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Kone N, Cassim N, Maposa I, George JA. Diabetic control and compliance using glycated haemoglobin (HbA1C) testing guidelines in public healthcare facilities of Gauteng province, South Africa. PLoS One 2023; 18:e0278789. [PMID: 37585388 PMCID: PMC10431606 DOI: 10.1371/journal.pone.0278789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 08/02/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE This study aimed at evaluating diabetic control and compliance with testing guidelines, across healthcare facilities of Gauteng Province, South Africa, as well as factors associated with time to achieve control. South Africa's estimated total unmet need for care for patients with type 2 diabetes mellitus is 80%. RESEARCH DESIGN, METHODS AND FINDINGS The data of 511 781 patients were longitudinally evaluated. Results were reported by year, age category, race, sex, facility and test types. HbA1C of ≤7% was reported as normal, >7 - ≤9% as poor control and >9% as very poor control. The chi-squared test was used to assess the association between a first-ever HbA1C status and variables listed above. The Kaplan-Meier analysis was used to assess probability of attaining control among those who started with out-of-control HbA1C. The extended Cox regression model assessed the association between time to attaining HbA1C control from date of treatment initiation and several covariates. We reported hazard ratios, 95% confidence intervals and p-values. Data is reported for 511 781 patients with 705 597 laboratory results. Poorly controlled patients constituted 51.5%, with 29.6% classified as very poor control. Most poorly controlled patients had only one test over the entire study period. Amongst those who started with poor control status and had at least two follow-up measurements, the likelihood of achieving good control was higher in males (adjusted Hazard Ratio (aHR) = 1.16; 95% CI:1.12-1.20; p<0.001) and in those attending care at hospitals (aHR = 1.99; 95% CI:1.92-2.06; p<0.001). CONCLUSION This study highlights poor adherence to guidelines for diabetes monitoring.
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Affiliation(s)
- Ngalulawa Kone
- Department of Chemical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
| | - Naseem Cassim
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Innocent Maposa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jaya Anna George
- Department of Chemical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service (NHLS), Johannesburg, South Africa
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Molina R, Enriquez M. Enhancing Diabetes Health Outcomes Among Haitian Migrants Living in Dominican Bateyes. Sci Diabetes Self Manag Care 2023; 49:281-290. [PMID: 37313730 DOI: 10.1177/26350106231178838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this study was to better understand the factors that influence the ability of batey adults to self-manage their type 2 diabetes mellitus (T2DM). METHODS A qualitative descriptive approach was used to conduct in-depth, individual interviews in Spanish. Participants (n = 12) were health care workers and members of a nongovernmental organization (NGO) that provides direct diabetes care to batey residents via free, pop-up, mobile medical clinics. Conventional content analysis was used to identify categories and common themes in the data. RESULTS Participants described daily existence in the bateyes as a constant "scarcity of resources." Additionally, four themes and one subtheme emerged that participants felt impacted diabetes health outcomes and the ability of NGO health care workers to provide diabetes care. CONCLUSIONS NGO members, while committed to serve and improve health outcomes for the batey population, often felt overwhelmed. Findings from this qualitative descriptive study may be used to inform novel interventions, which are needed, to enhance the diabetes outcomes of the batey residents who are living with T2DM. In addition, strategies are needed to build diabetes care infrastructure in the batey community.
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Affiliation(s)
- Rosalia Molina
- Research College of Nursing, Kansas City, Missouri
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri
| | - Maithe Enriquez
- Research College of Nursing, Kansas City, Missouri
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri
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Balakumar P, Venkatesan K, Abdulla Khan N, Raghavendra NM, Venugopal V, Bharathi DR, Fuloria NK. Mechanistic insights into the beneficial effects of curcumin on insulin resistance: opportunities and challenges. Drug Discov Today 2023:103627. [PMID: 37224995 DOI: 10.1016/j.drudis.2023.103627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/03/2023] [Accepted: 05/17/2023] [Indexed: 05/26/2023]
Abstract
The past couple of decades in particular have seen a rapid increase in the prevalence of type 2 diabetes mellitus (T2DM), a debilitating metabolic disorder characterised by insulin resistance. The insufficient efficacy of current management strategies for insulin resistance calls for additional therapeutic options. The preponderance of evidence suggests potential beneficial effects of curcumin on insulin resistance, while modern science provides a scientific basis for its potential applications against the disease. Curcumin combats insulin resistance by increasing the levels of circulating irisin and adiponectin, activating PPARγ, suppressing Notch1 signalling, and regulating SREBP target genes, among others. In this review, we bring together the diverse areas pertaining to our current understanding of the potential benefits of curcumin on insulin resistance, associated mechanistic insights, and new therapeutic possibilities. Teaser: Current approaches to manage insulin resistance are not highly efficacious, which necessitates additional therapeutic options; curcumin combats insulin resistance by improving the levels of circulating irisin and adiponectin, upregulating and activating PPARγ, and suppressing Notch‑1 signalling.
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Affiliation(s)
- Pitchai Balakumar
- The Office of Research and Development, Periyar Maniammai Institute of Science & Technology, Vallam, Thanjavur 613 403, Tamil Nadu, India.
| | - Kumar Venkatesan
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Khalid University, Al-Qara, Abha 61421, Saudi Arabia
| | - Noohu Abdulla Khan
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Al-Qara, Abha 61421, Saudi Arabia
| | - N M Raghavendra
- Department of Pharmaceutical Chemistry, College of Pharmaceutical Sciences, Dayananda Sagar University, Bengaluru 560 111, India
| | - Vijayan Venugopal
- School of Pharmacy, Sri Balaji Vidyapeeth Deemed-to-be University, Puducherry 607 402, India
| | - D R Bharathi
- Department of Pharmacology, Sri Adichunchanagiri College of Pharmacy, Adichunchanagiri University, B G Nagara, Nagamangala 571 448, India
| | - Neeraj K Fuloria
- Pharmaceutical Chemistry Unit, Faculty of Pharmacy, AIMST University, Semeling, 08100 Bedong, Malaysia
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Rao KD, Mehta A, Kautsar H, Kak M, Karem G, Misra M, Joshi H, Herbst CH, Perry HB. Improving quality of non-communicable disease services at primary care facilities in middle-income countries: A scoping review. Soc Sci Med 2023; 320:115679. [PMID: 36731302 DOI: 10.1016/j.socscimed.2023.115679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 12/02/2022] [Accepted: 01/13/2023] [Indexed: 01/22/2023]
Abstract
Health systems in middle-income countries face important challenges in managing the high burden of Non-Communicable Diseases (NCD). Primary health care is widely recognized as key to managing NCDs in communities. However, the effectiveness of this approach is limited by poor quality of care (QoC), among others. This scoping review identifies the types of interventions that have been used in middle-income countries to improve the quality of NCD services at primary care facilities. Further, it identifies the range of outcomes these quality interventions have influenced. This scoping review covered both the grey and peer-reviewed literature. The 149 articles reviewed were classified into four domains - governance, service-delivery systems, health workforce, and patients and communities. There was a remarkable unevenness in the geographic distribution of studies - lower middle-income countries and some regions (Middle East, North Africa, and South East Asia) had a scarcity of published studies. NCDs such as stroke and cardiovascular disease, mental health, cancer, and respiratory disorders received less attention. The thrust of quality interventions was directed at the practice of NCD care by clinicians, facilities, or patients. Few studies provided evidence from interventions at the organizations or policy levels. Overall, effectiveness of quality interventions was mixed across domains. In general, positive or mixed effects on provider clinical skills and behavior, as well as, improvements in patient outcomes were found across interventions. Access to care and coverage of screening services were positively influenced by the interventions reviewed. This review shows that quality improvement interventions tried in middle-income countries mostly focused at the provider and facility level, with few focusing on the organizational and policy level. There is a need to further study the effectiveness of organizational and policy level interventions on the practice and outcomes of NCD care.
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Affiliation(s)
- Krishna D Rao
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Akriti Mehta
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Hunied Kautsar
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | | | - Madhavi Misra
- Johns Hopkins India Private Limited, New Delhi, India
| | - Harsha Joshi
- Johns Hopkins India Private Limited, New Delhi, India
| | | | - Henry B Perry
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Chary AN, Nandi M, Flood D, Tschida S, Wilcox K, Kurschner S, Garcia P, Rohloff P. Qualitative study of pathways to care among adults with diabetes in rural Guatemala. BMJ Open 2023; 13:e056913. [PMID: 36609334 PMCID: PMC9827254 DOI: 10.1136/bmjopen-2021-056913] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE The burden of diabetes mellitus is increasing in low-income and middle-income countries (LMICs). Few studies have explored pathways to care among individuals with diabetes in LMICs. This study evaluates care trajectories among adults with diabetes in rural Guatemala. DESIGN A qualitative investigation was conducted as part of a population-based study assessing incidence and risk factors for chronic kidney disease in two rural sites in Guatemala. A random sample of 807 individuals had haemoglobin A1c (HbA1c) screening for diabetes in both sites. Based on results from the first 6 months of the population study, semistructured interviews were performed with 29 adults found to have an HbA1c≥6.5% and who reported a previous diagnosis of diabetes. Interviews explored pathways to and experiences of diabetes care. Detailed interview notes were coded using NVivo and used to construct diagrams depicting each participant's pathway to care and use of distinct healthcare sectors. RESULTS Participants experienced fragmented care across multiple health sectors (97%), including government, private and non-governmental sectors. The majority of participants sought care with multiple providers for diabetes (90%), at times simultaneously and at times sequentially, and did not have longitudinal continuity of care with a single provider. Many participants experienced financial burden from out-of-pocket costs associated with diabetes care (66%) despite availability of free government sector care. Participants perceived government diabetes care as low-quality due to resource limitations and poor communication with providers, leading some to seek care in other health sectors. CONCLUSIONS This study highlights the fragmented, discontinuous nature of diabetes care in Guatemala across public, private and non-governmental health sectors. Strategies to improve diabetes care access in Guatemala and other LMICs should be multisectorial and occur through strengthened government primary care and innovative private and non-governmental organisation care models.
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Affiliation(s)
- Anita Nandkumar Chary
- Medicine & Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
| | - Meghna Nandi
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Family Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - David Flood
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott Tschida
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
| | - Katharine Wilcox
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Family Medicine, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
| | - Sophie Kurschner
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Pablo Garcia
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Nephrology, Stanford University School of Medicine, Stanford, California, USA
| | - Peter Rohloff
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Nagata T, Aoyagi SS, Takahashi M, Nagata M, Mori K. Effects of Feedback From Self-Monitoring Devices on Lifestyle Changes in Workers with Diabetes: 3-Month Randomized Controlled Pilot Trial. JMIR Form Res 2022; 6:e23261. [PMID: 35943766 PMCID: PMC9399840 DOI: 10.2196/23261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/02/2021] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Background
Although lifestyle interventions are useful in the prevention and management of diabetes, they can be expensive and time-consuming. There is some evidence on the effectiveness of automated mobile technology for health self-monitoring; however, few studies have used such devices in the occupational health field.
Objective
We aimed to examine the effectiveness of a digital self-monitoring device on glucose levels and activity of workers with diabetes in Japan. The primary outcomes were changes in blood glucose levels, and the secondary outcomes were changes in weight and BMI.
Methods
A 2-arm randomized controlled pilot trial was conducted with workers from 23 organizations. The intervention group (n=50) wore an armband activity monitor, a body composition monitor, and a blood pressure monitor for 3 months and received semiautomated weekly email messages tailored to their device data. The control group (n=53) engaged in no self-monitoring. Messages were developed by a physician and a dietician. Postintervention changes in blood glucose levels, weight, and BMI were compared between the intervention and control groups, using blood tests and questionnaires.
Results
At the end of 3 months, the intervention group showed significantly lower blood glucose levels (HbA1c: intervention group mean 6.4% (SD 0.3%) vs control group mean 6.6% (SD 0.3%); Cohen d=0.7, 95% CI 0.2-1.1; P=.009). There were no significant between-group differences in weight and BMI.
Conclusions
Mobile digital self-monitoring was effective in improving blood glucose levels in workers with diabetes. The use of digital health devices is a cost-effective way of implementing health self-monitoring for large numbers of individuals in the workplace. However, due to the large volume of missing values in this study, we need to be careful in interpreting the results, and well-designed intervention studies need to be conducted.
Trial Registration
University Hospital Medical Information Network UMIN000023651;
https://upload.umin.ac.jp/cgi-open-bin/icdr/ctr_view_cb.cgi?recptno=R000027244&flwp_key=1008PYbOcXKmk7CAg4Th1FWS
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Affiliation(s)
- Tomohisa Nagata
- Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Sona-Sanae Aoyagi
- Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Minekazu Takahashi
- Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Masako Nagata
- Department of Occupational Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Koji Mori
- Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
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Xu Q, Hou X, Xiao T, Zhao W. Factors Affecting Medical Students’ Continuance Intention to Use Mobile Health Applications. J Multidiscip Healthc 2022; 15:471-484. [PMID: 35300179 PMCID: PMC8921670 DOI: 10.2147/jmdh.s327347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 02/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background With the dramatic growth in smartphones, mobile health applications (apps) in the field of healthcare or medicine, which are characterized by strong operability, flexibility and interactivity, provide a supplementary approach to medical learning. The aims of this study were to awaken medical students to pay more attention to the learning function of mobile health app and gain deeper insight into our understanding of the factors influencing medical students’ mobile health apps continuance intention for enhancing practical utilization. Methods A cross-sectional survey was conducted with a self-designed questionnaire administered to medical students at Chongqing Medical University. Data were collected from 450 participants from March to April 2019. SPSS V.25 was used for the descriptive statistical analysis of the results. Smart PLS 3.2.7 was used to construct a structural equation modelling framework to estimate the influencing factors of medical students’ continuance intention to use mobile health apps. Results The external characteristics of mobile health apps had a positive influence on perceived ease of use (β = 0.378, P < 0.001). Perceived ease of use had a positive impact on perceived usefulness (β = 0.573, P < 0.001). Perceived ease of use (β = 0.195, P = 0.011), perceived usefulness (β = 0.450, P < 0.001) and subjective norms (β = 0.255, P < 0.001) had a positive impact on attitude towards using mobile health apps. Additionally, perceived usefulness (β = 0.202, P < 0.001) and attitude (β = 0.730, P < 0.001) had a remarkable influence on continuance intention. Furthermore, the mediating effect of attitude between perceived usefulness and continuance intention was significant (β = 0.329, P < 0.001). Conclusion Both perceived usefulness and attitude have a significant effect on medical students’ mobile health apps continuance intention. So, we suggest apps providers and developers evoking and maintaining users’ interest in mobile health apps and perfecting apps’ features from various aspect. Also, more attention should be paid on social relationship to introduce medical students to familiarize mobile health apps and strengthen adhesiveness of medical students.
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Affiliation(s)
- Qian Xu
- College of Medical Informatics, Chongqing Medical University, Chongqing, People’s Republic of China
- Medical Data Science Academy, Chongqing Medical University, Chongqing, People’s Republic of China
- Department of Medical Informatics Library, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xiaorong Hou
- College of Medical Informatics, Chongqing Medical University, Chongqing, People’s Republic of China
- Medical Data Science Academy, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Tingchao Xiao
- Department of Medical Informatics Library, Chongqing Medical University, Chongqing, People’s Republic of China
| | - Wenlong Zhao
- College of Medical Informatics, Chongqing Medical University, Chongqing, People’s Republic of China
- Medical Data Science Academy, Chongqing Medical University, Chongqing, People’s Republic of China
- Correspondence: Wenlong Zhao, College of Medical Informatics Chongqing Medical University, Chongqing, People’s Republic of China, Tel +86 23 6571 4682, Email
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Mabunda D, Oliveira D, Sidat M, Cavalcanti MT, Cumbe V, Mandlate F, Wainberg M, Cournos F, de Jesus Mari J. Cultural adaptation of psychological interventions for people with mental disorders delivered by lay health workers in Africa: scoping review and expert consultation. Int J Ment Health Syst 2022; 16:14. [PMID: 35168650 PMCID: PMC8845308 DOI: 10.1186/s13033-022-00526-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/01/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Lay Health Workers (LHW) are important providers of community mental health services and help mitigate access and treatment gaps in Africa. However, there is a paucity of knowledge about the role and performance of these workers, as well as about the extent to which the interventions delivered are culturally adapted to the African context. AIMS This scoping review aimed to explore the content and aspects concerning the cultural adaptation and sustainability of psychological interventions delivered by LHW to people with mental disorders in Africa. METHODS We conducted a scoping review of the peer-reviewed literature published from January 2000 to December 2018 to identify psychological interventions delivered by LHW for people with mental disorders in Africa. We systematically searched PubMed, Google scholar and Hinari to select relevant publications. The articles were evaluated for risk of bias according to study design with the National Heart, Lung, and Blood Institute's (NHLBI) Quality Assessment Tools. Expert consultation was performed according to Arksey & O'Malley framework and cultural adaptation analysis was performed according to Bernal framework. RESULTS Out of 14,549 retrieved records, we identified ten peer-reviewed articles conducted in Zimbabwe, Uganda, South Africa and Zambia describing four distinct interventions. Six were randomized controlled trials; none addressed implementation outcomes. Group-based interpersonal therapy (n = 5), trauma-focused cognitive behaviour therapy (n = 1), problem solving therapy (n = 3) and narrative exposure therapy (n = 1) emerged as psychological interventions delivered by LHW for people with depression, anxiety, trauma and suicidal behavior. Psychological interventions delivered by LHW in Africa were all culturally adapted to meet the competence of LHW. All the interventions were associated with symptom improvement, but the quality of this evidence varied widely with study design. CONCLUSION Task-shifting psychological interventions delivered by LHW after appropriate cultural adaptation show promise for addressing unmet mental health care needs in Africa. More effectiveness and implementation evidence is needed, especially with regard to psychological interventions delivered by LHW for adolescence, older people and those with severe mental disorders and suicidal behaviors.
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Affiliation(s)
- Dirceu Mabunda
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil.
- Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Avenue Salvador Allende nr. 702, P.O Box: 1106, Maputo, Mozambique.
| | - Déborah Oliveira
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
| | - Mohsin Sidat
- Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Avenue Salvador Allende nr. 702, P.O Box: 1106, Maputo, Mozambique
| | | | - Vasco Cumbe
- Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Avenue Salvador Allende nr. 702, P.O Box: 1106, Maputo, Mozambique
| | - Flávio Mandlate
- Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Avenue Salvador Allende nr. 702, P.O Box: 1106, Maputo, Mozambique
| | - Milton Wainberg
- Department of Psychiatry, Columbia University College of Physician and Surgeons, New York, USA
| | - Francine Cournos
- Department of Psychiatry, Columbia University College of Physician and Surgeons, New York, USA
| | - Jair de Jesus Mari
- Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil
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