Antibiotic use from formal and informal healthcare providers in the Democratic Republic of Congo: a population-based study in two health zones

ObjectiveIn the Democratic Republic of Congo and other low-resource countries, community-acquired pathogens are increasingly resistant to most locally available antibiotics. To guide efforts to optimize antibiotic use to limit antibiotic resistance, we quantified healthcare provider–specific and community-wide antibiotic use.MethodsFrom household surveys, we estimated monthly healthcare visit rates by provider. From healthcare visit exit surveys, we estimated prevalence, defined daily doses, and access/watch/reserve distribution of antibiotic use by provider. Combining both, we estimated community-wide antibiotic use rates.ResultsOf 88.7 (95% CI 81.9–95.4) healthcare visits per 1000 person-months (n = 31221), visits to private clinics (31.0, 95% CI 30.0–32.0) and primary health centres (25.5, 95% CI 24.6–26.4) were most frequent. Antibiotics were used during 64.3% (95% CI 55.2–73.5%, 162/224) of visits to private clinics, 51.1% (95% CI 45.1–57.2%, 245/469) to health centres, and 48.8% (95% CI 44.4–53.2%, 344/454) to medicine stores. Antibiotic defined daily doses per 1000 inhabitants per day varied between 1.75 (95% CI 1.02–2.39) in rural Kimpese and 10.2 (95% CI 6.00–15.4) in (peri) urban Kisantu, mostly explained by differences in healthcare utilisation (respectively 27.8 versus 105 visits per 1000 person-months), in particular of private clinics (1.23 versus 38.6 visits) where antibiotic use is more frequent. The fraction of Watch antibiotics was 30.3% (95% CI 24.6–35.9%) in private clinics, 25.6% (95% CI 20.2–31.1%) in medicine stores, and 25.1% (95% CI 19.0–31.2%) in health centres. Treatment durations <3 days were more frequent at private clinics (5.3%, 9/169) and medicine stores (4.1%, 14/338) than at primary health centres (1.8%, 5/277).DiscussionPrivate healthcare providers, ubiquitous in peri-urban settings, contributed most to community-wide antibiotic use and more frequently dispensed Watch antibiotics and shortened antibiotic courses. Efforts to optimize antibiotic use should include private providers at community level.     

Spread of human immunodeficiency virus 1 among men who have sex with men is emerging as a genuine social concern and affecting the general populace - case reports from Eastern India

Human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) has increased to a drastic proportion throughout India in the last couple of years due to a lack of productive identification and management framework. In apprehension of social disgrace these men attempt to live a normal hetero conjugal life and, in the process, act as a bridge in spreading the virus to their women partners. In this case report we have highlighted two cases which clearly distinguished the adequacy of HIV treatment among MSM when they are diagnosed during early or late phases of infection. An intensive and ample counseling to comprehend the psychology and sexual behavior of these men was found to be critically important in both the cases. Our study, which is actually the first of its kind, recorded and documented evidence of HIV infected MSM from Eastern India and renders a ray of hope among this marginally isolated group to comprehend the challenges and health risks faced by the MSM population. It also provides a format for the medical practitioners here in managing and treating related cases.     

CBT for late‐life insomnia and the accuracy of sleep and wake perceptions: Results from a randomized‐controlled trial

Subjective and objective estimates of sleep are often discordant among individuals with insomnia who typically under‐report sleep time and over‐report wake time at night. This study examined the impact and durability of cognitive‐behavioural therapy for insomnia on improving the accuracy of sleep and wake perceptions in older adults, and tested whether changes in sleep quality were related to changes in the accuracy of sleep/wake perceptions. One‐hundred and fifty‐nine older veterans (97% male, mean age 72.2 years) who met diagnostic criteria for insomnia disorder were randomized to: (1) cognitive‐behavioural therapy for insomnia (n = 106); or (2) attention control (n = 53). Assessments were conducted at baseline, post‐treatment, 6‐months and 12‐months follow‐up. Sleep measures included objective (via wrist actigraphy) and subjective (via self‐report diary) total sleep time and total wake time, along with Pittsburgh Sleep Quality Index score. Discrepancy was computed as the difference between objective and subjective estimates of wake and sleep. Minutes of discrepancy were compared between groups across time, as were the relationships between Pittsburgh Sleep Quality Index scores and subsequent changes in discrepancy. Compared with controls, participants randomized to cognitive‐behavioural therapy for insomnia became more accurate (i.e. minutes discrepancy was reduced) in their perceptions of sleep/wake at post‐treatment, 6‐months and 12‐months follow‐up (p < .05). Improved Pittsburgh Sleep Quality Index scores at each study assessment preceded and predicted reduced discrepancy at the next study assessment (p < .05). Cognitive‐behavioural therapy for insomnia reduces sleep/wake discrepancy among older adults with insomnia. The reductions may be driven by improvements in sleep quality. Improving sleep quality appears to be a viable path to improving sleep perception and may contribute to the underlying effectiveness of cognitive‐behavioural therapy for insomnia.     

Patient safety and communication: A new assessment for doctors trained in countries where language differs from that of the host country: Results of a pilot using a domain-based assessment

Objective

Global migration of healthcare workers places responsibility on employers to comply with legal employment rights whilst ensuring patient safety remains the central goal. We describe the pilot of a communication assessment designed for doctors who trained and communicated with patients and colleagues in a different language from that of the host country. It is unique in assessing clinical communication without assessing knowledge.

Methods

A 14-station OSCE was developed using a domain-based marking scheme, covering professional communication and English language skills (speaking, listening, reading and writing) in routine, acute and emotionally challenging contexts, with patients, carers and healthcare teams. Candidates (n = 43), non-UK trained volunteers applying to the UK Foundation Programme, were provided with relevant station information prior to the exam.

Results

The criteria for passing the test included achieving the pass score and passing 10 or more of the 14 stations. Of the 43 candidates, nine failed on the station criteria. Two failed the pass score and also the station criteria. The Cronbach's alpha coefficient was 0.866.

Conclusion

This pilot tested ‘proof of concept’ of a new domain-based communication assessment for non-UK trained doctors.

Practice implications

The test would enable employers and regulators to verify communication competence and safety in clinical contexts, independent of clinical knowledge, for doctors who trained in a language different from that of the host country.     

Histopathological study of the spreading neoplastic cells in cervical glands and surface epithelia in cervical intra-epithelial neoplasia and microinvasive squamous cell carcinoma: Ki-67 immunostaining is a useful marker for pathological diagnosis from the gland involvement site

The purpose of the present study was to clarify the spreading status of neoplastic cells in the cervical glands and surface epithelia in cervical intra-epithelial neoplasia (CIN) and microinvasive squamous cell carcinoma (MiSCC), and to evaluate the diagnostic usefulness of Ki-67 immunostaining from the gland involvement (GI) site. Cervical conization samples from 120 patients, including 110 with CIN (CIN1, n=2; CIN2, n=21; CIN3, n=87) and 10 patients with MiSCC, was examined using HE and Ki-67 immunostaining. The linear extent, lateral extent in the surface epithelia and depth of GI were significantly increased from CIN1 to MiSCC. A significant correlation was found between the linear extent and lateral extent, between the linear extent and depth, and between the lateral extent and depth. These results indicated that the size of the surface epithelial lesion and the depth in CIN gradually increased in accordance with the grade of CIN, and that GI became deeper according to the increase in the size of the surface epithelial lesion. The Ki-67 labeling index in the GI site gradually increased from CIN1 to MiSCC, which indicated that Ki-67 immunostaining is a useful marker for the pathological diagnosis of CIN from the GI site.