained 6 hours per week. The discourse of swimmers was analysed using the ALCESTE (Analyse de Lexèmes Coocurents dans les Enoncés Simples d'un Texte) method of discourse analysis. Discourse analysis was performed on speech samples produced by swimmers. All the swimmers showed alexithymic verbal behaviour as regards both the means of expression used and the feelings and emotions expressed. This lack of articulateness was more pronounced in the Expert than in the Amateur group. The difference of alexithymic features in correlation with the intensity of sport practice raises the question of the health benefits of intense sports practice and the need for psychological assessment of athletes.

General practitioners' attitudes towards patients with disabilities: the need for training and support.

PURPOSE: Some general practitioners (GPs) report discomfort in caring for people with disabilities. These feelings may impede the provision of quality health care to these patients. METHOD: A cross-sectional survey interviewed 600 GPs in southeastern France and assessed their personal and professional characteristics, their attitudes and opinions towards people with disabilities, and their knowledge and practices in this field. RESULTS: 21.3% of the GP reported discomfort in treating people with mental impairments and 8.2% people with physical impairments. Discomfort with either type of impairment was more frequent among GPs who perceived frequent communication problems with persons with disabilities (p < 0.05) or who did not belong to a professional network (p < 0.10). GPs who reported less experience with the disabled patients (p < 0.05), no medical training about disabilities (p = 0.04), a lack of assistance during consultations (p = 0.02), and inadequate consultation time (p = 0.09) expressed more discomfort in caring for patients with mental impairments. GPs' discomfort was associated with their assessment of the patient's level of disability among patients with physical impairments (p = 0.01). CONCLUSION: This study suggests that substantial obstacles related to GPs' attitudes impede the delivery of quality health care to patients with disabilities and that GPs need more support and guidance in dealing with them. These results raise also the issue of adequate time and remuneration for consultations with these patients.

Women with disabilities: general practitioners and breast cancer screening.

BACKGROUND: Because they undergo breast cancer screening (BCS) relatively infrequently, women with physical or mental impairments may be at higher risk of late-stage breast cancer than women without impairments. A panel of 600 general practitioners (GPs) in Provence (southeastern France) provided information from which barriers potentially associated with BCS practices for women with disabilities were evaluated. METHODS: In 2002, a telephone questionnaire collected data about GPs' personal and professional characteristics and their attitudes and practices regarding patients with disabilities. Analysis in 2003 used simple and multiple logistic regressions. RESULTS: More than a quarter of the GPs reported apparently inadequate BCS practices for people with disabilities. Feelings of discomfort when treating people with disabilities, lack of assistance, and communication difficulties were inversely associated with BCS for women with mental and physical impairments. General practitioners' information-seeking strategies were associated with BCS for women with mental impairments, and nursing home work experience was inversely associated with BCS for women with physical impairments. CONCLUSIONS: Appropriate training sessions should be made available to improve primary health care quality and prevention practices and to reduce GPs' misperceptions of people with disabilities.

Participation in sports and alcohol consumption among French adolescents.

Using an anonymous self-report questionnaire (N=816 participants), we examined the relation between participation in sports and alcohol consumption and identified the risk factors associated with alcohol consumption among French high-school students. Univariate analysis showed that sport involvement was related to higher alcohol use (P<.05). Participants who participated in group sports drank significantly more than those who participated as individuals (P<.01). Multivariate analysis underlined factors associated with alcohol consumption, but these varied considerably according to the level of alcohol consumption. Three factors were associated with weekly and daily alcohol use: male gender, daily cigarette use, and perception of poor health.

Socio-economic and health characteristics of HIV-infected patients seeking care in relation to access to the Drug Access Initiative and to antiretroviral treatment in Côte d'Ivoire.

OBJECTIVE: To compare socio-economic and health characteristics of HIV-infected patients in Côte d'Ivoire whether or not they had access to the Drug Access Initiative (DAI) and to antiretroviral drug (ARV) treatment. DESIGN AND METHODS: Cross-sectional survey using medical files, blood sampling for CD4 cell counts and face-to-face interviews among all patients, informed of their HIV status, who attended during a 6-week period in the five DAI referral centres and three additional centres in charge of HIV care in Abidjan and Bouaké (participation rate = 65.4%). Multiple logistic regression using generalized estimating equations (GEE) to identify factors related to non-access to DAI and to ARV treatment. RESULTS: Among the 711 respondents, 23.0% were ARV-treated, 14.2% had been included in the DAI but were still waiting for initiation of ARV, and 62.7% were neither part of the DAI nor ARV-treated. In this latter group, less than one-third (29.6%) declared that they knew about the existence of the DAI. Among the 164 ARV-treated patients, 59.1% had benefited from DAI public subsidies partially covering the costs of drugs. In the non-DAI-non-ARV-treated group, 86% could have qualified for ARV treatment according to the DAI medical criteria (CD4 cell counts < 500 x 10(6) cells/l), and only 32.9% of those medically eligible were prescribed cotrimoxazole prophylaxis. In multivariate analysis, not being in the DAI and not being ARV-treated was related to: being a male, not having health care insurance, having a low level of education, living in poor housing conditions (absence of refrigerator in the household, absence of ventilation in patient's bedroom), and not being under cotrimoxazole prophylaxis. CONCLUSION: The Ivoirian DAI has facilitated access to ARV treatment for a significant number of patients with limited ability to pay. The majority of HIV-infected patients seeking care however face persisting socio-economic and informational barriers to access to these treatments.

Physicians' knowledge and attitudes toward HIV care in the context of the UNAIDS/Ministry of Health Drug Access Initiative in Côte d'Ivoire.

OBJECTIVE: To evaluate the impact of the availabity of highly active antiretroviral therapies (HAART) in the context of the Drug Access Initiative (DAI) on physicians' knowledge, attitudes and practices toward HIV care in Côte d'Ivoire. DESIGN AND METHODS: Cross-sectional survey using self-administered questionnaires among all consulting physicians in the six 'referral centers' of the DAI and five additional centers in charge of HIV care. RESULTS: Among the 123 respondents (response rate = 82.0%), 45.1% took care of more than 20 HIV-infected patients during the previous year. These physicians with the most experience in HIV care had a better knowledge than the rest of the sample about HIV disease, cotrimoxazole prophylaxis and antiretroviral treatment, and were more likely to declare that HIV-infected patients may be 'dangerous for others' (33.9 versus 17.9%; P = 0.03). Although 54.5% declared that the eligibility medical criteria for HAART 'should be the same in both developing and developed countries', only 30.9% adhered to the recently issued DAI guideline (October 1999) recommending initiation of HAART for patients with CD4 cell counts < 500 x 10(6) cells/l. CONCLUSION: Physicians involved in the DAI in Côte d'Ivoire have acquired appropriate expertise and knowledge about HAART, but dissemination of information about HAART must be extended to physicians with more limited experience in HIV care. Current international efforts to adapt HIV treatment guidelines for resource-limited settings may face difficulties for reaching consensus among the African health professionals in charge.

Efficacy of an educational and counseling intervention on adherence to highly active antiretroviral therapy: French prospective controlled study.

PURPOSE: The objective was to evaluate the impact of an intervention for improving adherence to antiretroviral therapies (HAART) in HIV-infected patients. METHOD: We designed a prospective, controlled, randomized trial to assess the impact of an educational and counseling intervention in addition to standard of care. At M0, the study enrolled 244 HAART-treated patients who attended a medical consultation between September and December 1999 who were not included in another protocol. Patients in the intervention group (IG) were offered three individual sessions by trained nurses. The proportions of adherent patients at 6 months followup (M6) and the change in HIV RNA between M0 and M6 were measured. RESULTS: Between M0 and M6, HIV RNA significantly decreased in the 123 patients of the IG (mean difference = -0.22 log [+/-0.86], p =.013), while it increased (+0.12 log [+/-0.90], p =.14) in the 121 patients of the control group. However, the proportion of patients with HIV RNA <40 copies/mL remained similar in both groups. In an intent-to-treat analysis, the only significant predictor of 100% adherence at M6 was the intervention group (p =.05) after adjustment for baseline adherence (p =.001). Among the 202 patients with available data on adherence, the proportion of adherent patients was similar in both groups at M0 (58% vs. 63%, p =.59) but became higher in the IG at M6 (75% vs. 61%, p =.04). CONCLUSION: The educational and counseling intervention was efficient for increasing adherence to HAART and could be implemented in most clinical settings.

Adherence to highly active antiretroviral therapies (HAART) in HIV-infected patients: from a predictive to a dynamic approach.

To-date, most socio-behavioural research about HTV-infected patients' adherence to highly active antiretroviral therapies (HAART) has been based on cross-sectional studies. The French APROCO cohort gave us the opportunity to conjointly analyse the relationships between short-term adherence to HAART and HIV-infected patients' characteristics before initiation of treatment on the one hand, factors related to patients' subjective experience with HAART on the other hand. At the fourth-month follow-up visit (M4) after first prescription of HAART (M0), 26.7% of our sample of 445 patients self-reported non-adherence behaviour. Some patients' characteristics at M0 (younger age, poor housing conditions, lack of social support, and problems of adherence with previous antiretroviral regimens) were related to non-adherence at M4 in multivariate analysis. Non-adherence at M4 was, however, also related to the evolutions that affected a number of factors between M0 and M4: levels of depression, symptoms associated with treatment side effects, perception of individual state of health, beliefs towards effectiveness and toxicity of HAART. increases in alcohol and tobacco consumption, as well as contacts with other physicians than hospital HAART prescribers. Our prospective study brings additional evidence that even short-term non-adherence cannot be reliably predicted on the sole basis of a few a priori patient characteristics that clinicians could easily identify before initiation of HAART. It suggests that a dynamic approach to adherence, continuously monitoring the impact of experience with HAART on patients' daily lives, is needed for improving management of HIV/AIDS care.