Clinical Features and Management of Chronic Chikungunya Arthritis

Chikungunya virus is a single-stranded RNA alphavirus transmitted to humans by Aedes species mosquitos, causing an acute illness known as chikungunya fever with maculopapular rash, headache, polyarthritis/arthralgias, and gastrointestinal symptoms. Up to half of affected patients develop a chronic disabling arthritis following resolution of the acute infection, which can last for months or even years. The pathophysiology of chronic chikungunya arthritis remains controversial; it may result from a dysregulated immune response or be caused by persistent viral infection. Treatment for patients with chronic chikungunya arthritis remains investigational. Limited data suggests that immunosuppressive therapies such as methotrexate and TNF alpha inhibitors may be beneficial, though randomized clinical trials are needed

Topological Censorship

All three-manifolds are known to occur as Cauchy surfaces of asymptotically flat vacuum spacetimes and of spacetimes with positive-energy sources. We prove here the conjecture that general relativity does not allow an observer to probe the topology of spacetime: any topological structure collapses too quickly to allow light to traverse it. More precisely, in a globally hyperbolic, asymptotically flat spacetime satisfying the null energy condition, every causal curve from \scri^- to {\scri}^+ is homotopic to a topologically trivial curve from \scri^- to {\scri}^+. (If the Poincar\'e conjecture is false, the theorem does not prevent one from probing fake 3-spheres).Comment: 12 pages, REVTEX; 1 postscript figure in a separate uuencoded file. Our earlier version (PRL 71, 1486 (1993)) contained a secondary result, mistakenly attributed to Schoen and Yau, regarding ``passive topological censorship'' of a certain class of topologies. As Gregory Burnett has pointed out (gr-qc/9504012), this secondary result is false. The main topological censorship theorem is unaffected by the erro

On Static n-body Configurations in Relativity

The static n-body problem of General Relativity states that there are, under a reasonable energy condition, no static $n$-body configurations for $n > 1$, provided the configuration of the bodies satisfies a suitable separation condition. In this paper we solve this problem in the case that there exists a closed, noncompact, totally geodesic surface disjoint from the bodies. This covers the situation where the configuration has a reflection symmetry across a noncompact surface disjoint from the bodies.Comment: 10 pages; result generalized to allow for more than one asymptotically flat en

Blow-up solutions for linear perturbations of the Yamabe equation

For a smooth, compact Riemannian manifold (M,g) of dimension N \geg 3, we are interested in the critical equation $$\Delta_g u+(N-2/4(N-1) S_g+\epsilon h)u=u^{N+2/N-2} in M, u>0 in M,$$ where \Delta_g is the Laplace--Beltrami operator, S_g is the Scalar curvature of (M,g), $h\in C^{0,\alpha}(M)$, and $\epsilon$ is a small parameter

Gravitating Opposites Attract

Generalizing previous work by two of us, we prove the non-existence of certain stationary configurations in General Relativity having a spatial reflection symmetry across a non-compact surface disjoint from the matter region. Our results cover cases such that of two symmetrically arranged rotating bodies with anti-aligned spins in $n+1$ ($n \geq 3$) dimensions, or two symmetrically arranged static bodies with opposite charges in 3+1 dimensions. They also cover certain symmetric configurations in (3+1)-dimensional gravity coupled to a collection of scalars and abelian vector fields, such as arise in supergravity and Kaluza-Klein models. We also treat the bosonic sector of simple supergravity in 4+1 dimensions.Comment: 13 pages; slightly amended version, some references added, matches version to be published in Classical and Quantum Gravit

Does backreaction enforce the averaged null energy condition in semiclassical gravity?

The expected stress-energy tensor of quantum fields generically violates the local positive energy conditions of general relativity. However, may satisfy some nonlocal conditions such as the averaged null energy condition (ANEC), which would rule out traversable wormholes. Although ANEC holds in Minkowski spacetime, it can be violated in curved spacetimes if one is allowed to choose the spacetime and quantum state arbitrarily, without imposition of the semiclassical Einstein equation G_{ab} = 8 \pi . In this paper we investigate whether ANEC holds for solutions to this equation, by studying a free, massless scalar field with arbitrary curvature coupling in perturbation theory to second order about the flat spacetime/vacuum solution. We "reduce the order" of the perturbation equations to eliminate spurious solutions, and consider the limit in which the lengthscales determined by the incoming state are much larger than the Planck length. We also need to assume that incoming classical gravitational radiation does not dominate the first order metric perturbation. We find that although the ANEC integral can be negative, if we average the ANEC integral transverse to the geodesic with a suitable Planck scale smearing function, then a strictly positive result is obtained in all cases except for the flat spacetime/vacuum solution. This result suggests --- in agreement with conclusions drawn by Ford and Roman from entirely independent arguments --- that if traversable wormholes do exist as solutions to the semiclassical equations, they cannot be macroscopic but must be ``Planck scale''. A large portion of our paper is devoted to the analysis of general issues concerning the nature of the semiclassical Einstein equation and of prescriptions for extracting physically relevant solutions.Comment: 54 pages, 3 figures, uses revtex macros and epsf.tex, to appear in Phys Rev D. A new appendix has been added showing consistency of our results with recent results of Visser [gr-qc/9604008]. Some corrections were made to Appendix A, and several other minor changes to the body of the paper also were mad

The stability inequality for Ricci-flat cones

In this article, we thoroughly investigate the stability inequality for Ricci-flat cones. Perhaps most importantly, we prove that the Ricci-flat cone over CP^2 is stable, showing that the first stable non-flat Ricci-flat cone occurs in the smallest possible dimension. On the other hand, we prove that many other examples of Ricci-flat cones over 4-manifolds are unstable, and that Ricci-flat cones over products of Einstein manifolds and over Kähler-Einstein manifolds with h^{1,1}>1 are unstable in dimension less than 10. As results of independent interest, our computations indicate that the Page metric and the Chen-LeBrun-Weber metric are unstable Ricci shrinkers. As a final bonus, we give plenty of motivations, and partly confirm a conjecture of Tom Ilmanen relating the lambda-functional, the positive mass theorem and the nonuniqueness of Ricci flow with conical initial data

Declining Rates in Male Circumcision amidst Increasing Evidence of its Public Health Benefit

BACKGROUND: Recent experimental evidence has demonstrated the benefits of male circumcision for the prevention of human immunodeficiency virus (HIV) infection. Studies have also shown that male circumcision is cost-effective and reduces the risk for certain ulcerative sexually transmitted diseases (STDs). The epidemiology of male circumcision in the United States is poorly studied and most prior reports were limited by self-reported measures. The study objective was to describe male circumcision trends among men attending the San Francisco municipal STD clinic, and to correlate the findings with HIV, syphilis and sexual orientation. METHODS AND FINDINGS: A cross sectional study was performed by reviewing all electronic records of males attending the San Francisco municipal STD clinic between 1996 and 2005. The prevalence of circumcision over time and by subpopulation such as race/ethnicity and sexual orientation were measured. The findings were further correlated with the presence of syphilis and HIV infection. Circumcision status was determined by physical examination and disease status by clinical evaluation with laboratory confirmation. Among 58,598 male patients, 32,613 (55.7%, 95% Confidence Interval (CI) 55.2-56.1) were circumcised. Male circumcision varied significantly by decade of birth (increasing between 1920 and 1950 and declining overall since the 1960's), race/ethnicity (Black: 62.2%, 95% CI 61.2-63.2, White: 60.0%, 95% CI 59.46-60.5, Asian Pacific Islander: 48.2%, 46.9-49.5 95% CI, and Hispanic: 42.2%, 95% CI 41.3-43.1), and sexual orientation (gay/bisexual: 73.0%, 95% CI 72.6-73.4; heterosexual: 66.0%, 65.5-66.5). Male circumcision may have been modestly protective against syphilis in HIV-uninfected heterosexual men (PR 0.92, 95% C.I. 0.83-1.02, P = 0.06). CONCLUSIONS: Male circumcision was common among men seeking STD services in San Francisco but has declined substantially in recent decades. Male circumcision rates differed by race/ethnicity and sexual orientation. Given recent studies suggesting the public health benefits of male circumcision, a reconsideration of national male circumcision policy is needed to respond to current trends

Balancing influence between actors in healthcare decision making

<p>Abstract</p> <p>Background</p> <p>Healthcare costs in most developed countries are not clearly linked to better patient and public health outcomes, but are rather associated with service delivery orientation. In the U.S. this has resulted in large variation in healthcare availability and use, increased cost, reduced employer participation in health insurance programs, and reduced overall population health outcomes. Recent U.S. healthcare reform legislation addresses only some of these issues. Other countries face similar healthcare issues.</p> <p>Discussion</p> <p>A major goal of healthcare is to enhance patient health outcomes. This objective is not realized in many countries because incentives and structures are currently not aligned for maximizing population health. The misalignment occurs because of the competing interests between "actors" in healthcare. In a simplified model these are individuals motivated to enhance their own health; enterprises (including a mix of nonprofit, for profit and government providers, payers, and suppliers, etc.) motivated by profit, political, organizational and other forces; and government which often acts in the conflicting roles of a healthcare payer and provider in addition to its role as the representative and protector of the people. An imbalance exists between the actors, due to the resources and information control of the enterprise and government actors relative to the individual and the public. Failure to use effective preventive interventions is perhaps the best example of the misalignment of incentives. We consider the current Pareto efficient balance between the actors in relation to the Pareto frontier, and show that a significant change in the healthcare market requires major changes in the utilities of the enterprise and government actors.</p> <p>Summary</p> <p>A variety of actions are necessary for maximizing population health within the constraints of available resources and the current balance between the actors. These actions include improved transparency of all aspects of medical decision making, greater involvement of patients in shared medical decision making, greater oversight of guideline development and coverage decisions, limitations on direct to consumer advertising, and the need for an enhanced role of the government as the public advocate.</p