Abstract. Health-care workers are on the front line to combat the peculiar coronavirus disease-19 (COVID-19) pandemic and are susceptible to acquiring this infection. This study is aimed at documenting the effect of “coronaphobia” on mental well-being and to report burnout among physicians. The study was conducted as a cross-sectional survey between November 17, 2020 and January 1, 2021 via a Google form distributed among the physicians of a tertiary care hospital, in Karachi, Pakistan. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) was used to assess the mental well-being of physicians. Burnout was documented by using the Maslach Burnout Inventory Human Services Survey for Medical Personnel. Eighty-seven physicians participated in the survey (mean age, 30.9 ± 7.3 years). The mean WEMWBS score of the study participants was 51.6 ± 10.8. Regarding the WEMWBS, emotional exhaustion was observed in 54% (N = 47) of participants, depersonalization in 77% (N = 67), and low personal accomplishment was reported in 31% (N = 27) of participants. The results of the survey further highlight that depersonalization, emotional exhaustion, and low personal accomplishment were associated significantly with a history of COVID-19 infection and COVID-19 postings. Hence, immediate measures are required to reduce the burnout among physicians while battling the second wave of the pandemic.
For decades, early modern historians have stressed the religious differences between the Dutch Republic and the Habsburg Netherlands. The former is usually represented as a tolerant Reformed state, while the latter is represented as a repressive Catholic regime. By consequence, the similarities in terms of confessional coexistence have never been considered. This article seeks to fill that gap by reviewing the Geuzenhoek, a small rural Reformed minority group in Flanders. Fortunately, a plethora of available sources allows us to research the interactions between the Protestants and the Catholic majority. This article shows that the divide between public worship and private devotion played a key role in keeping peaceful interreligious relations and that a stable system of connivance dominated the local framework. This situation was very similar to that of the Dutch Republic. As a result, this study concludes that confessional coexistence in the Habsburg Netherlands should be re-evaluated and merits further investigation.
Vroegmoderne historici hebben jarenlang vooral de religieuze verschillen tussen de Republiek der Verenigde Nederlanden en de Habsburgse Nederlanden benadrukt. De een werd gewoonlijk voorgesteld als een tolerante gereformeerde staat, terwijl de andere bekendstond als een repressief katholiek regime. De gelijkenissen op vlak van confessionele co-existentie zijn daarom nooit nader onderzocht. Dit artikel wil dit hiaat opvullen door de Geuzenhoek, een kleine landelijke gereformeerde minderheidsgroep in Vlaanderen, onder de loep te nemen. Dankzij een ruime collectie aan bronnen konden de interacties tussen de protestanten en de katholieken in beeld gebracht worden. Dit artikel toont aan dat de scheiding tussen publieke en private devotie een grote invloed had op het bewerkstelligen van vredige contacten, en dat in deze lokale context een systeem van ‘oogluikendheid’ domineerde. Deze situatie is vergelijkbaar met die in de Republiek. De conclusie van deze studie is dan ook dat de confessionele co-existentie in de Habsburgse Nederlanden een herevaluatie en verder onderzoek verdient.
Actualiteitsparagraaf
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Katholieken en protestanten in vroegmodern Vlaanderen
Over de interacties van protestanten en katholieken in het verleden overheersen ook vandaag nog hardnekkige clichés: ze konden elkaars bloed wel drinken, geweld tussen religieuze groepen kwam vaak voor en verdraagzaamheid was vrijwel onbestaand. Toch was de historische realiteit vaak anders. Roman Roobroeck toont in zijn artikel in BMGN – Low Countries Historical Review over de Geuzenhoek aan dat de verhoudingen tussen katholieken en protestanten in het zeventiende-eeuwse overwegend katholieke Vlaanderen opvallend vreedzaam waren. Tussen de leden van deze rurale protestantse groep nabij Oudenaarde en hun katholieke buren ontsponnen zich conflicten, maar over het algemeen waren hun relaties vreedzaam. De protestantse dorpelingen profiteerden van het afwachtende beleid van de Habsburgers en ontwierpen samen met de lokale katholieken een gedoogsamenleving. Deze vorm van religieuze co-existentie kwam dus niet enkel in de Noordelijke Nederlanden voor, maar ook in de Habsburgse Nederlanden. Misschien was het religieuze klimaat in de Zuidelijke Nederlanden dan toch niet zo rigide als vaak gedacht?
BACKGROUND In the multi-country PROMISE 1077BF/1077FF trial, the risk of low birth weight (LBW; <2500g) and preterm delivery (PTD; <37 weeks) was significantly higher among women initiating a protease inhibitor (PI)-based antiretroviral treatment (ART) regimen than those receiving ZDV alone. Among those assigned to a PI regimen, tenofovir/emtricitibine was associated with the more severe outcomes of very LBW (VLBW; <1500g) and very PTD (VPTD; <34 weeks) compared to zidovudine/lamivudine. METHODS We used multivariate logistic regression to further explore these treatment findings, taking into account demographic baseline clinical and post-entry obstetrical factors. We evaluated individual adverse outcomes and composites that included stillbirth and early loss/spontaneous abortion. RESULTS Among 3333 women delivering at least one live infant, median maternal age at enrollment was 26 years; 661 (20%) were primiparous, and 110 (3.3%) reported at least one prior PTD. Seventeen percent of newborns were LBW, 1% were VLBW, 17% had PTD, and 3% VPTD. Treatment allocation remained strongly associated with multiple adverse outcomes after controlling for other risk factors with both ART regimens exhibiting increased risk relative to ZDV alone. Other risk factors remaining significant in at least one of the multivariate models included: country, gestational age at entry, maternal age, maternal BMI, prior PTD, history of alcohol use, baseline HIV viral titer, multiple gestation and several obstetric risk factors. CONCLUSION ART effects on adverse pregnancy outcomes reported in the randomized PROMISE trial remained strongly significant even after controlling for demographic, baseline clinical and obstetrical risk factors, which were also associated with these outcomes.
Most guidelines recommend statins for primary prevention of cardiovascular disease (CVD) if 10-year risk exceeds 7.5% to 10%, often in addition to such other criteria as high cholesterol level or presence of at least 1 specific risk factor (15). However, use of statins for primary prevention of CVD is controversial and varies greatly among countries because of several factors, such as uncertainty about the applicability of the results of randomized controlled trials (RCTs) on primary prevention to real-world populations, the definition of eligible persons likely to benefit, and potential differential reporting of harms (69). Nevertheless, guidelines must make recommendations and deal with the uncertainties of the existing evidence base. Guidelines should consider multiple factors that influence the balance of benefits and harms of statins, including preventive effects and harms, baseline risks for benefit and harm outcomes, and outcome preferences of persons who may benefit from statins for primary prevention of CVD (10, 11). However, none of the current guidelines used a systematic assessment of the benefitharm balance of statins that considered these factors (12). In addition, whether the currently recommended risk thresholds of 7.5% and 10% are justified is unclear. Therefore, this study aimed to assess the balance of benefits and harms of statins for primary prevention of CVD and determine age- and sex-specific 10-year risk thresholds at which the net benefits of statins outweigh the net harms. Because not all statins have the same benefit and harm profiles (1315), we analyzed 4 commonly used statins separately. Methods Target Population and Setting We performed a quantitative benefitharm balance modeling study on use of statins for primary prevention of CVD for persons in the general population aged 40 to 75 years with no history of CVD events. We excluded persons older than 75 years because of scarce data in this age group. Our study evaluated the balance of benefits and harms and accounted for baseline risks for the benefit and harm outcomes, the magnitude of the increase or decrease in risk due to statins, the relative importance of the outcomes, and a specific time horizon. Statins and Benefit and Harm Outcomes This analysis focused on low- or moderate-dose statins, which are frequently prescribed for primary prevention of CVD (3), and excluded high-dose statins. We performed the benefitharm analysis for 4 statins (atorvastatin, simvastatin, pravastatin, and rosuvastatin) for which there were sufficient data from RCTs about their effects. We selected clinically relevant benefit and harm outcomes from systematic reviews (14, 16) and quantified their relevance in a preference-eliciting survey reported elsewhere (17). Benefit outcomes (those favoring statin use) were fatal and nonfatal CVD events. Harm outcomes (adverse effects of statins) were myopathy, hepatic and renal dysfunction, cataracts, hemorrhagic stroke, type 2 diabetes, any cancer, nausea or headache, and treatment discontinuation due to adverse effects. We considered non-CVD mortality as a competing risk because we found insufficient evidence that statins reduce deaths due to causes other than CVD. Although it would be possible to use specific CVD events in the benefitharm balance modeling, we considered a composite outcome of CVD events as the end point because most clinical guidelines and risk scores refer to such a composite outcome. This study did not consider costs associated with statins. Data Sources We systematically selected evidence on the following input parameters needed for the quantitative benefitharm balance modeling (18). Preventive or Adverse Effects of Statins We based estimates of statin effects on a network meta-analysis of CVD events and harm outcomes in a primary prevention population that we performed previously for the purpose of the current study (Figures 1 to 3 of the Supplement). We obtained information on preventive effects on cataracts and hemorrhagic stroke from 2 RCTs (HOPE-3 [Heart Outcomes Prevention Evaluation-3] [19] and MEGA [Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese] [20], respectively) because there were not enough trials for a meta-analysis. Data on harm outcomes from trials might be incomplete because of short follow-up or limited external validity or may be affected by differential reporting bias (8, 21). Observational studies may be more suitable for providing real-world estimates of harms, but they are often inherently biased (8, 21). We thus considered combined statin effect estimates for the harm outcomes from large observational studies and RCTs using a Bayesian inverse varianceweighted averaging method (Appendix Table 1 and Table 1 of the Supplement) (2225). The preventive effects from observational studies contributed less to the pooled effect due to higher variances. We also performed a sensitivity analysis using estimates of statin effects on harms from RCTs only. Supplement. Supplementary Information Appendix Table 1. Effect Estimates of Statins on Benefit and Harm Outcomes Considered From Randomized Controlled Trials and Observational Studies* Baseline Outcome Risks in the Population Population-based baseline risks are favored over event rates in control groups of RCTs because they better reflect the real-world population (18). We extracted age- and sex-specific baseline rates of type 2 diabetes, any cancer, hemorrhagic stroke, and non-CVD mortality from Global Burden of Disease estimates for Switzerland (26) and rates of myopathy, renal and hepatic dysfunction, and cataracts from other observational data (age- or country-specific rates were not available for these) (23) (Table 2 of the Supplement). We chose Switzerland for some of these age- and sex-specific risks because the weights of the outcomes were elicited there and because outcome risks are moderate there, except for competing risk for death, which is low compared with other countries. However, we also performed the analysis for the United States and the United Kingdom (see Sensitivity Analyses). Because baseline risks for nausea or headache and treatment discontinuation were not available, we used rates from control groups of RCTs. Outcome Preferences We considered population average preference weights from a preference-eliciting study designed to inform the current study. The bestworst scaling survey elicited preferences for benefit and harm outcomes of statins from a primary prevention population in Switzerland and Ethiopia (17). We considered preference weights reported as the surface under the cumulative ranking curve (SUCRA) (analyzed using a network meta-analytic approach) for the base-case analysis (27) and additional preference scales, including bestworst score and log-odds, for sensitivity analyses. The SUCRA indicates the probability of an outcome that patients would rather avoid or a weight showing the relative importance of an outcome to patients (larger values correspond to more important outcomes) (Appendix Table 2). Appendix Table 2. Preference Weights for Benefit and Harm Outcomes Considered for the BenefitHarm Balance Modeling* Time Horizon Although data from RCTs are available for follow-up less than 5 years, we extended the time horizon to 10 years with the assumption of smaller CVD risk accumulation and similar effects of statins over the period in low- to moderate-risk persons. Subgroups We modeled the balance of benefits and harms and determined risk thresholds for 350 subgroups according to age and sex across 10-year CVD risks ranging from 1% to the value above which the benefits consistently outweighed the harms. We did not need to predict 10-year CVD risks because we repeated the analysis for each percentage point increase up to 25% (all statins) or 40% (specific statins). Although not relevant to this study, the use of well-calibrated risk scores is important for clinical practice to determine a person's risk and whether this risk justifies use of statins. Statistical Analysis BenefitHarm Balance Index We used a benefitharm balance model developed by Gail and colleagues at the National Cancer Institute (NCI) (28, 29) and extended it to fit our research question of determining risk thresholds. A detailed description of our model is provided in the Appendix. In brief, we estimated the expected age- and sex-specific number of benefit and harm outcome events per 1000 persons not using statins over 10 years by using an exponential model that assumed constant risk rates over the time horizon and accounted for competing risk for non-CVD death. We then calculated the corresponding number of expected events for each outcome among statin recipients by using the same model but with consideration of estimates of statin effects. The differences in expected events with and without statin use provided attributable absolute events for each benefit and harm outcome. We then weighted the differences by their respective preference weights and summed them to yield a single benefitharm index. The resulting index could have any negative (harms outweighed benefits), zero (harms equaled benefits), or positive (benefits outweighed harms) value on an arbitrary scale. To account for statistical uncertainty of the input parameters, we repeated the analysis 100000 times for each subgroup with resampling of the parameters independently from normal distributions defined by their mean estimates (log risk ratio, SUCRA, and baseline risks) and their SEs. Determining 10-Year Risk Thresholds for Net Benefits We calculated the probability of net benefits as the proportion of repetitions for which the benefitharm index was positive (benefits outweighed harms). This probability could have any value between 0% and 100%. We defined statins as having net benefits if the probability of the index exceeding zero was at least 60% and net harms if the probability was less than 40%. Thus, probabilities of at
INTRODUCTION In Georgia as in most Eastern European countries, injecting drug use remains one of the leading transmission modes of HIV infection. This paper aims to identify HIV prevalence and risk determinants among people who inject drugs (PWID). METHODOLOGY A cross -sectional, anonymous bio-behavioral survey of PWID was conducted in seven cities of Georgia in 2014-2015. Overall 2,022 PWID were investigated. Bivariate and multivariate regression analyses were performed to identify association of HIV positivity with other factors. RESULTS HIV prevalence among PWID was (2.2%, 95% CI 1.53-2.99). Significant associations were found between HIV positivity and history of drug injection (OR 1.03, p < 0.05), older age at first drug injection (OR 3.94, p < 0.01), safe sex behavior last year (OR 5.32, p < 0.01) and preventive program coverage (OR 2.0, p < 0.05). CONCLUSIONS HIV prevalence among PWID is stable and remains at low level. Our study shows that preventive interventions influence the sexual behavior of HIV positive PWID, however, the majority of injecting drug users are still not reached with these interventions. A changing environment may present additional challenges for harm reduction and current safe practices may change unless continuously supported by innovative HIV prevention programming.
Hans Hulshof, Erik Kwakernaak en Frans Wilhelm, Geschiedenis van het talenonderwijs in Nederland. Onderwijs in de moderne talen van 1500 tot heden (Groningen: Passage, 2015, 468 pp., isbn 978 90 5452 315 4).
In de zomer van 2013 bood Nederland voor het eerst in de geschiedenis officieel excuses aan voor misdaden begaan tijdens de onafhankelijkheidsoorlog in Indonesië (1945-1949). Indonesische slachtoffers hadden de Nederlandse regering hiertoe gedwongen door middel van twee civiele rechtszaken. Het bewandelen van de juridische weg verschafte aan hen een stem in het land van de daders en gaf ze een kans hun rechten op te eisen.
Maar de juridische benadering van het spreken over historisch onrecht kan ook keerzijden hebben. Het beperkt namelijk het publieke debat tot nauw omlijnde gevallen die binnen de parameters van de juridische bewijsvoering vallen. Bovendien zorgt het feit dat excuses juridisch afgedwongen moeten worden ervoor dat de kans op verzoening – het doel van de excuses – aanmerkelijk vermindert. De juridisering van het spreken over historische excuses is daarmee een tweesnijdend zwaard.
Dit artikel maakt deel uit van het forum 'Historische excuses'.
Legally Sanctioned Apologies: Rawagedeh, South Sulawesi, and Dutch Reticence
In the summer of 2013, for the first time in history, the Netherlands decided to officially apologise for crimes committed by its troops during the Indonesian war of independence (1945-1949). Indonesian victims had forced the Dutch government to take this step by suing it in two consecutive civil lawsuits. Taking legal steps had offered these victims a chance to demand justice and have their voices heard in the land of the perpetrators.
However the legal approach to bringing historical injustice to public attention can also have adverse effects. It confines public debate to very specific types of incidents that fall within the parameters of legal responsibility and legal evidence. Moreover, the fact that apologies have to be legally enforced diminishes the chance of successful reconciliation – the apparent goal of apologies. The juridification of speaking about historical apologies is therefore a double-edged sword.
This article is part of the forum 'Historical apologies'.