Health Care Providers\u27 Intention to Provide Culturally Competent Health Care to Somali Based Upon the Indirect Measures of the Integrated Behavioral Model

The purpose of this cross-sectional study was to assess health care providers\u27 intention to provide culturally competent health care to Somali based upon the constructs of the Integrated Behavioral Model by indirect measures. Using ZoomerangTM data collection systems, data were collected on a non-random and purposive sample. Every physician, nurse practitioner, and physician assistant in a non-administrative role at a rural primary care clinic located in Minnesota was recruited by email. A sample of thirty-one health care providers was used in this study. The survey was divided into four main scales based on the constructs of the Integrated Behavioral Model. These constructs included intention, attitudes, subjective norms, and perceived behavioral control. Each main scale, with the exception of intention, was further divided into subscales measuring construct components. The subscales included instrumental attitudes, experiential attitudes, injunctive norms, descriptive norms, motivation to comply with injunctive norms, motivation to comply with descriptive norms, self-efficacy and perceived control. Data analysis showed that overall intention of participants\u27 to provide Somali with culturally competent health care was high. The constructs of the Integrated Behavioral Model, as each related to intention, showed mixed results. Only the relationship between intention and overall subjective norms was statistically significant. More specific correlations were identified when each construct was further divided into construct components. Significant positive correlations between behavioral intention and instrumental attitudes, subjective norms, injunctive norms, descriptive norms and self-efficacy were found. Correlational analysis between demographic characteristics and overall intention did not reveal any significant relationships. Further investigation into gender and years of experience using independent samples t-tests did show some significant findings. Female participants responded to survey items pertaining to experiential attitudes and motivation to comply with injunctive norms more favorably than males. Health care workers with 11 years or more experience were found to have lower overall intention, experiential attitudes, instrumental attitudes, and motivation to comply with injunctive norms scores than those with 10 years of experience or less

Practical applications of probabilistic model checking to communication protocols

Probabilistic model checking is a formal verification technique for the analysis of systems that exhibit stochastic behaviour. It has been successfully employed in an extremely wide array of application domains including, for example, communication and multimedia protocols, security and power management. In this chapter we focus on the applicability of these techniques to the analysis of communication protocols. An analysis of the performance of such systems must successfully incorporate several crucial aspects, including concurrency between multiple components, real-time constraints and randomisation. Probabilistic model checking, in particular using probabilistic timed automata, is well suited to such an analysis. We provide an overview of this area, with emphasis on an industrially relevant case study: the IEEE 802.3 (CSMA/CD) protocol. We also discuss two contrasting approaches to the implementation of probabilistic model checking, namely those based on numerical computation and those based on discrete-event simulation. Using results from the two tools PRISM and APMC, we summarise the advantages, disadvantages and trade-offs associated with these techniques

High dietary zinc feeding promotes persistence of multi-resistant E. coli in the swine gut

High levels of zinc oxide are used frequently as feed additive in pigs to improve gut health and growth performance and are still suggested as an alternative to antimicrobial growth promoters. However, we have recently described an increase of multi-resistant E. coli in association to zinc feeding in piglets. This previous study focused on clonal diversity of E. coli, observing the effect on multi-resistant strains by chance. To shed further light into this highly important topic and falsify our previous findings, we performed a zinc pig feeding trial where we specifically focused on in-depth analysis of antimicrobial resistant E. coli. Under controlled experimental conditions, piglets were randomly allocated to a high dietary zinc (zinc group) and a background zinc feeding group (control group). At different ages samples were taken from feces, digesta, and mucosa and absolute E. coli numbers were determined. A total of 2665 E. coli isolates were than phenotypically tested for antimicrobial resistance and results were confirmed by minimum inhibitory concentration testing for random samples. In piglets fed with high dietary zinc, we detected a substantial increase of multi-resistant E. coli in all gut habitats tested, ranging from 28.9-30.2% multi-resistant E. coli compared to 5.8-14.0% in the control group. This increase was independent of the total number of E. coli. Interestingly, the total amount of the E. coli population decreased over time. Thus, the increase of the multi-resistant E. coli populations seems to be linked with persistence of the resistant population, caused by the influence of high dietary zinc feeding. In conclusion, these findings corroborate our previous report linking high dietary zinc feeding of piglets with the occurrence of antimicrobial resistant E. coli and therefore question the feeding of high dietary zinc oxide as alternative to antimicrobial growth promoters

Der Einfluss hoher Zinkkonzentrationen in Futtermitteln auf die Antibiotikaresistenz von intestinalen Escherichia coli

The usage of feed additives to increase growth performance and health in livestock is very common. For pigs, zinc oxide in concentrations ranging from 2000 – 3000 mg zinc/kg diet is often used after weaning. However, more and more evidence exists that high dietary zinc feeding is associated with the emergence of antimicrobial resistant bacteria in the pigs. As antimicrobial resistant bacteria represent a worldwide problem for human and veterinary medicine, it was necessary to shed further light into this highly important area. This study focuses on E. coli, a highly variable bacterial species which is ubiquitously distributed, colonizes the intestine of warm-blooded animals, birds, and reptiles and is of clinical relevance as beside commensal strains also pathogenic ones of intestinal and extraintestinal pathogenicity exist. For pigs E. coli represent an important infectious agent for diarrhea of suckling and weaned piglets which lead to large economic losses in the pig industry. In the first part of this study, a zinc pig feeding trial was performed, focusing on in-depth analysis of antimicrobial resistant E. coli. For three different habitats (feces, digesta, and mucosa), absolute E. coli numbers were investigated at different time points around weaning for the zinc and the control group. For 2665 isolates, phenotypic antimicrobial resistance was determined and confirmed by minimum inhibitory concentration testing for random samples. Finally, whole genome sequencing and multi-locus sequence typing were performed for random samples of porcine isolates. In piglets of the zinc group, a substantial increase of multi-resistant E. coli was detected in all gut habitats tested, ranging from 28.9-30.2% multi-resistant E. coli compared to 5.8-14.0% in the control group. This zinc effect was independent of the total number of E. coli, for which a general decrease over time was determined for both groups. The higher resistance rates of the zinc group, therefore, seem to be linked with persistence of the resistant population under the influence of high dietary zinc feeding. Interestingly, mainly isolates of two different phylogenetic clusters namely ST10 and ST34 are involved in the increased resistance of the zinc group. In the second part of this study, conjugation experiments were performed to investigate if bacterial conjugation is influenced by zinc and therefore, plays a role for the detected increased resistance under high dietary zinc feeding. Values for colony forming units and conjugation rates were investigated for two different recipient/donor combinations. For in vivo experiments with gnotobiotic mice, feces were investigated daily over 20 days, and caecum digesta and small intestine digesta were examined to complement the analysis. In addition four different zinc concentrations were tested in vitro. Overall, some results indicate that zinc decreases the bacterial conjugation. However, results were very versatile and not all results support this suggestion. Therefore, an increasing effect of high dietary zinc feeding on plasmid exchange is unlikely. In conclusion, results of this study further corroborate recent reports on the association of high dietary zinc feeding with antimicrobial resistance. Both parts of this study point toward a situation where mainly the phylogenetic background of the plasmid host bacteria is of importance for the increased resistance and an increased plasmid exchange plays only a minor role. Although the mechanism by which high dietary zinc feeding leads to the increased resistance is still not clear, this study with the clear focus on resistance confirms the hypothesis that high dietary zinc feeding is no acceptable alternative to antimicrobial growth promoters. The usage of high dietary zinc feeding should therefore be stopped.Die Anwendung von Futterzusatzstoffen in der Landwirtschaft ist weit verbreitet um Wachstum und Gesundheit der Tiere zu unterstützen. So werden Schweine nach dem Absetzen oft mit Zinkoxid in Konzentrationen von 2000 – 3000 mg Zink/kg Futter gefüttert. Jedoch häufen sich die Hinweise, dass das Füttern dieser hohen Zinkkonzentrationen zu einem erhöhten Aufkommen von antibiotikaresistenten Bakterien führt. Antibiotika resistente Bakterien stellen ein weltweites Problem in der Human- und auch Tiermedizin dar. Daher war es nötig den Hinweisen auf einen Zusammenhang zwischen Zinkfütterung und Antibiotikaresistenzen weiter nachzugehen und diese noch genauer zu untersuchen. Die aktuelle Studie fokussiert sich dabei auf Bakterien der Spezies E. coli. Bakterien dieser Spezies sind sehr variabel, ubiquitär verbreitet, besiedeln den Darmtrakt von Warmblütern, Vögeln und Reptilien und haben eine hohe klinische Bedeutung da neben den kommensalen auch pathogene Bakterien existieren die zu intestinalen und extraintestinalen Erkrankungen führen können. Bei Schweinen stellen E. coli einen wichtigen Krankheitserreger dar, der bei säugenden und abgesetzten Ferkeln zu Durchfällen führt und mit großen wirtschaftlichen Verlusten einhergeht. Im ersten Teil der aktuellen Studie wurde ein Schweine-Zink-Fütterungsversuch durchgeführt, der im Versuchsaufbau klar auf die Untersuchung von antibiotikaresistenten E. coli ausgerichtet war. Sowohl für die Zink- als auch für die Kontroll- Gruppe wurden die absoluten E. coli Zahlen für drei unterschiedliche Habitate (Fäzes, Digesta und Mukosa) zu drei unterschiedlichen Zeitpunkten um das Absetzen herum untersucht. 2665 Isolate wurden auf ihre phänotypische Antibiotikaresistenz untersucht und für eine repräsentative Stichprobe dieser Isolate wurde zur Bestätigung zusätzlich die minimale Hemmkonzentration bestimmt. Abschließend wurden Isolate einer Stichprobe Gesamtgenom-sequenziert und die Sequenztypen für die entsprechenden Isolate bestimmt. Für Schweine der Zinkgruppe wurde in allen untersuchten Habitaten ein erheblicher Anstieg der multi-resistenten E. coli detektiert mit 28.9-30.2% multi-resistenten E. coli in der Zinkgruppe und 5.8-14.0% in der Kontrollgruppe. Dieser Zink-Effekt war unabhängig von der Gesamtzahl der E. coli, für welche ein Absinken über die Zeit in beiden Futtergruppen beobachtet wurde. Die höheren Resistenzraten der Zinkgruppe scheinen daher durch die Persistenz der resistenten Population unter dem Einfluss der Fütterung von hohen Zinkkonzentrationen zu entstehen. Interessanterweise sind hauptsächlich Isolate aus den zwei phylogenetischen Clustern ST10 und ST34 an der vermehrten Resistenz in der Zinkgruppe beteiligt. Im zweiten Teil der Studie wurden Konjugationsexperimente durchgeführt um zu analysieren ob die Konjugation von Bakterien durch Zink beeinflusst wird und somit für die erhöhte Resistenz unter dem Einfluss von hohen Zinkkonzentrationen eine Rolle spielt. Die Anzahl der koloniebildenden Einheiten und die Konjugationsraten wurden für zwei unterschiedliche Akzeptor/Donor Kombinationen untersucht. In in vivo Experimenten mit gnotobiotischen Mäusen wurde über 20 Tage Fäzes und abschließend auch zusätzlich Caecumdigesta und Dünndarmdigesta untersucht. Zusätzlich wurden vier unterschiedliche Zinkkonzentrationen in vitro untersucht. Zusammenfassend deuten einige Ergebnisse darauf hin, dass Zink die bakterielle Konjugation verringert. Jedoch waren die Ergebnisse sehr variabel und nicht alle Ergebnisse unterstützen diese Annahme. Eine Steigerung des Plasmidaustausches durch Fütterung von hohen Zinkkonzentrationen ist somit sehr unwahrscheinlich. Die Ergebnisse dieser Studie untermauern somit den beschriebenen Zusammenhang von Fütterung hoher Zinkkonzentrationen mit erhöhter Antibiotikaresistenz. Beide Teile der Studie deuten darauf hin, dass der phylogenetische Hintergrund der plasmidtragenden Stämme bedeutend für den Anstieg der Resistenzen ist und ein erhöhter Plasmidaustausch nur eine Nebenrolle spielt. Obwohl der Mechanismus nicht geklärt werden konnte, über welchen es zu einem Anstieg der Resistenz unter der erhöhten Zinkfütterung kommt, zeigt die Studie mit ihrem Fokus auf Resistenz, dass das Füttern hoher Zinkkonzentrationen keine akzeptable Alternative zum Einsatz von antimikrobiellen Wachstumsförderern ist. Der Einsatz von hohen Zinkkonzentrationen in der Fütterung sollte daher gestoppt werden