Health system strengthening in fragile and conflict-affected states: a call to action.

Although the speed of global development has been impressive, not all countries have developed at the same pace. The World Bank Group (WBG) report that Fragile and Conflict-Affected States (FCAS) are those countries that have lower health and development outcomes, and risk not being able to achieve Sustainable Development Goals (SDGs) in the next few years. Health systems play an important role in building capacity and infrastructure that can lead towards fulfilling the SDGs. In this editorial, we set the context, and launch a call to action, for a BMC Health Service Research Collection titled "Health services and systems in fragile and conflict-affected regions".

Automated virtual reality (VR) cognitive therapy for patients with psychosis: study protocol for a single-blind parallel group randomised controlled trial (gameChange).

INTRODUCTION: Many patients with psychosis experience everyday social situations as anxiety-provoking. The fears can arise, for example, from paranoia, hallucinations, social anxiety or negative-self beliefs. The fears lead patients to withdraw from activities, and this isolation leads to a cycle of worsening physical and mental health. Breaking this cycle requires highly active treatment directly in the troubling situations so that patients learn that they can safely and confidently enter them. However patients with psychosis seldom receive such life-changing interventions. To solve this problem we have developed an automated psychological treatment delivered in virtual reality (VR). It allows patients to experience computer simulations of the situations that they find anxiety-provoking. A virtual coach guides patients, using cognitive techniques, in how to overcome their fears. Patients are willing to enter VR simulations of anxiety-provoking situations because they know the simulations are not real, but the learning made transfers to the real world. METHODS AND ANALYSIS: 432 patients with psychosis and anxious avoidance of social situations will be recruited from National Health Service (NHS) secondary care services. In the gameChange trial, they will be randomised (1:1) to the six-session VR cognitive treatment added to treatment as usual or treatment as usual alone. Assessments will be conducted at 0, 6 (post-treatment) and 26 weeks by a researcher blind to allocation. The primary outcome is avoidance and distress in real-life situations, using a behavioural assessment task, at 6 weeks. The secondary outcomes are psychiatric symptoms, activity levels and quality of life. All main analyses will be intention-to-treat. Moderation and mediation will be tested. An economic evaluation will be conducted. ETHICS AND DISSEMINATION: The trial has received ethical approval from the NHS South Central - Oxford B Research Ethics Committee (19/SC/0075). A key output will be a high-quality automated VR treatment for patients to overcome anxious avoidance of social situations. TRIAL REGISTRATION NUMBER: ISRCTN17308399.

Identification of Escherichia coli from broiler chickens in Jordan, their antimicrobial resistance, gene characterization and the associated risk factors.

BACKGROUND: Avian pathogenic Escherichia coli (APEC) is the principle cause of colibacillosis affecting poultry. The main challenge to the poultry industry is antimicrobial resistance and the emergence of multidrug resistant bacteria that threaten the safety of the food chain. Risk factors associated with emergence of antimicrobial resistance among avian pathogenic E. coli were correlated with the inappropriate use of antimicrobials along with inadequate hygienic practices, which encourages the selection pressure of antimicrobial resistant APEC. The aim of this study was to isolate, identify, serogroup and genotype APEC from broilers, assess their antibiotic resistance profile, expressed genes and the associated risk factors. RESULTS: APEC was isolated from the visceral organs of sick chickens with a prevalence of 53.4%. The most prevalent serotypes were O1, O2, O25 and O78, in percentage of 14.8, 12.6, 4.4 and 23.7%, respectively. Virulence Associated Genes; SitA, iss, iucD, iucC, astA, tsh cvi and irp2 were detected in rate of 97.4, 93.3, 75, 74, 71, 46.5, 39 and 34%, respectively and 186 (69.2%) isolates possess > 5-10 genes. The highest resistance was found against sulphamethoxazole-trimethoprim, florfenicol, amoxicillin, doxycycline and spectinomycin in percentage; 95.5, 93.7, 93.3, 92.2 and 92.2%, respectively. Sixty-eight percent of APEC isolates were found to have at least 5 out of 8 antimicrobial resistant genes. The most predominant genes were Int1 97%, tetA 78.4%, bla TEM 72.9%, Sul1 72.4%, Sul2 70.2%. Two risk factors were found to be associated with the presence of multi-drug resistant APEC in broiler chickens, with a P value ≤0.05; the use of ground water as source of drinking water and farms located in proximity to other farms. CONCLUSIONS: This study characterized the VAGs of avian pathogenic E. coli and establish their antimicrobial resistance patterns. The widespread of antimicrobial resistance of APEC isolates and detection of ARGs highlighted the need to monitor the spread of ARGs in poultry farms and the environment in Jordan. Use of ground water and closely located farms were significant risk factors associated with the presence of MDR APEC in broiler chickens in Jordan.