Geographical perspective on antibiotic resistance in a metropolitan sewershed : Investigating socio-spatial hotspots of antibiotic use and antibiotic-resistant bacteria in Dortmund, Germany

Antibiotic resistance is a serious global health threat, driven by the inadequate and excessive use of antibiotics. Environmental compartments, particularly wastewater, occupy a pivotal role in the spread of antibiotic-resistant bacteria. Wastewater treatment plants reduce the bacterial load significantly but cannot remove everything. Reducing the input of antibiotics and antibiotic-resistant bacteria into wastewater at the source, this doctoral thesis focused on the sewershed of a wastewater treatment plant and the role of the general population. The goal was to investigate socio-spatial hotspots of antibiotic use in the community and antibiotic-resistant bacteria in untreated municipal wastewater. Three working packages formed the core of this work: a systematic literature review on the determinants of antibiotic use, a cross-sectional household survey in the general population and culture-based laboratory analyses of untreated municipal wastewater in three socio-spatially different urban areas within a metropolitan sewershed. Findings from the systematic literature review emphasise the importance of considering both individual- and space-related factors as determinants of antibiotic use in the community. Compositional variables, i.e. the characteristics of individuals living in a specific area, predominated, but potential area effects of contextual (i.e. opportunity structures in the local environment) and collective (i.e. socio-cultural and historical features) factors also showed some influence. The cross-sectional household survey revealed small-scale area differences in antibiotic use, and related knowledge, attitudes and practices between communities. Study participants in the socio-spatially disadvantaged area were less knowledgeable, reported more often attitudes contrary to common recommendations and displayed more often antibiotic use and potential mishandling practices. Untreated municipal wastewater from the three areas was tested for the occurrence of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli). This work demonstrated that the general community is an essential source of phenotypic ESBL-producing E. coli in wastewater and revealed spatial variations. ESBL-producing E. coli counts and proportions of multidrug-resistant isolates were higher in the socio-spatially disadvantaged area. Integrating the results, self-reported antibiotic use and the counts of phenotypic ESBL-producing E. coli were higher in the socio-spatially disadvantaged area pointing towards a possible spatial association. This doctoral thesis highlights the importance of considering higher spatial resolutions and the local spatial context and thereby demonstrates the benefit of applying a geographical perspective by explicitly considering the spatial dimension of antibiotic resistance.Antibiotikaresistenzen sind eine schwerwiegende Gesundheitsbedrohung, verursacht durch unsachgemäßen und exzessiven Antibiotikaeinsatz als einer der treibenden Hauptfaktoren. Umweltkompartimente, insbesondere Abwasser, spielen eine wichtige Rolle bei der Verbreitung von antibiotikaresistenten Bakterien. Konventionelle Kläranlagen können die bakterielle Fracht erheblich reduzieren, aber nicht restlos entfernen. Diese Dissertation fokussiert sich auf das Abwassereinzugsgebiet einer Kläranlage und die Rolle der allgemeinen Bevölkerung. Das Hauptziel der Arbeit war die Analyse möglicher sozialräumlicher Hotspots von Antibiotikanutzung in der allgemeinen Bevölkerung und von antibiotikaresistenten Bakterien im Abwasser. Dazu wurden drei Arbeitspakete konzipiert: eine systematische Literaturanalyse zu den Determinanten von Antibiotikanutzung, eine Querschnittserhebung in der allgemeinen Bevölkerung und kulturbasierte Laboranalysen von unbehandeltem kommunalen Abwasser in drei sozialräumlich unterschiedlichen Stadtgebieten innerhalb eines großstädtischen Abwassereinzugsgebiets. Die Ergebnisse der systematischen Literaturanalyse unterstreichen die Wichtigkeit von individuellen als auch raumbezogenen Determinanten von Antibiotikanutzung in der allgemeinen Bevölkerung. Während kompositorische Variablen, d. h. Merkmale der in einem Gebiet lebenden Personen, überwogen, wurden potenzielle räumliche Auswirkungen kontextueller (d. h. Gelegenheitsstrukturen im lokalen Umfeld) und kollektiver (d. h. soziokulturelle und historische Merkmale) Faktoren auf Antibiotikanutzung identifiziert. Der Antibiotikaverbrauch und das damit verbundene Wissen sowie die Einstellungen und Praktiken variierten zwischen den drei Stadtgebieten. Studienteilnehmende aus dem sozialräumlich benachteiligten Gebiet waren weniger gut informiert, berichteten häufiger über Einstellungen, die im Widerspruch zu gängigen Empfehlungen stehen, und von möglichen Fehlhandhabungen als auch einen höheren Antibiotikaverbrauch. Unbehandeltes kommunales Abwasser aus den drei Gebieten wurde auf Beta-Laktamasen mit erweitertem Spektrum (ESBL)-produzierende Escherichia coli (E. coli) untersucht. Diese Arbeit zeigte, dass die allgemeine Bevölkerung eine wichtige Quelle von ESBL-produzierenden E. coli im Abwasser ist. Räumliche Variationen wurden ebenfalls beobachtet. Die Anzahl von ESBL-produzierenden E. coli und der Anteil von multiresistenten Isolaten waren höher im sozialräumlich benachteiligten Gebiet. Eine Integration der Ergebnisse zeigt, dass der Antibiotikaverbrauch und die Anzahl von ESBL-produzierenden E. coli jeweils höher im sozialräumlich benachteiligten Gebiet waren, was auf einen möglichen räumlichen Zusammenhang hindeutet. Die Dissertation unterstreicht somit die Bedeutung einer hohen räumlichen Auflösung und des lokalen räumlichen Kontexts und demonstriert den Mehrwert einer geographischen Perspektive durch die explizite Berücksichtigung der räumlichen Dimension von Antibiotikaresistenz

Forging new paths : life course transitions for American women and their families

Families of remarriage constitute a growing number of American families. The spiraling divorce rate of the 1970s was accompanied by a concomitant increase in the number of remarriages. Forty percent of American families today contain at least one spouse that has been previously married, thus studying relationships within families of remarriage is crucial to understanding the experiences of both children and adults in American families. This study uses a life-span perspective to examine the qualitative accounts of 62 women 43 of whom divorced, spent some time as a single parent of at least one child, and remarried and 19 of whom had divorced and did not remarry. Some of those women also had a remarriage end in divorce. Both qualitative and quantitative analysis techniques were used to both explore relationships within families of remarriage, and differences between those women that remarried and those who remained single parents. Quantitative analyses revealed that women who did not remarry were better educated and had more conflict with their former spouse over time. Women who were younger when they became a single parent for the first time, had more children, had jobs rather than careers, and had less education reported more marriages overall. Qualitative analyses showed that particular problem areas in families of remarriage centered around the adjustment period between the children and the new partner, finances, and communication. Remarriages that failed were characterized by problematic relationships between children and their mother's partner. As this was predominantly a white, middle-class sample, generalizations to other populations should be made with caution. Directions for future research are discussed

Stress among working women : an examination of family structure, occupational status, and workplace relationships

Since the industrial revolution, work and family have been viewed as separate spheres, with women relegated to the family sphere. With the advent of women into the paid labor force, few studies have considered the potentially complex context of women's work and family experiences. The purpose of this study was to examine the impact of family structure, occupational status, and workplace relationships on women workers' perceptions of stress. The sample for this study included 379 women dental assistants and hygienists who responded to mailed questionnaires sent to the dental offices where they worked. The dependent variables used in this analysis were mental stress, physical stress, and four social stress items. Analysis of variance was performed for the family structure groups on physical, mental, and social stress items. Single parents and parents in general were especially stressed in terms of financial stress and marital stress. The second series of analyses included t-tests on stress by occupation. Dental assistants had more financial stress than hygienists. Hygienists had more mental stress than assistants. Workplace relationships were assessed in the full regression models. Frequency of talking with fellow workers was strongly and positively associated with financial problems. The full regression models supported the findings in earlier analyses that tensions from children and financial problems were associated with the presence of children in the home. The findings in this study suggest that for women workers, work and family do not occupy separate spheres. Women workers think about family matters at the workplace and discuss them with their other women workers. Further research needs to focus on women workers, especially those in traditionally female occupations, and the work and family connections for these workers

Sleep Duration Mediates the Relationship Between Health Behavior Patterns and Obesity

Objective: To examine associations between health behavior patterns and childhood obesity, and the mediating effect of sleep duration. Design: Population-based survey. Participants: Secondary analysis of data from the Infant Feeding Practices Study (age 6 years, n = 1073). Measurements: Mothers self-reported their child’s health behaviors including physical activity (PA), screen time, sleep duration, and diet. Latent class analysis determined the child’s patterns based on health behaviors. Sleep was examined as a mediator between the class membership variable and %BMIp95. Results: A 3-class model fit the data best, with classes labeled as “Poorest eaters” (low fruit/vegetable consumption, high fast food), “Healthy” (low screen time, highest fruit/vegetable consumption) and “Active, super-eaters, highest screen time” (highest PA and screen time, ate the most). “Poorest eaters” had an increased %BMIp95 (β = 4.11, P = .006) relative to the “Healthy” class. The “Poorest eaters” and “Active, super-eaters, highest screen time” classes had shorter sleep duration (β = −0.51, P \u3c .001; β = −0.38, P \u3c .001; respectively) relative to the “Healthy” class. Independent of class membership, each additional hour of sleep was associated with a %BMIp95 that was 2.93 U lower (P \u3c .001). Conclusions: Our results indicate that health behavior patterns mediated by sleep duration may influence a child’s %BMIp95. The bi-directionality of the relationship between health behaviors and sleep remains unclear. Our findings suggest the importance of a constellation of health behaviors on childhood obesity. Interventions should include a multitude of health behaviors and consider the possibility that improving diet and activity behaviors may facilitate improved sleep and lowered obesity risk among children

“A question of human dignity”. Identifying solutions to improve WASH for people experiencing homelessness. A case study from Germany

Urban poverty and homelessness keep growing while investments in health-promoting services and public infrastructure, including drinking water, sanitation and hygiene (WASH) have been decreasing. We used a mixed-method approach to collect data from 45 unhoused individuals in Germany identifying individual, infrastructure-specific, and location-based solutions to improve public WASH. Suggestions included adapting existing infrastructure, opening up existing, but inaccessible and constructing new inclusive infrastructure. Proactive, long-term sustainable solutions were preferred over reactive short-time options. Realizing safe WASH for all requires collaboration between homeless communities, governmental bodies, NGOs, businesses, and sanitation experts.</p

Dichlorido{2-morpholino-N-[1-(2-pyrid­yl)ethyl­idene]ethanamine-κ3 N,N′,N′′}manganese(II)

In the title compound, [MnCl2(C13H19N3O)], the MnII ion is penta­coordinated in a distorted square-pyramidal geometry. The coordination environment is defined by the N,N′,N′′-tridentate Schiff base ligand and one Cl atom in the basal positions and one Cl atom in the apical position. In the crystal, inter­molecular C—H⋯Cl hydrogen bonds link the mol­ecules into a three-dimensional network. An intra­molecular C—H⋯Cl hydrogen bond is also observed

Testing of a novel questionnaire of Household Exposure to Wood Smoke

Household air pollution from wood smoke (WS), contributes to adverse health effects in both low- and high-income countries. However, measurement of WS exposure has been limited to expensive in-home monitoring and lengthy face-to-face interviews. This paper reports on the development and testing of a novel, self-report nine-item measure of WS exposure, called the Household Exposure to Wood Smoke (HEWS). A sample of 149 individuals using household wood stoves for heating from western states in the U.S., completed the HEWS during the winter months (November to March) of 2013 through 2016 with 30 subjects having in-home particle monitoring. Hard copy or online surveys were completed. Cronbach\u27s alpha (α), intraclass correlations (ICC), exploratory factor analysis (EFA) and tests of associations were done to evaluate reliability and validity of the HEWS. Based on initial analysis, only 9 of the 12 items were retained and entered in the EFA. The EFA did not support a unitary scale as the 9 items demonstrated a 3-factor solution (WS exposure duration, proximity, and intensity) with Cronbach\u27s α of 0.79, 0.91, and 0.62, respectively. ICC was 0.86 of the combined items with single items ranging from 0.46 to 0.95. WS intensity was associated with symptoms and levoglucosan levels, while WS duration was associated with stove and flume maintenance. The three-dimensional HEWS demonstrated internal consistency and test-retest reliability, structural validity, and initial criterion and construct validity

Immune Dysregulation and Glucocorticoid Resistance in Minority and Low Income Pregnant Women

Chronic prenatal stress contributes to poor birth outcomes for women and infants. Importantly, poor birth outcomes are most common among minority and low income women. To investigate underlying mechanisms, we tested the hypothesis that chronic stress related to minority or low income status is associated with glucocorticoid resistance as indicated by disruption in the cytokine-glucocorticoid feedback circuit. Home visits were conducted during which 3rd trimester pregnant women completed stress and depression surveys and provided blood for pro- and anti-inflammatory cytokines. Saliva was collected 5 times the preceding day for diurnal cortisol levels. For statistical analyses, women were grouped 3 ways, by race, income, and the presence or absence of either of those risk factors; this last group was labeled high or low general risk. Immune regulation was evaluated by evidence of a functioning negative feedback relationship between cytokines and cortisol. Of 96 participants, 18 were minority, 22 of low income, and 29 either minority or low income (high general risk). Pearson partial correlation identified a significant negative relationship between cortisol area under the curve (AUC) and pro- to anti-inflammatory cytokine ratios in the low general risk women (i.e., Caucasian, higher income) including IFNγ/IL10 (r = −0.73, p \u3c 0.0001), IL6/IL10 (r = −0.38, p = 0.01), IL1β/IL10 (r = −0.44, p = 0.004) and TNFα/IL10 (r = −0.41; p = 0.005); no such correlations existed in the high general risk women (i.e., minority, low income) for (IFNγ/IL10: r = −0.25, p = 0.43; IL6/IL10: r = 0.12, p = 0.70; IL1 β/IL10: r = 0.05, p = 0.87; TNFα/IL10: r = 0.10; p = 0.75), suggestive of glucocorticoid resistance. Cortisol levels throughout the day also were higher in minority and high general risk groups (p \u3c 0.05). Without cytokine glucocorticoid feedback, a pregnant woman\u27s ability to regulate inflammation is limited, potentially contributing to adverse maternal and infant outcomes

Effects of nicotine and tyramine on contractile activity of the colon,

Contractile activity of the descending colon of the anesthetized dog was monitored with strain gage force transducers. Nicotine and tyramine caused primarily a relaxation of the circular and longitudinal muscle. A secondary stimulation frequently followed the inhibition. Adrenalectomy partially antagonized the effects of nicotine. Xylocholine and reserpine petreatment reduced the early portion of the inhibitory response to nicotine. Hexamethonium or a combination of adrenalectomy with either xycholine or reserpine pretreatment abolished the effects of nicotine. The effects of tyramine were antagonized by cocaine and reserpine-pretreatment. Tolazoline and propranolol (in combination) reduced the effects of both nicotine and tyramine. We conclude that both nicotine and tyramine relaxed the colon by releasing catecholamines. Nicotine caused release from the adrenal glands and adrenergic nerve endings; tyramine produced release from the adrenergic nerve endings.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/32663/1/0000028.pd