Genomic insights into the diversity, virulence and resistance of Klebsiella pneumoniae extensively drug resistant clinical isolates.

Klebsiella pneumoniae has been implicated in wide-ranging nosocomial outbreaks, causing severe infections without effective treatments due to antibiotic resistance. Here, we performed genome sequencing of 70 extensively drug resistant clinical isolates, collected from Brasília's hospitals (Brazil) between 2010 and 2014. The majority of strains (60 out of 70) belonged to a single clonal complex (CC), CC258, which has become distributed worldwide in the last two decades. Of these CC258 strains, 44 strains were classified as sequence type 11 (ST11) and fell into two distinct clades, but no ST258 strains were found. These 70 strains had a pan-genome size of 10 366 genes, with a core-genome size of ~4476 genes found in 95 % of isolates. Analysis of sequences revealed diverse mechanisms of resistance, including production of multidrug efflux pumps, enzymes with the same target function but with reduced or no affinity to the drug, and proteins that protected the drug target or inactivated the drug. ß-Lactamase production provided the most notable mechanism associated with K. pneumoniae. Each strain presented two or three different ß-lactamase enzymes, including class A (SHV, CTX-M and KPC), class B and class C AmpC enzymes, although no class D ß-lactamase was identified. Strains carrying the NDM enzyme involved three different ST types, suggesting that there was no common genetic origin.

A Pilot Initiative to Deliver Community-based Psychiatric Services in Rural Haiti After the 2010 Earthquake.

BACKGROUND: Worldwide, there is a gap between the burden of mental distress and disorder and access to mental health care. This gap is particularly large in low- and middle-income countries (LMICs). After the 2010 earthquake in Haiti, the international health care organizations Partners in Health and Zanmi Lasante worked to expand local mental health services in rural Haiti. OBJECTIVE: The aims of this study are to describe clinical characteristics of the patients served during a pilot project to deliver community-based psychiatric services in rural Haiti and to show how this experience complements the Mental Health Gap Action Programme ("mhGAP"), a tool developed by the World Health Organization to support mental health care delivery by nonspecialists in LMICs. METHODS: The pilot was conducted in March 2011. A visiting psychiatrist traveled to rural Haiti and paired with local clinicians to evaluate patients and to support quality improvement practices in psychiatric care. Patients received a standard neuropsychiatric evaluation. mhGAP was an important clinical reference. To assess the experience, we conducted a retrospective chart review of outpatient encounters. FINDINGS: Sixty-five patients presented with a wide range of common psychiatric, neurologic, and general medical conditions. Forty-nine of these patients (75%) reported primary problems subsumed by an mhGAP module. Fifteen patients (23%) reported headache as their chief complain, a condition that is not currently covered by mhGAP. Surprisingly, only 3 patients (5%), reported earthquake-related distress. CONCLUSIONS: Our clinical data reinforce the need for provision of standard psychiatric and neurologic services in LMICs. Such services ought to accompany interventions targeted specifically at disaster-related problems. Clinical situations falling outside existing mhGAP modules inspired the development of supplemental treatment protocols. These observations informed coordinated efforts at Zanmi Lasante to build a sustainable, integrated mental health system in Haiti that may be relevant to other resource-limited settings.

Safety of Noninvasive Electrical Stimulation of Acupuncture Points During a Routine Neonatal Heel Stick.

BACKGROUND: Hospitalized infants may undergo frequent painful procedures with inadequate pain relief. Alternative pain relief interventions are needed. OBJECTIVE: The aim of this research was to determine the safety of noninvasive electrical stimulation of acupuncture points (NESAP) in neonates who were receiving routine heel sticks. DESIGN: This was a descriptive study performed to assess the safety of using a transcutaneous electrical nerve stimulation (TENS) unit to deliver NESAP to neonates. SETTING/SUBJECTS: The subjects were healthy newborn infants<3 days old before hospital discharge. INTERVENTION: The intervention was NESAP delivered via a TENS unit, administered before, during, and after heel stick. The electrodes of the TENS unit were applied at four acupuncture points. Settings were gradually increased: 6 infants received 1.0 mA, 2 Hz; the second 6 infants received 2.0 mA, 10 Hz; and the last 18 infants received 3.5 mA, 10 Hz. MAIN OUTCOME MEASURES: THREE MAIN MEASURES WERE USED: (1) skin assessment (2) vital signs; (3) pain scores using the Premature Infant Pain Profile (PIPP). RESULTS: There were no significant changes in vital signs during and after NESAP. There were no changes in PIPP scores in the first 12 infants after initiation of NESAP. A slight but nonsignificant increase in PIPP scores (from 2.65 to 3.5 on a scale of 0-18) occurred in the last 18 infants. There were no adverse events during or after NESAP. CONCLUSIONS: NESAP is safe for infants with low settings on a TENS unit.

Unintended benefits: leadership skills and behavioral change among Guatemalan fieldworkers employed in a longitudinal household air pollution study.

The RESPIRE and CRECER studies measured the effects of reduced household air pollution (HAP) from wood-fired cookstoves on respiratory health in rural highland Guatemala. This article examines behavior change and leadership skill development in local community members who were hired as fieldworkers to assist with research. Fieldworkers administered household questionnaires, shared functions similar to community health workers, and bridged health resources to communities. A mixed-methods design for data collection (in-depth interviews, focus groups, impact drawings, knowledge questionnaire, and retrospective pre-test) was used. Purposive sampling included 10 fieldworkers and 13 local service providers. Fieldworkers showed an increase in knowledge, positive attitudes, and practices around HAP. They developed new technical, interpersonal, and leadership skills. Fieldworkers played a crucial role in building confianza (trust) with the community, bridging resources, and improving outside researchers' relationships with locals. Recommendations for future researchers include inclusion of additional training courses and adoption of community participatory approaches.

A concept of Caribbean fatherhood

OBJECTIVE: To investigate the manner in which Jamaican men view themselves and their relationships with women and their role in family life as partners and fathers. METHODS: A two-stage stratified random sample was used to select men aged 15-40 years in three parishes, Kingston, St.Andrew and Hanover. Enumeration districts and dwellings were selected in the first and second stages, respectively. In selected dwellings, all males 15-40 years were identified among the eligible males who had fathered at least one child. From these, one respondent was randomly selected. A questionnaire was administered to the sample yield of 714. Focus group discussions were held with a subset of the sample. Eight focus groups were held, four each in rural and urban areas among men 15-24 years, and similarly among men 25-40 years. RESULTS: The majority (64 percent) of the men who currently either in visiting or common-law unions and 23 percent had formed these unions between the ages of 15 and 19 years. Most (58 percent) had spent one to six years in their current union, of which the largest group (26 percent) spent one and a half to three years. Just over two-thirds of the children were born in current unions and those born outside of the current union were born in visiting unions (41 percent). Approximately 44 percent of the respondents' children were not living with them; 80 percent were living with their mothers. Respondents (87 percent) reported that they were involved in their children's lives. Major involvement was the provision of food (52 percent), clothes (51 percent) and health care (51 percent). The main obstacle identified for male participation in parenting was their marginal economic status. Significant relationships (p<0.1) were: the increase in the fathering role with age; fathers who were not household heads were less involved in their children's lives, especially when a step-father was present and the economic contribution of fathers was strongly related to their economic status. Contact between parents was significantly influenced by the age of both the father and the children. CONCLUSIONS: The findings indicate that fatherhood is hinged in the ability of the men to make economic and material contributions to their family. In general, men wanted a better life for their children but faced real constraints. Poverty was the major factor preventing men from performing the role they consider central to their concept of fatherhood. (AU)

Disparities in access to family planning in Jamaica

In order to improve the effectiveness and subtainability of the family planning programme, the National Family Planning Board has devised a strategy to shift users to longer-acting methods and increase the role of the private sector. To design interventions, a better understanding of existing services was thought to be necessary. This study examines the distribution of family planning service delivery points in Jamaica and the services offered by the public and private sectors through an examination of records and questionnaire interviews. The study found that, because of the concentration of private sector providers - the main outlets for longer-acting methods - in urban areas, rural areas had poor access to these methods. Because rural areas are not attractive to private sector providers, the public sector should recognize the need to continue to serve these areas (AU)

Disparities in access to family planning in Jamaica

In order to improve the effectiveness and subtainability of the family planning programme, the National Family Planning Board has devised a strategy to shift users to longer-acting methods and increase the role of the private sector. To design interventions, a better understanding of existing services was thought to be necessary. This study examines the distribution of family planning service delivery points in Jamaica and the services offered by the public and private sectors through an examination of records and questionnaire interviews. The study found that, because of the concentration of private sector providers - the main outlets for longer-acting methods - in urban areas, rural areas had poor access to these methods. Because rural areas are not attractive to private sector providers, the public sector should recognize the need to continue to serve these areas

Show, no show and sterilization

The study investigates the factors involved in the decision of a sample of women to break appointments for sterilizations at the Fertility Management Unit of the University of the West Indies. A case control study involved 50 women who did not show up (no-shows) and an equal number who did show up (shows) over the same period. The no-shows had spent a shorter time in their current union than the shows, and some had no children for their partners at the time the appointments were made. Marriage was the single most important event that would encourage the no-shows to consider sterilization in the future. As long as poor women see child bearing as a precondition for financial assistance from spouses, they will hesitate to give up this capability (AU)

The effect of user fees on the utilization of family planning services: a clinical study

A new fee structure was introduced to the Advanced Training and Research in Fertility Management Unit in 1992. The study looked at the effect of the new fees on attendance and the choice of contraceptive methods through an examination of clinic records and a questionnaire survey. There was a decline in attendance of roughly 28 per cent between 1992 and 1993. The decline affected mainly new clients and those who accepted injectables. A reduction in the price of injectables is suggested since the fee for this short-term method is more in line with those charged for long-term and permanent methods. (AU)

The effect of user fees on the utilization of family planning services: a clinical study

A new fee structure was introduced to the Advanced Training and Research in Fertility Management Unit in 1992. The study looked at the effect of the new fees on attendance and the choice of contraceptive methods through an examination of clinic records and a questionnaire survey. There was a decline in attendance of roughly 28 per cent between 1992 and 1993. The decline affected mainly new clients and those who accepted injectables. A reduction in the price of injectables is suggested since the fee for this short-term method is more in line with those charged for long-term and permanent methods.

Show, no show and sterilzation

The study investigates the factors involved in the decision of a sample of women to break appointments for sterilizations at the Fertility Management Unit of the University of the West Indies. A case control study involved 50 women who did not show up (no-shows) and an equal number who did show up (shows) over the same period. The no-shows had spent a shorter time in their current union than the shows, and some had no children for their partners at the time the appointments were made. Marriage was the single most important event that would encourage the no-shows to consider sterilization in the future. As long as poor women see child bearing as a precondition for financial assistance from spouses, they will hesitate to give up this capability.

Mapping study and private physicians' survey opportunities for expanded family planning services in Jamaica: final report

Reports on a project aimed at importing the effectiveness and sustainability of Jamaica's National Family Planning Programme in light of the planned phasedown of international donor support particularly the reduction of USAID-donated contraceptive supplies. A "Mapping Study and Private Physicians Survey" was designed to collect background information on the existing infrastructure of service delivery points (SDPs)and a better undrestanding of physicians' skill and interest levels pertaining to long-term and permanent methods. This information would enable interventions to be designed that would target less-well-served areas offer appropriate incentives for private-practice physicians to become more involved in family planning, and meet specific needs among the private physician community as they try to become more involved. Among the noteworthy findings of this study are, given that a key goal of the project is to increase use of longer-acting methods, these methods are not readily available at affordable prices to rural consumers/patients ie. half the Jamaican population. long-term and permanent methods are concentrated in urban areas and offered primarily by private physicians. Short-term or supply methods were widely available to both urban and rural users and were quite affordable. Another significant finding is that private physicians have an interest in increasing their understanding of and involvement in family planning, widespread interest was expressed in the Private Physicians' Pilot Project. The private sector it was found offers the most SDPs, the widest range of methods and the greatest number of hours of operation, however, it is the public sector that provides the most services ie. about 60 percent of family planning services. These was a tendency for private sector providers to be concentrated in urban areas due to available supporting medical services; a further intra-urban clustering of private sector sites was also found; ther was a tendency among newer doctors to establish practices in urban areas outside of Kingston; a more evenly distributed pattern for public sector SDP was found, along with a clear emphasis on serving rural communities; an expansionary trend in terms of number of SDPs in urban areas is noticeable whereas a slight reduction in overall number of SDPs serving rural areas was noted. The recommendations are, to use the findings from this mapping study to plan future activities; to improve availability on long-term and permanent methods for rural groups; to encourage the private sector to increase its participation in family planning; to engage pharmacies and private physicians in expanded social marketingprogrammes; and that the social marketing programme be encouraged to expand its marketing support to include longer-acting methods.

Mapping study and private physicians' survey opportunities for expanded family planning services in Jamaica: final report

Reports of a project aimed at importing the effectiveness and sustainability of Jamaica's National Family Planning Programme in light of the planned phasedown of international donor support particularly the reduction of USAID-donated contraceptive supplies. A "Mapping Study and Private Physicians Survey" was designed to collect background information on the existing infrastructure of service delivery points (SDPs)and a better undrestanding of physicians' skill and interest levels pertaining to long-term and permanent methods. This information would enable interventions to be designed that would target less-well-served areas offer appropriate incentives for private-practice physicians to become more involved in family planning, and meet specific needs among the private physician community as they try to become more involved. Among the noteworthy findings of this study are, given that a key goal of the project is to increase use of longer-acting methods, these methods are not readily available at affordable prices to rural consumers/patients ie. half the Jamaican population. long-term and permanent methods are concentrated in urban areas and offered primarily by private physicians. Short-term or supply methods were widely available to both urban and rural users and were quite affordable. Another significant finding is that private physicians have an interest in increasing their understanding of and involvement in family planning, widespread interest was expressed in the Private Physicians' Pilot Project. The private sector it was found offers the most SDPs, the widest range of methods and the greatest number of hours of operation, however, it is the public sector that provides the most services ie. about 60 percent of family planning services. These was a tendency for private sector providers to be concentrated in urban areas due to available supporting medical services; a further intra-urban clustering of private sector sites was also found; ther was a tendency among newer doctors to establish practices in urban areas outside of Kingston; a more evenly distributed pattern for public sector SDP was found, along with a clear emphasis on serving rural communities; an expansionary trend in terms of number of SDPs in urban areas is noticeable whereas a slight reduction in overall number of SDPs serving rural areas was noted. The recommendations are, to use the findings from this mapping study to plan future activities; to improve availability on long-term and permanent methods for rural groups; to encourage the private sector to increase its participation in family planning; to engage pharmacies and private physicians in expanded social marketingprogrammes; and that the social marketing programme be encouraged to expand its marketing support to include longer-acting methods. (AU)

Race, integration and family planning in Trinidad and Tobago

The study considered the effect of the integration of the health services on family planning in Trinidad and tobago. A drop-out study was based on a sample of six clinics, three representing integrated and three clinics that were non-integrated or vertical. Efforts were also made to solicit the views of a sample of drops outs, current acceptors and health-care providers. The study found that there were characteristics of the population from which acceptors were drawn that were more important in explaining utilization than the question of integration or non-integration of the clinics. Many of the problems were organizational and could, with adequate financing, be met by an even higher level of integration.(AU)

Women in search of stability

This paper is based on a study of 97 recuits-50 sterilized and 47 non-sterilized--to a family planning programme in Kingston, Jamaica and tries to account for the reluctance of Jamaican women to accept contraceptive sterilization. The study demonstrates the association between mating patterns in the island and the acceptance of sterilization. This irreversible method was more likely to be chosen by women in more stable sexual unions.(AU)

Distance and continuation rates in a family planning clinic: A case study from Jamaica

The care records of all women accepting medroxyprogestrone acetate (Depo Provera) between July 1981 and June 1983 at the Advanced Training in Research and Fertility Management Unit of the University of the West Indies were examined and home addresses mapped. The distance between the homes of acceptors and the Unit were measured and travel-distance bands super-imposed on the distribution map. Continuation rates using life table determination were calculated for clients residing within separate two-mile bands at increasing distances from the Unit. Continuation rates decreased up to eight miles but increased considerably in the peri urban and rural areas beyond eight miles of the Corporate Area. This increase was due the better performance of the large teenage component attracted from distant areas. The decline in continuation rates suggest that the four-mile travel band would be the most effective service area for the Unit (AU)