Clostridium difficile infection (CDI) and antibiotic-resistant infections. Information is needed on the frequency of incorrect prescribing in hospitals and how improved prescribing will benefit patients.Antibiotics are essential to effectively treat many hospitalized patients. However, when antibiotics are prescribed incorrectly, they offer little benefit to patients and potentially expose them to risks for complications, including A national administrative database  and CDC’s Emerging Infections Program (EIP) data were analyzed to assess the potential for improvement of inpatient antibiotic prescribing. Variability in days of therapy for selected antibiotics reported to the National Healthcare Safety Network (NHSN) antimicrobial use option was computed. The impact of reducing inpatient antibiotic exposure on incidence of CDI was modeled using data from two U.S. hospitals.In 2010, 55.7% of patients discharged from 323 hospitals received antibiotics during their hospitalization. EIP reviewed patients’ records from 183 hospitals to describe inpatient antibiotic use; antibiotic prescribing potentially could be improved in 37.2% of the most common prescription scenarios reviewed. There were threefold differences in usage rates among 26 medical/surgical wards reporting to NHSN. Models estimate that the total direct and indirect effects from a 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI.Antibiotic prescribing for inpatients is common, and there is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing.Hospital administrators and health-care providers can reduce potential harm and risk for antibiotic resistance by implementing formal programs to improve antibiotic prescribing in hospitals. Antibiotics offer tremendous benefit to patients with infectious diseases and are commonly administered to patients cared for in U.S. hospitals. However, studies have demonstrated that treatment indication, choice of agent, or duration of therapy can be incorrect in up to 50% of the instances in which antibiotics are prescribed . One stuClostridium difficile, an anaerobic, spore-forming bacillus that causes pseudomembranous colitis, manifesting as diarrhea that often recurs and can progress to sepsis and death; CDC has estimated that there are about 250,000 C. difficile infections (CDI) in hospitalized patients each year  describe the extent and rationale for antibiotic prescribing in U.S. acute care hospitals, 2) present data illustrating the potential for improving prescribing in selected clinical scenarios, and 3) estimate the potential reductions in CDI among patients when antibiotic use is improved. For this report, antibiotics include parenteral, enteral, and inhaled antibacterial agents.The first objective was accomplished using proprietary administrative data from the Truven Health MarketScan Hospital Drug Database (HDD) and data from CDC’s Emerging Infections Program (EIP). EIP is a network of state health departments, academic institutions, and local collaborators funded by CDC to assess the effect of emerging infections and evaluate methods for their prevention and control.For the second objective, additional data from the EIP were used to determine the frequency of opportunities to improve prescribing for selected urinary tract infections (UTIs) and prescribing of intravenous vancomycin. In addition, data reported during October 2012–June 2013 to the National Healthcare Safety Network (NHSN) Antimicrobial Use Option were analyzed; key percentile distributions of usage rates and differences in usage (between usage at 90th percentile and at 10th percentile) were calculated. This difference should be small when comparing usage rates among patient care locations caring for similar types of patients.The third objective was accomplished through development of a dynamic model that was used to interpret the findings of an observational study and predict changes in CDI with changes in antibiotic use. First, a retrospective cohort study was conducted to quantify the relative risk for CDI using hospital discharge data and pharmacy data from two large academic centers, in New York and Connecticut, linked to active population-based CDI surveillance data from the EIP . The pri§In 2010, based on data obtained from all 323 hospitals by MarketScan HDD, 55.7% of patients received an antibiotic during their hospitalization, and 29.8% received at least 1 dose of broad-spectrum antibiotics . The EIPNHSN began receiving antibiotic use data in 2012. Among the 19 hospitals reporting to the NHSN Antimicrobial Use Option that had completed data validation and submitted antibiotic use data from one or more patient care locations, results were reported for 266 patient care locations. Among the six most common types of patient locations, critical care units reported higher rates of antibiotic use  compared with ward locations . The variability in usage rates within any one patient location type was highest (threefold difference between 90th and 10th percentile) among combined medical/surgical wards . When limiting the comparisons within combined medical/surgical wards, differences in usage were eightfold for fluoroquinolones, sixfold for antipseudomonal agents, threefold for broad-spectrum agents (antibiotics considered high risk for subsequent CDI), and threefold for vancomycin . OverallAntibiotics are commonly prescribed in hospitals.Evidence of incorrect prescribing and observed variability in current usage patterns suggest that improvements are needed and will benefit patients.CDC recommends that all hospitals implement antibiotic stewardship programs that include, at a minimum, seven core elements: 1) leadership support; 2) accountability through a single physician lead; 3) drug expertise through a single pharmacy lead; 4) action including at least one intervention, such as an “antibiotic timeout,” to improve prescribing; 5) tracking prescribing and resistance patterns; 6) reporting local prescribing and resistance information directly to clinicians, and 7) education for clinicians.Urgent action is needed to promote correct antibiotic prescribing to ensure these lifesaving drugs work in the future.http://www.cdc.gov/vitalsigns.Additional information is available at Antibiotics are prescribed for the majority of patients hospitalized in U.S. acute care hospitals, usually to treat infections. This post prescription review of two common prescribing scenarios for treating suspected infections identified opportunities to improve 37.2% of prescriptions, often by timely use of diagnostic tests or documentation of symptoms. This observation is similar to results of older studies  and a reC. difficile throughout the community.The data in this report confirm the findings of several previous studies demonstrating that antibiotic prescribing in hospitals is common and often incorrect. In particular, patients are often exposed to antibiotics without proper evaluation and follow-up. Misuse of antibiotics puts patients at risk for preventable health problems. These include immediate complications; antibiotics are among the most frequent causes of adverse drug events among hospitalized U.S. patients , and neaAn additional near-term complication of the unnecessary and incorrect use of inpatient antibiotics is the growing problem of antibiotic resistance in U.S. hospitals, creating treatment challenges not only for patients who are exposed to the antibiotics, but for other patients to whom these resistant bacteria spread . Some hoPrograms dedicated to improving antibiotic prescribing in hospitals are commonly referred to as antibiotic stewardship programs. Such programs serve to ensure optimal treatment for hospitalized patients with infection and reduce unnecessary antibiotic use to minimize harm to patients and prolong the length of time antibiotics are effective . VariabiCorrect antibiotic treatment  is critical to saving lives of hospitalized patients with certain infectious diseases. Given the proven benefit of hospital stewardship programs to patients and the urgent need to address the growing problem of antibiotic resistance, CDC recommends that all hospitals implement an antibiotic stewardship program. CDC has developed guidance that can assist hospitals in either starting or expanding a program to improve antibiotic prescribing . CentralBOXLeadership commitment: Dedicating necessary human, financial, and information technology resources.Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs has shown that a physician leader is effective.Drug expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use.Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment .Tracking: Monitoring antibiotic prescribing and resistance patterns.Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff members.Education: Educating clinicians about resistance and optimal prescribing.Source: CDC. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html.


To measure Met protein content in prostate biopsies guided by fused magnetic resonance and ultrasound imaging, and to measure soluble Met (sMet) protein concentration in plasma samples from patients presenting evidence of prostate cancer.345 patients had plasma samples drawn prior to image-guided biopsy of the prostate. Of these, 32% had benign biopsies. Of the 236 that were positive for prostate adenocarcinoma (PCa), 132 treated by total prostatectomy had Gleason scores of 6 (17%), 7, (55%), 8 (16%), or 9–10 (12%). 23% had evidence of local invasion. Plasma samples were also obtained from 80 healthy volunteers. Tissue Met and plasma sMet were measured by two-site immunoassay; values were compared among clinically defined groups using non-parametric statistical tests to determine significant differences or correlations.PCa tumor Met correlated significantly with plasma sMet, but median values were similar among benign and malignant groups. Median plasma sMet values were also similar among those groups, although both medians were significantly above normal. Median Met content in primary PCa tumors and sMet concentrations were independent of Gleason score, final pathologic stage and age.MET gene features that occur at relatively low frequency in non-metastatic PCa.Plasma sMet is not predictive of PCa or its severity in patients with organ-confined or locally invasive disease. Quantitative analysis of Met protein content and activation state in PCa tumor biopsy samples was highly feasible and may have value in follow-up to genomic and/or transcriptomic-based screens that show evidence of oncogenically relevant  Prostate cancer (PCa) is the second most common cancer in men and second most common cause of cancer deaths of men in the United States . Over thThe hepatocyte growth factor (HGF) receptor tyrosine kinase, known as Met, is overactivated, overproduced and/or mutated in a wide spectrum of prevalent malignancies . EvidencThe present study extends our prior work by adapting the two-site electrochemiluminescent sMet immunoassay for use on detergent extracts prepared from flash frozen primary PCa tumor biopsies, and correlates these measurements with PCa stage, grade, Gleason score and plasma sMet levels. Since the advent of PSA screening, the pathologic diagnosis of PCa has been based on the use of systematic trans-rectal ultrasound guided biopsies. Advances in multiparametric magnetic resonance imaging (MRI) have allowed high quality visualization of the prostate and can aid in identification of prostate cancer lesions. We have previously reported on the use of a novel MRI and ultrasound (US) fusion biopsy system for the targeted detection of lesions detected on MRI , 25. TakFrom 2009 to 2012, primary prostate tumor biopsy specimens and plasma samples were collected from patients who underwent MRI-ultrasound fusion guided prostate biopsy and from patients who proceeded to have radical prostatectomy at the National Cancer Institute (NCI). All patients were enrolled in a NCI Center for Cancer Research (CCR) Institutional Review Board (IRB) approved tissue procurement protocol (NCI-97-C-0147) at the National Institutes of Health (NIH) Clinical Center by informed written consent. Consent documentation records are maintained by the NCI/CCR/IRB and the NIH Clinical Center Office of Protocol Services for a minimum of three years after the completion of the research. Tissue specimens were obtained by MRI-ultrasound fusion guided biopsy using a method reported previously , 25. SerMet, phosphotyrosyl-Met, and soluble Met ectodomain (sMet) proteins were measured in tissue and plasma samples as described previously . BrieflyAbsolute plasma sMet concentration and tissue Met content  were compared among groups defined by final pathologic stage (in those who underwent prostatectomy) and Gleason score. Statistical analyses were performed using JMP v10.0.2 (SAS Institute Inc.), Excel 2008 for Mac (Microsoft Inc.) and Prism v6.0f (GraphPad Software Inc.) software packages. Wilcoxon, Mann Whitney and Kruskal-Wallis tests, in conjunction with the Bonferroni multiple test correction where necessary, were used to determine statistical differences between groups. Receiver Operating Curves (ROC) were calculated and Area Under the Curve (AUC) determined using JMP. Cutoff values determined using a 45° line drawn tangential to the ROC curve were used to develop specificity, sensitivity and prediction values. Reverse-phase protein array (RPPA) and clinical data for a cohort of 352 cases in the Prostate Adenocarcinoma (PRAD) TCGA Provisional data set were obtained from the M.D. Anderson Reverse Phase Protein Array Core. RPPA scores for Met and phosphoMet (pMet) content were analyzed for relationships with T stage, Gleason score and PSA using Prism v6.0f (GraphPad Software Inc.) software. Within the 352 case cohort, Gleason score was available for 352, clinical T stage data for 348, PSA data for 318, clinical N stage data for 309 and clinical M stage data for 327. Of the latter, all but one case were M0, so correlative tests related distant metastases were not performed.MET gene amplification (determined using GISTIC) and/or mRNA overexpression (2-fold or greater as determined by RNA Seq V2 RSEM) obtained using the cBioPortal [vs. clear cell RCC (53/531 cases or 10%). Phosphotyrosyl-Met content was undetectable in these tissue samples, which is likely to reflect minimal receptor activation, since maximal receptor activation stimulated in vitro by the addition of ATP to several of these samples was readily detected (data not shown). Plasma sMet concentration was significantly correlated with primary tumor Met content in the 14 malignant PCa cases .As for tissue Met, median plasma sMet values in benign (n = 109) and malignant (n = 236) patient groups were not significantly different (Mann-Whitney p = 0.0575); however, both were significantly higher than the median of a healthy volunteer group  analysis results for Met content in a subset (352) of primary tumor samples in the PRAD TCGA data set were negatively correlated with Gleason score  informing others compelled to do similar work so that resources are used optimally; (2) showing the feasibility and precision of the methods and measurements made in tissue samples obtained with MRI/US-fusion guidance; and (3) improving our understanding of extent and nature of HGF/Met signaling pathway involvement in localized prostate cancer.Plasma sMet concentration is not predictive of PCa or its severity in patients with organ-confined or locally invasive disease. Analysis of Met protein content and activation state in primary PCa tumor samples obtained by image-guided biopsy as described here was highly feasible and quantitative. The low incidence of


MET mutation and/or amplification. MET amplification was found in 5 of 76 (6.6%) patients . The only MET mutation detected in 3 of 41 (7.3%) patients was N375S. No demographic and histologic characteristics were associated with specific MET abnormalities. Median overall survival was 3 and 5 months for patients with and without a MET alteration, respectively . Sixteen of 81 (20%) patients were enrolled in a c-MET inhibitor trial. Best responses were stable disease in 3 patients (19%), including a patient with esophageal adenocarcinoma that remained on the trial for 9.9 months . All tumors with MET abnormality (n=3) progressed on a c-MET inhibitor in fewer than 2 months. In conclusion, MET abnormalities can be found in a small group of patients with GE adenocarcinoma and further studies are necessary to better characterize the prognostic and predictive impact of MET alterations.We sought to investigate the demographics and tumor-associated features in patients with gastroesophageal (GE) malignancies referred to our Phase I Program who had formalin-fixed, paraffin-embedded tissue from archival or new biopsies tested for  Cancers of the upper digestive system are a global burden. The progMET-positive GE cancer is a promising molecular subtype, particularly as a potential target for c-MET inhibitors. MET encodes a tyrosine kinase receptor whose activation is involved in cancer progression.[MET gene amplification is one of the well-recognized mechanisms of c-MET overexpression and constitutive activation of MET/HGF pathway [MET positivity is an independent factor for poor survival regardless of disease stage. In agreement with this observation, MET amplified tumors display a higher pathologic grade and present at a more advanced stage.[gression., 8 c-METgression.. Paracrigression. Moreover pathway , and has pathway , 13 The ed stage. Taken toMET mutations have also been described as a mechanism for c-MET pathway activation in gastric cancer and in other malignancies.[MET-amplified GEJ cancers had some tumor shrinkage with crizotinib, a c-MET inhibitor.[Although far less frequent, gnancies., 15 The gnancies. In a recnhibitor. Rilotumunhibitor. leading MET genetic abnormalities in patients with advanced GE tumors is sorely needed, especially considering the wide availability of different c-MET inhibitors being assessed in clinical protocols. We sought to investigate the demographics and tumor-associated features in consecutive patients with GE malignancies referred to our Phase I Clinical Trials Program who had MET amplification/mutation testing. We also assessed the outcomes of patients with GE cancer who were included in protocols containing a c-MET inhibitor.A way to better characterize MET mutation/variant (41 patients) or amplification (76 patients). Thirty-six patients were tested simultaneously for both genetic abnormalities. Except for two patients with a neuroendocrine histology and one with squamous cell cancer, all remaining patients had adenocarcinoma. Median age at diagnosis was 56 years . The median number of prior therapies was 2 . Patient characteristics according to MET status are summarized in Table A total of 81 patients with advanced esophageal (n=36), GEJ (n=17) or gastric (n=28) cancers were evaluated for MET gene amplification in FISH analysis . The copy number of the MET gene in relation to CEP7 ranged from 3.11 to 16.4. A MET mutation/variant was detected in 3 out of 41 patients (7.3%). Of these patients, two had gastric and one had esophageal cancer. All mutations/variants detected were N375S, which has been previously reported as a polymorphism[MET amplification and mutation were mutually exclusive in patients simultaneously tested for both aberrations (n=36). The prevalence of MET mutation/variant and amplification was similar regardless what site of disease was tested Five out of 76 (6.6%) patients had a ymorphism  although the numbers are too small for definitive conclusions to be drawn. The proportion of poorly differentiated tumors was similar in MET positive patients compared to wild-type as well (1 out of 3 for MET mutated versus 22 out of 38 for nonmutated and 3 out of 5 for MET amplified versus 37 out of 71 for patients with non-amplified MET). Few concomitant mutations were observed in the MET positive population: one patient with a MET variant and one with MET amplification had a concomitant TP53 mutation, while MET and HER-2 amplification were simultaneously detected in one patient  were compared with patients wild-type for both abnormalities . Median OS from Phase I consult was 3 months versus 5 months for the MET positive and negative groups, respectively  for MET negative patients. Of note, the three patients with a MET abnormality were treated on a Phase I protocol containing a c-MET inhibitor. These patients had a PFS on these protocols of 1.0, 1.0 and 1.5 months . Sixteen out of the 81 patients included in this study (20%) were enrolled on a protocol with a c-MET inhibitor. All of the c-MET inhibitors reported here were small-molecule inhibitors of the MET receptor tyrosine kinase (11 selective and 5 non-selective). No partial responses were detected and best responses were stable disease in three patients  were treated on at least one Phase I protocol. This proportion was 37.5% (3 out of 8) for hs Table . Median s Figure . Median s Figure  and all MET amplification in 6.6% (5 out of 76) patients with advanced GE cancers referred to our Phase I department. MET mutation occurred at a similar frequency (7.3%), but was considered to be germline.[MET amplification in 2-7% of GE adenocarcinomas.[MET amplification in this histology is reported to be as low as 1%.[Here we report germline. Our datarcinomas., 19, 20 ow as 1%.MET amplification in GE cancer increased up to 5% with higher grade and more advanced disease in a previous report.[MET amplification compared to previous reports. However, we could not demonstrate any significant demographic and/or tumor associated features of MET positive tumors, including poor differentiation and an aggressive histology, as was previously reported for GE tumors and other malignancies.[The prevalence of s report. Considergnancies., 15 SeleMET positive GE cancers. Although this difference was not statistically significant, the small number of patients in this cohort may contribute to the lack of statistical power. We previously detected similar findings for patients with ovarian[MET genetic abnormalities is not dependent on tissue origin. In agreement with our results, patients with esophageal cancer and high c-MET expression had significantly reduced OS and disease-free survival in another series.[MET-amplified GE cancers was previously reported as 7.1 months[As expected, we detected a trend for a worse OS for h ovarian and genir series. The OS o.1 months. Of noteMET abnormalities in our study, only three were included in trials with c-MET inhibitors. Other authors reported an even worse accrual. Notably, of 10 patients with MET-amplified GE cancers, none were included in a crizotinib trial.[MET amplified gastric tumors may be sensitive to c-MET inhibitors.[MET abnormalities included in trials with these agents (1 patient with a MET variant and 2 with MET amplification). None of them had a response and their tumors invariably progressed in fewer than 2 months after starting treatment with a c-MET inhibitor. Similar findings were reported for two patients with MET-amplified gastric cancers treated with foretinib, a non-selective c-MET inhibitor.[MET-amplified GE tumors had rapid disease progression when treated with crizotinib. The other two patients had tumor reduction (up to 39%), although it did not last more than 4 months. Of note, responding patients had a MET/CEP7 ratio of more than 5 and both of our MET-amplified patients treated with a c-MET inhibitor had a ratio inferior to this. Interestingly, a recent series showed that the level of HER-2 amplification predicted sensitivity to trastuzumab.[MET amplification and sensitivity to c-MET inhibitors.It is somewhat challenging to enroll patients with relatively rare molecular abnormalities that are associated with a poor prognosis on clinical trials. Out of eight patients with ib trial. Preclinihibitors. We repornhibitor. Both werstuzumab. In this MET variant. As demonstrated in preclinical models, this variant may confer resistance to c-MET inhibitors.[Additionally, one of the patients receiving a c-MET inhibitor in our series had a N375S hibitors. Clinicalhibitors. Althoughhibitors. In the lMET mutation and amplification, as well for other mutations tested . Interestingly, encouraging preliminary results for treatment with onartuzumab and rilotumumab, which are antibodies against hepatocyte growth factor, were reported for GEJ and gastric cancers with a high expression of c-MET in immunohistochemical analysis[MET biomarkers simultaneously, such as via genetic and immunohistochemical analysis, is necessary to better understand predictive factors for response to c-MET inhibitors.Among all patients treated on trials with c-MET inhibitors in our series, the best result was stable disease for almost 10 months in a patient with esophageal adenocarcinoma who had received 3 prior therapies. Of note, this patient was negative for  analysis, leadingMET abnormalities in our series is another intrinsic limitation and precludes drawing definitive conclusions. Nonetheless, our results add to the current body of knowledge correlating the presence of MET genetic abnormalities with aggressive behavior and a worse prognosis in GE cancers. It is not clear if c-MET inhibition will offer reasonable antitumor activity for this population, but further exploration of biomarkers will likely clarify this issue.One of the weaknesses of this work is the lack of analysis of c-MET receptor expression levels, limiting some of our comparisons with previous studies correlating receptor overexpression with clinical and pathological features of GE cancers., 30 The MET mutation or amplification status. This study and all associated treatments were conducted in accordance with the guidelines of the MD Anderson Institutional Review Board.We retrospectively reviewed the electronic medical records of consecutive patients with advanced esophageal, GEJ and gastric carcinoma referred to the Department of Investigational Cancer Therapeutics at The University of Texas MD Anderson Cancer Center (MD Anderson) starting in May 2010 until March 2013. Patients were eligible for inclusion in data analysis if a primary diagnosis of any of these malignancies was confirmed and a tumor sample was sent to evaluate MET mutation/variant and amplification were investigated in archival formalin-fixed, paraffin-embedded tissue blocks or material from fine needle aspiration biopsies obtained from diagnostic and/or therapeutic procedures. All histology was centrally reviewed at MD Anderson. MET mutation or variant analysis was performed in different Clinical Laboratory Improvement Amendment-certified laboratories as part of a gene panel analysis or in a single test. This included assessment of 182 genes using a targeted next-generation sequencing Foundation One platform , 46 genes in an Ion Torrent next-generation sequencing procedure  and 53 genes using a Sequenom Mass ARRAY platform  or a PCR-based primer extension assay assessing mutational hot spots in the MET gene in the Division of Pathology and Laboratory Medicine at MD Anderson.MET amplification was analyzed via fluorescence in situ hybridization (FISH) at MD Anderson or Baylor`s Cancer Genetic Laboratory. Copy numbers were expressed as gene copy number in relation to CEP7, a gene located near the centrosome of the same chromosome. MET was considered amplified when the MET/CEP7 signal ratio was ≥ 2.0 or when this ratio was < 2.0 but there were > 20 copies of MET signals and/or clusters in > 10% of the tumor nuclei counted.MET inclusion criteria were enrolled in clinical trials judged to be clinically appropriate by attending physicians. Treatment continued until disease progression, withdrawal of consent by the patient, clinical judgment deeming the necessity of removing a patient from a clinical trial, or development of unacceptable toxicity or death. Clinical assessments were performed as specified in each protocol, typically before the initiation of therapy and then at a minimum at the beginning of each new treatment cycle. Treatment response was assessed using computed tomography scans, magnetic resonance imaging and/or positron emission tomography scans at baseline before treatment initiation and then every 2 cycles (6-8 weeks). All radiographs were read in the Department of Radiology at MD Anderson and were reviewed in the Department of Investigational Cancer Therapeutics tumor measurement clinic. Responses were categorized using RECIST on the basis of specific protocol requirements[Patients referred to the Phase I Clinic who uirements, 32 and MET mutation and/or amplification status and associated genetic abnormalities were summarized using frequency distributions and percentages. Progression-free survival (PFS) was defined as the interval from the start of therapy to treatment discontinuation for disease progression or death related to disease progression. Overall survival (OS) was assessed using Kaplan-Meier curve analysis starting from the date of the first appointment in the Phase I Clinic.Patient characteristics including demographics, tumor type,


The aim of this study was to develop a Chinese HIV/AIDS Stigma Scale (C-HSS) and test its reliability and validity among migrant workers in eastern China.Nine hundred sixty four migrant workers completed the C-HSS questionnaire in Zhejiang province. The Split-half reliability coefficient (R) and Cronbach’s alpha coefficient (a) for internal consistency of the scale were used. Factor analysis was applied for construct validity. Scores of total and subscales were compared among migrants. Correlation between scores and knowledge of HIV/AIDS was analyzed.p < 0.01). The cumulative contribution rate was 54.17 % by five public factors based on exploratory factor analysis. Except for the thirteenth item and twentieth item, four public factors were in accordance with the basic conceived concept. The confirmatory factor analysis indicated a good fit to the data for the four-domain structure. Negative correlation existed between the level of HIV/AIDS knowledge and stigma.The 24-items scale and the four subscales of C-HSS had good internal consistency . Correlation coefficients between each domain and total score were significant  contains supplementary material, which is available to authorized users. Since 1990s, research on HIV and AIDS-related stigma has increased worldwidely. Many researchers suggest that stigma and discrimination is a barrier to the adoption of precautionary behaviors and reduces the quality of life of people living with HIV and AIDS . Stigma Migrant workers are prone to have high-risk HIV behaviors, with a large proportion of male migrants visiting commercial sex workers (CSWs) either alone or in a group. Related survey also showed that some migrants including men who have sex with men (MSM), female sex workers, sexual promiscuity, drug addicts and so on are frequently mobile , 5. MigrReducing HIV-related stigma could potentially increase HIV testing, prevention and treatment . A comprZelaya AIDS discrimination scale included 24 items and four subscales, which had good internal consistency  . PermissA cross-sectional population-based study was conducted in Zhejiang province, China in 2013. Using a multistage stratified sampling method, at first, three stratifications were divided by economic level (Gross Domestic Productin) in Zhejiang province. The first stratification: Hangzhou, Ningbo and Wenzhou; the second stratification: Shaoxing, Jinhua, Taizhou and Jiaxing; the third stratification included four other cities. Most rural–urban migrants worked in the first and second stratification cities, so the study was carried out all in the first stratification: Hangzhou, Ningbo and Wenzhou. Jinhua and Shaoxing were sampled randomly among the second stratification cities. In each city a list of work units where migrant workers gathered was drawn up such as shoe factory in Wenzhou, textile industry in Shaoxing. In the company of staff who worked in local Center for Disease Control and Prevention, the researchers investigated migrant workers during coffee break. Questionnaire need to be finished independently within half an hour in the factory meeting room. Interviews were carried out with individuals’ informed consent.The C-HSS includes 24 questions and four domains: fear of transmission and disease (domain1), association with shame, blame and judgment (domain2), personal support of discriminatory actions or policies (domain3), perceived community support of discriminatory actions or policies (domain4). Response categories for items include ‘strongly disagree, disagree, no opinion, agree and strongly agree’  and raw scores for items range from one to five, no opinion = 3 . After rThe knowledge of HIV/AIDS measured was based on questionnaire from Chinese National Center for Disease Control. The questionnaire consisted of eight questions , which was applied in general populations and special populations . Some study results related with migrant workers were reported –20.p < 0.05 indicate a correlation relationship. Data for this study had been provided as Additional file Data were analyzed using SPSS version 18.0 and Mplus version 6.11 software. Reliability and the internal consistency for C-HSS were measured using Cronbach’s alpha coefficient and an alpha equal to or greater than 0.70 was considered satisfactory . ExploraThe 964 migrant workers were approached in the final analysis (response rate 96.4 %). Their mean age and standard deviation was 29.2 ± 9.1 years (18–65 years). The main reasons for rural-to-urban migration were earning money (67.2 %), learning skill (16.3 %) and longing for city life (11.1 %). They came from 25 of the 31 Chinese provinces, including 178 (18.5 %) from Zhejiang, 15.0 % from Jiangxi, 13.4 % from Anhui, 12.3 % from Henan and 10.1 % from Hunan. The demographic characteristics of the study sample are shown in Table Internal consistency was measured using the Split-half reliability coefficient (R) and Cronbach’s alpha coefficient (a). The split-half reliability coefficient for the scale was 0.877, and R for the four subscales ranged from 0.693 to 0.862. Cronbach’s alpha for the subscales ranged from 0.709 to 0.810, and the alpha for the total score was 0.845. Correlation coefficients between each domain and total score ranged from 0.124 to 0.765 . Five factors were extracted based on the principle of Initial Eigenvalues >1. The five-factor structure jointly accounted for 54.17 % of the variance based on exploratory factor analysis. Except for item 13 and item 20, four public factors were in accordance with the basic conceived concept . The mean scores of HIV/AIDS stigma were reported in Table There was no significant difference in the four domains and total scale between male and female migrant workers. However, the scores of domain 2 and domain 3 for the old migrants (over 31 years old) were higher compared to the younger (18–30 years old). The score of domain 1 for single migrants was higher compared to those married or other marital status. The scores of each domain and total scale showed significant difference among workers of different educational status. The overall knowledge of HIV/AIDS scores was 4.48 ± 2.18. There was a negative correlation between the level of HIV/AIDS knowledge and stigma, including the four dimensions of scale and total scale  in 2013 . The aveThe translation of the Zelaya’s scale went through a rigorous method and was approved by Dr. Zelaya. Our previous study showed that the Chinese version of Zelaya HIV/AIDS discrimination scale has good reliability and validity among medical students in China . Now theWith regard to construct validity, this was found to be satisfactory for both the total score and subscores of the C-HSS. Except for item 13 and 20, the other 22 items attributed to the four domains in consistent with the concept based on CFA  [t = 21.54, p < 0.001). The lack of knowledge of AIDS will further intensify stigma and fear against AIDS [The mean score for C-HSS was 2.75, higher than the score among medical students  . The finnst AIDS . So an enst AIDS , 30.Limitations should be considered when interpreting the results. The sample selected is not random completely because migrant workers are scattered in various work units in China, which is very difficult to comply with random completely sampling principles. So participants were chosen based on the labor-intensive industries where migrants gathered such as shoe factory, textile industry, building industry and services industry. Thence this sampling method might have biased our results. We only surveyed migrant workers in Zhejiang province, so this study population may not be representative of general or other populations in China. Further piloting may be required before widespread use of the C-HSS in low risk populations or the general population.This is the first study that describes the psychometric properties of the Chinese version of HIV/AIDS Stigma Scale (C-HSS) among migrant workers in China. The results demonstrated an acceptable reliability and validity and provided a useful tool for monitoring and assessing HIV/AIDS stigma in specific population.


This study investigated compressive strength, chloride penetration, and freeze-thaw resistance of multiwalled carbon nanotube (MWNT) concrete. More than 100 cylindrical specimens were used to assess test variables during sensitivity observations, including water-cement ratios  and exposure to chemical agents . To determine the adequate sonication time for MWNT dispersal in water, the compressive strengths of MWNT concrete cylinders were measured after sonication times ranging from 2 to 24 minutes. The results demonstrated that the addition of MWNT can increase the compressive strength of concrete by up to 108%. However, without chemical treatment, MWNT concretes tend to have poor freeze-thaw resistance. Among the different chemical treatments, MWNT concrete treated with sodium polyacrylate has the best compressive strength, chloride resistance, and freeze-thaw durability. After CNTs were treated with polyacrylic acid and polymers, analysis via scanning electron microscope (SEM) revealed improved dispersion within a cement matrix, with the persistence of a small percentage of CNTs clusters  penetration at the depth of 0.25 inches. This sodium polyacrylate-CNT concrete was quite compacted, so it did not allow much [Cl−] penetration, making it the best chemical treatment option . An ultrasonic impulse method was used to test the relative dynamic elastic modulus. The transmit time was tested at the beginning and every 30 cycles after that. Changes in weight and length were also measured every 30 cycles. The formula for the dynamic modules is shown in  found that adding methylcellulose increases thermal stability. This affects the coefficient of thermal expansion (CTE) in an unstable manner, leading to substantial freeze-thaw damage [2–CH(COONa)–] linked together in a long flexible chain. In terms of quantifying properties, sodium polyacrylate must absorb 100 times more water than its original weight, forming a product that resembles artificial snow. Sodium polyacrylate is a polymer with negatively charged ionic groups along its length, with accompanying positively charged sodium ions associated from the solution. Treatment methods involving silane, sodium polyacrylate, and methylcellulose differ. Methylcellulose involves covalent surface modification; in other words, it will increase the wettability of CNTs, thus reducing their tendency to agglomerate. Sodium polyacrylate and silane both involve noncovalent surface modification, which means that the hydrophobic part of the molecule is attached to MWNT sidewalls. The hydrophilic part is capable of increasing the solubility of treated CNTs. −; the hydrophilic part of silane is [Si]4+, and that of sodium polyacrylate is [Na]+. Sodium polyacrylate is better in concrete applications because of its long chain, where hydrogen molecules will be absorbed by MWNT sidewalls. Strong van der Waals forces between hydrogen molecules and the sidewall attach this long-chain polymer more easily than the shorter, single silane molecule. Additionally, [Na]+ dissolves more easily in water than [Si]4+ does, due to the stronger polarity of [Na]+ compared to [Si]4+. These properties make sodium polyacrylate a better chemical additive to CNT concrete. Additionally, these results demonstrate that noncovalent modification is better than covalent modification for improving both the compressive strength and durability of CNT concrete.All three chemical treatments dispersed CNTs well, producing good results for compressive strength at a water/cement ratio of 0.75, but they differed substantially in terms of durability. Silane is a silicon analogue of methane, with a chemical formula of SiHw damage . They alw damage . Sodium Adding CNTs to concrete can significantly increase strength, by as much as 108%. With a high w/c , the strength first increases but reaches a maximum strength at an optimal CNT concentration. This optimum CNT content depends on the w/c ratio. For w/c values of 0.4 and 0.5, the optimum CNT content is 1% by cement weight; for a w/c of 0.75, the optimum CNT content is 1.25% by cement weight. A well-dispersed CNT solution may not lead to high-strength CNT concrete. The test results demonstrated that an overdispersed CNT solution reduces the workability of CNT concrete and results in poor strength. The hydrophobic properties of CNTs can be changed dramatically, and concrete workability can be rapidly reduced with increasing dispersion time. Despite these findings, the exact causal mechanism behind these trends is not well understood. Methylcellulose, sodium polyacrylate, and silane are effective dispersion agents for CNTs; among these chemicals, treatment with sodium polyacrylate produces CNT concrete with superior freeze-thaw durability, increased compressive strength, and reduced chloride permeability.


It has been estimated that every year more than quarter a million health care workers exposed to HIV risky conditions in health care settings, more so in developing countries, with high incidence of HIV/AIDS and unsafe practices. Particularly, Sub-Saharan African countries share at least half of these occupational exposures to HIV risky conditions among health care workers. The aim of this study was to determine the epidemiology of health care workers’ exposure to HIV/AIDS risky conditions and associated factors in the healthcare settings in Gondar city.Institution based quantitative cross sectional study was conducted from April 1–20, 2014. The study included 401 health care workers who were selected from the source population by simple random sampling technique. Data were collected by interviewing health care workers using structured and pretested questionnaire. After the collected data entered to EPI INFO version 3.5.3 statistical software and exported to SPSS version 20.0 for analysis, both binary and multivariable logistic regressions were done to identify factors associated with exposure to HIV/AIDS risky conditions.From a total of 401 health care workers involved in this study, 162(40.4%) reported at least one history of occupational exposure to HIV/AIDS risky conditions in the last one year. More than half (52.31%) of physicians and 47.62% of anesthetists were exposed to HIV/AIDS risky conditions within one year. Lack of training on infection prevention, 5–10 years work experience, long working hours per week, absence of work guidelines, and dissatisfaction with current job were significantly associated with accidental occupational exposure to HIV/AIDS risky conditions.This study found quite high prevalence of health care workers exposure to HIV/AIDS risky conditions in the health care settings in Gondar city. Therefore, effective and goal oriented educational programmes targeting at health care workers and establishment of surveillance systems for registering, reporting and management of occupational exposures in health care settings are quite important. Health care workers (HCWs) are at risk of many infections in health setups , such asEach day thousands of HCWs, around the world, experience accidental occupational exposures during the course of their role of caring for patients . These eOf 35 million HCWs worldwide, it has been estimated that every year more than quarter a million health care workers exposed to HIV risky conditions in health care settings. As a result, 1,000 are likely to be infected with HIV . Most ofWhile there is still lack of hard data, anecdotal evidence suggests that, in Africa, the health systems may lose one-fifth of their employees due to HIV/AIDS over the next several years . Given tIn Ethiopia, the information concerning the events surrounding this accidental occupational exposure to HIV/AIDS risky conditions in the health setups is critically lacking. Particularly, there is no published study showing the clear picture of occupational exposure to HIV/AIDS risky conditions among HCWs. Therefore, this study was undertaken to primarily find out the epidemiology and characteristics of health care workers exposure to HIV/AIDS risky conditions in the health care settings in Gondar city, which can then be used as a baseline for developing a surveillance system, preventive guidelines and educational programs.Institution based quantitative cross-sectional study was conducted to determine epidemiology of health care workers’ exposure to HIV/AIDS risky conditions and associated factors in the healthcare settings in Gondar city, North West Ethiopia.Sample size was determined using the formula for single population proportion by considering e 50% prevalence of exposure to HIV/AIDS risky conditions (because there is no previous study), 95% level of confidence and 5% margin of error. Therefore, sample size was determined as follows:By adding 10% non response rate, the final sample size was 422 HCWs.In Gondar city, there were a total of 4 public health institutions, 1 hospital and 3 health centers, with a total number of 1032 HCWs. These HCWs were working in outpatient department (OPD), pediatric, maternity, gynecology, medical, surgical, and orthopedic wards, and laboratory, operation, dental, ophthalmology, injection and dressing rooms. The sampling frame consisting of all HCWs in each health institution were obtained from each health institution management. Then, new sampling frame was prepared through compilation of the list of each HCW into a single sampling frame and simple random sampling technique was administered to identify the study subjects.Data were collected through interviewing health care workers using structured and pre-tested questionnaire.Data were entered using EPI INFO version 3.5.3 statistical software and then exported to and analyzed using SPSS version 20.0. Descriptive statistics such as percentages, means and standard deviations were done for most variables in the study. Multivariable logistic regression analysis was done for controlling the possible effects of confounders after bivariable logistic regression analysis has been done by defining exposure to HIV/AIDS risky conditions as a percutaneous injury (needle stick or a cut by sharp objects) or the contact of mucus membranes or non-intact skin with blood, tissue or other body fluids that are considered to be potentially infectious. Finally, variables which have significant association with exposure to HIV/AIDS risky conditions were identified based on AOR with 95% CI and P-value ≤ 0.05.The study was carried out after getting permission from the ethical review board (IRB) of university of Gondar. Informed consent was also obtained from each health institutions and study participants to participate in the study and confidentiality was granted for information collected from each health institution and study participants by omitting their names from the questionnaires.Out of 422 selected HCWs, 401 participated in this study giving 95% response rate. Of the total study participants, 224 (55.9%) were males. Respondents’ age range from 20–60 years with a mean (standard deviation) age of 29.5 (6.75) years. Majority, 249 (62.1%) of the study participants were found in the age group of 20–29 years (Table One hundred sixty two (40.4%) HCWs involved in this study reported at least one history of accidental exposure to HIV/AIDS risky conditions in the last one year. Most, 102 (62.96%) of the exposures were mentioned by males and the rest 60 (37.04%) by females. About 47% of the exposed HCWs experienced the exposure more than once, while the rest 53% HCWs exposed just once. Majority, 92 (56.79%) of the exposure episodes occurred through percutaneous injury (needle stick or cut by sharp objects), followed by 90 (55.56%) through contact of mucus membranes and non-intact skin with blood, and 37 (22.85%) through contact of mucus membranes and non-intact skin with tissue or other body fluids that are considered to be potentially infectious. The leading perceived cause of exposure was heavy work load followed by failure to use of protective equipments, and lack of knowledge on standard precautions as reported by 103 (63.58%), 40 (24.69%), 19 (11.73%), respectively. More than half (52.31%) of physicians and 47.62% of anesthetists were exposed to HIV/AIDS risky conditions in the last one year  of them reported the incidence, while the rest 108 (66.67%) HCWs failed to so. The most common reasons stated by HCWs for not reporting their exposures were: busy work/workload 35 (32.40%), fear of stigma/discrimination 25 (23.15%), lack of support by management 18 (16.67%), reporting is too time consuming 18 (16.67%), and lack of awareness about reporting procedure 12 (11.11%).A considerable proportion, 163 (40.6%) of respondents reported that their work place had no safety instructions. Similarly, 124 (30.9%) of the respondents reported that they had no work guideline at their work place. Only 237 (59.1%) of the study participants took training on infection prevention. Majority, 262(65.3%) of the respondents reported that there was not a written protocol for reporting exposure to HIV/AIDS risky conditions at their workplace. More than half (51.1%) of HCWs had worked greater than 48 hours per week  of the HCWs perceived that exposure to HIV/AIDS risky conditions is highly risky, only 42.3% of them never recapped needles at all. Concerning job satisfaction, only 223 (55.6%) HCWs satisfied with their current job  of physicians exposed to HIV/AIDS risky conditions. This result is comparable with the study done in Tanzania , where dAlthough occupational exposure to HIV/AIDS risky conditions should be reported, in this study, a large proportion of HCWs (66.67%) failed to do so. This figure is higher compared to the studies done in Kenya  and TanzIn this study, the major reasons articulated by HCWs for not reporting their exposures are in agreement with previous studies –22. HCWsConsistent with previous studies , 24, lacIt is recognized that adverse schedule characteristics such as long work hours significantly increased the risk of occupational exposure , 26. In Existence of work/procedural guideline at workplace was also associated with occupational exposure to HIV/AIDS risky conditions. Those HCWs who lack work guidelines at their workplace were more likely report one year history of occupational exposure to HIV/AIDS risky conditions compared to their counter parts. This might be linked to the fact that those HCWs who lack work guideline may fail to follow the correct procedures, such as safe injections while they play their role of caring patients in such a high risky environment.Consistent with previous study , HCWs whThis study found high prevalence of health care workers’ exposure to HIV/AIDS risky conditions in the healthcare settings in Gondar city. This fact puts HCWs into a great risk for acquiring health care associated HIV infection. Lack of training on infection prevention, lack of work guidelines at workplace, long working hours, and dissatisfaction with current job were avoidable factors which raised the likelihood of HCWs exposure to HIV/AIDS risky conditions. Therefore, effective and goal oriented educational programmes targeting at HCWs and establishment of surveillance systems for registering, reporting and management of occupational exposures in health institutions are required. Specifically, hospitals and health centers should provide training on infection prevention, safety guidelines, and should reduce long working hours. The use of protective measures and post exposure prophylaxis (PEP) utilization against accidental occupational exposure to HIV/AIDS risky conditions are also important ways to prevent viral transmission among HCWs. Moreover, strengthening health systems and highlighting occupational exposure is necessary to prevent further spread of blood borne pathogens including the current Ebola outbreak in general, not just HIV/AIDS.


A substantial evidence has shown that the general community plays a role in the increase and spread of antibiotic resistance. The present study was designed to determine knowledge, attitude and practice towards antibiotic use.The emergence and spread of bacterial resistance to antibiotics is a growing problem worldwide, which presents a significant threat to public health globally in the 21A cross-sectional survey was performed using a pretested self-administered questionnaire on a sample of 770 randomly selected Kuwaiti individuals. Descriptive and multivariate logistic regression analysis were used in data analysis.The response rate was 88.3%. Nearly three-quarters (72.8%) of respondents had been prescribed antibiotics within 12 months prior to the study period, and 36% of them had not finished the course of treatment. Over one-quarter (27.5%) were self-medicated with antibiotics to treat mainly common cold, sore throat and cough. Self-medication was more prevalent among those who were prescribed antibiotics and those who had attitudes towards using and accessing antibiotic inappropriately. Almost 47% of participants had low knowledge regarding action, use, safety and resistance of antibiotics. Forty one percent of respondents had attitudes towards using and accessing antibiotic inappropriately. Better knowledge was found to be a predictor for positive attitude. Respondents level of agreement that doctors often prescribe antibiotics to meet the patient’s expectation, and that doctors often take time to consider carefully the need for an antibiotic were 52.7% and 35.3%, respectively.These findings will aid in the assessment of the adequacy of present public educational campaigns. Also, it will provide further insight in designing future multifaceted interventions to promote specific messages to rationalize antibiotic use, and compensate for knowledge and attitude gaps as an effort towards preventing development of antibiotic resistance. Spearman rank correlation was also used to analyze the association between the four dependent variables. Due to large number of statistical associations that were tested in this study there was a possibility of spurious significances. Hence, Benjamini-Hochberg-Yekutieli (FDR) adjusted p values were computed using R software and reported along with the unadjusted p values. An FDR score < 0.05 was considered as statistically significant.A total of 770 Kuwaiti subjects were approached to be included in the study, 680 agreed to participate giving a response rate of 88.3%. Their median  age was 30.5 (19) years. Of the 680 respondents, 68.7% were females and 87.5% had high education. One hundred and eighty seven  of the study population had used antibiotics without a medical consultation within 12 months prior to the study period. Most of them  were also prescribed an antibiotic within 12 months prior to the study period. The majority of them  were self-medicated with the antibiotics two to five times within 12 months prior to the study period. On the multivariate logistic regression analysis, there were no significant associations between the respondents’ characteristics and self-medication with antibiotics. Self-medication was found to be significantly correlated with being prescribed an antibiotic within 12 months prior to the study period  and attitudes towards antibiotics’ use . Respondents more likely to be self-medicated with antibiotics were those who reported being prescribed an antibiotic within 12 months prior to the study period and those who had negative attitude towards use of antibiotics. There was no significant relationship between self-medication and respondents’ knowledge of antibiotics. Ninety seven (51.9%) of the self-medicated responders indicated that they had given an antibiotic to someone else to use without a medical consultation. One hundred and nineteen (63.6%) stated that they used antibiotics that were originally prescribed for an infection which recurred later, and 21 (11.2%) for another type of infection. Fifty nine (31.6%) of the respondents who had self-medicated obtained the antibiotics directly from private pharmacies in Kuwait, and from pharmacies abroad 20 (10.7%) without a prescription. Other sources of obtaining antibiotics included family members  and friends . The self-medication with antibiotics was mainly to treat common cold , sore throat , cough , genitourinary infections , and superficial wounds .The median (IQR) knowledge score of respondents was 7 (4.0) out of a maximum score of 13 [moderate knowledge]: 2.8% (n = 19) did not indicate any correct response, whereas 43.8% (n = 298) listed one to six correct responses, 43.4% (n = 295) seven to ten, and 10% (n = 68) eleven to thirteen correct responses. In contrast, participants were less knowledgeable about whether antibiotics were effective against coughs and colds, viruses, bacteria and normal flora. Over half of the respondents incorrectly agreed that ‘antibiotics speed up the recovery from most coughs and colds’  and ‘antibiotics work on most coughs and colds’ . Confusion about whether antibiotics were effective against bacteria or viruses was existing in this study. One third  of participants did not agree that ‘antibiotics are effective against bacteria’ and 46.2% (CI: 42.4–50.0) incorrectly agreed that ‘antibiotics are effective against viruses’. Almost 40% of those agreed that antibiotics are effective against bacteria also agreed that antibiotics are effective against viruses. Over two-fifths of respondents did not agree that antibiotics can cause imbalance in the body’s own bacterial flora  and that antibiotics can kill the bacteria that normally live on the skin and in the gut . Further, the study population were also less knowledgeable about antibiotic resistance. Over half of participants did not agree on the statements: ‘the unnecessarily use of antibiotics can increase the resistance of bacteria to them’ , ‘resistance to antibiotics is a worldwide problem’ , and ‘the use of antibiotics among animals can reduce the effect of antibiotics among humans’ . Almost six-in-ten responders incorrectly agreed that humans can be resistant to antibiotics’ .On the multivariate logistic regression analysis, the findings revealed that respondents who work or study in a health-care related field were found to be more knowledgeable than those who did not work or study in a health-care related field . There were no significant associations between respondents’ knowledge about antibiotics and the other independent variables.The multivariate logistic regression analysis revealed that two independent variables have a significant influence on the respondents’ overall attitude towards use of antibiotics. Respondents with high education and those who work or study in a health-care related field were found to express more positive attitude than those with lower education  and those who did not work or study in a health-care related field .A significantly higher percentage of participants agreed that pharmacists often tell them how antibiotics should be used than the doctors during the consultation . A significantly greater percentage of respondents indicated trusting the doctor who is not prescribing an antibiotic , than the doctor prescribing an antibiotic  . Five-in ten responders (52.7%) agreed that doctors often prescribe an antibiotic because the patient expects it. Only 35.3% (CI: 31.7–39.0) of respondents agreed that doctors often take time to consider carefully whether antibiotics are needed or not.This is the first known study to be conducted in Kuwait, and probably in the GCC countries to comprehensively demonstrate knowledge, attitudes, and practice towards antibiotic use among the public. The present findings would be the first step in providing a baseline quantitative data of patterns of antibiotics use, knowledge and attitudes regarding antibiotics among Kuwaiti citizens. This will aid in the assessment of the adequacy of the present community educational campaigns on antibiotics, and provide further insight in designing future multifaceted interventions targeting specific areas to promote rational antibiotic use, and replenish the knowledge and attitude gaps as an effort against antibiotic resistance.High rates of antibiotic prescribing were identified by the present study. These results are close to previous studies from Italy, Syria and Jordan, ,21,24 buMore than one-third of those being prescribed an antibiotic did not complete their last antibiotic course as prescribed, most of them stopped treatment because they felt better. In addition, 45% of respondents expressed negative attitude to stop taking antibiotics before completing the course once they felt better. This misconception in the antibiotic use may put the patient at risk of relapse with resistant pathogenic bacteria. It is widely believed that inadequate dosing, incomplete courses, and indiscriminate drug use have contributed to the emergence and spread of antibiotics resistance, which is a current problem in Kuwait ,9–11.The current finding that almost three-in-ten of the study population had self-medicated with antibiotics is close to that reported from Italy and 11 European countries ,33. HoweThe present findings reveal that other sources of obtaining antibiotics included family members and friends, and over half of the self-medicated responders indicated that they had given an antibiotic to someone else to use without a medical consultation. Moreover, 44.3% of the study participants expressed negative attitude to keep left-over antibiotics for future use, and 23.3% to get antibiotics from relatives or friends without advice from a physician. These findings demonstrated that a proportion of Kuwaiti individuals share used antibiotics with others, thus subjecting the general population to the problem of antibiotics misuse.Respondents self-medicated with antibiotics for minor ailments such as common cold, sore throat, and cough, all of which can be self-limiting with the appropriate medical and supportive care. In addition, over 60% of participants expressed negative attitude to take antibiotics for treatment of sore throat or cough. This could be explained by the low respondents’ knowledge about whether antibiotics were effective against coughs and colds, viruses, and bacteria. Over half of them incorrectly thought that antibiotics work on most coughs and colds and speed up their recovery, which is comparable to the rates reported in Jordan and South Korea, ,25 but cIn the present study, there were no significant associations between self-medication with antibiotics and the background characteristics of the respondents. In contrast, previous studies reported significant association between self-medication and age, gender, level of education and income ,24,33–39Respondents’ adequate knowledge of antibiotics was identified to correlate positively with attitude, which is consistent with previous studies, where appropriate knowledge of antibiotics was identified to be a predictor for positive attitude towards antibiotic use ,25. The Interpretation of the findings of this study should take into account certain potential limitations that might impact upon its conclusions. While efforts were made to obtain representative samples, the over representation of female gender and higher educational level in the study sample indicates selection bias. That would have affected the external validity in terms of generalizing the findings to the wider population. We acknowledge that this type of study, using a self-administered questionnaire, has its limitations. It depends very much upon information given by respondents and open to recall bias. It is possible that respondents may over-report socially desirable behaviors or under-report socially undesirable behaviors. The extent of truthful answers or verifying respondents’ claims is not possible in this type of study, which were taken at face value. The completion of the questionnaires anonymously and assurance of confidentiality would minimize the over- and under-reporting. A further limitation is the cross-sectional nature of the data that represented one point in time and, therefore, do not reflect any changes in respondents’ knowledge and attitude over time in relation to antibiotics use. Despite these limitations, the present findings provide important information for evaluating and improving knowledge, attitude and practice towards antibiotics use.The present findings allow for important comparative work with existing and future investigations in middle-eastern countries, and worldwide. Given the rapid growth rate of antibiotic resistance in Kuwait, and documented health issues related to inappropriate use of antibiotics, the present findings highlight important concerns regarding antibiotics among Kuwaiti citizens. The key findings of this study will help policy makers in Kuwait to plan and establish future effective multifaceted interventions to improve the appropriate use of antibiotics. These should include the followings: (i) policies of auditing antibiotic prescriptions in the healthcare facilities, and investigating the consultation behavior and other behavioral components engaged in patients’ expectations for antibiotics, (ii) improve communication about antibiotic appropriateness between healthcare professionals and patients, (iii) public education programs using all media means that should be targeted more efficiently at those who have low knowledge, negative attitude and inappropriate practice towards antibiotic use. These campaigns should not only disseminate information, but also use behavioral and persuasion theories and repetition to target modifications in health risk attitudes. Every campaign should be followed by an evaluation of its effectiveness, (iv) highlighting pharmacists’ role in health education and promotion, and responsibility in prohibiting antibiotic dispensing without prescription, and (v) monitoring sources of obtaining antibiotics through enforcing the strict regulations. Further research to investigate knowledge, attitude and practice towards antibiotic use among expatriates will help in the adoption and implementation of successful future policies to promote rational antibiotic use among the public in Kuwait. S1 Dataset(SAV)Click here for additional data file.


The scaling up of antiviral treatment (ART) coverage in the past decade has increased access to care for numerous people living with HIV/AIDS (PLWHA) in low-resource settings. Out-of-pocket payments (OOPs) represent a barrier for healthcare access, adherence and ART effectiveness, and can be economically catastrophic for PLWHA and their family. We evaluated OOPs of PLWHA attending outpatient and inpatient care units and estimated the financial burden for their households in the Lao People's Democratic Republic. We assumed that such OOPs may result in catastrophic health expenses in this context with fragile economical balance and low health insurance coverage.We conducted a cross-sectional survey of a randomized sample of routine outpatients and a prospective survey of consecutive new inpatients at two referral hospitals . After obtaining informed consent, PLWHA were interviewed using a standardized 82-item questionnaire including information on socio-economic characteristics, disease history and coping strategies. All OOPs occurring during a routine visit or a hospital stay were recorded. Household capacity-to-pay , direct and indirect OOPs, OOPs per outpatient visit and per inpatient stay as well as catastrophic spending  were calculated. A multivariate analysis of factors associated with catastrophic spending was conducted.A total of 320 PLWHA  were enrolled. Monthly median household income, essential expenses and capacity-to-pay were US$147.0 (IQR: 86–242), $126 (IQR: 82–192) and $14 (IQR: 19–80), respectively. At the provincial hospital OOPs were higher during routine visits, but three fold lower during hospitalization than in the central hospital ($21.0 versus $18.5 and $110.8 versus $329.8 respectively (p<0.01). The most notable OOPs were related to transportation and to loss of income. A total of 150 patients  were affected by catastrophic health expenses; 36 outpatients  and 114 inpatients . A total of 141 (44.0%) patients had contracted loans, and 127 (39.6%) had to sell some of their assets. In the multivariate analysis, being of Lao Loum ethnic group ; being poor  and living more than 100 km away from the hospital  were positively associated with catastrophic spending. Conversely being in the highest wealth quartile , living alone , attending the provincial hospital , and being on ART , were negatively associated with catastrophic spending.PLWHA’s households face catastrophic OOPs that are not directly attributable to the cost of ART or to follow-up tests, particularly during a hospitalization period. Transportation, distance to healthcare and time spent at the health facility are the major contributors for OOPs and for indirect opportunity costs. Being on ART and attending the provincial hospital were associated with a lower risk of catastrophic spending. Decentralization of care, access to ART and alleviation of OOPs are crucial factors to successfully decrease the household burden of HIV-AIDS expenses. The introduction of multidrug antiretroviral therapy (ART), has significantly improved the health status and survival of people living with HIV/AIDS (PLWHA) over the past decade ,2. WhileCatastrophic spending occurs when the ratio between total health expenditure and the difference between income and necessary expenditures  is more than 40%. This increases the risk of impoverishment . ThreshoEconomic support to patients is becoming an essential component of successful HIV/AIDS programs. It still represents a small proportion of the Global Fund grants to Fight AIDS, Tuberculosis and Malaria . Still, In South and South-East Asia approximately 1 028 000 adults and 56 000 child patients are living on ART. In Lao People’s Democratic Republic  the proportion of the population living below the official national poverty line dropped from 45% in 1992 to 23.2% in 2012, when the country was classified as a low-middle income country by the World Bank ,35. A frWe conducted an assessment of the OOPs for health care for PLWHA during hospitalization periods and routine visits in different health facilities in Laos. We assumed that these disbursements for HIV care lead to catastrophic expenditures for PLHIV and their families, in the context of the fragile economic balance of Lao families. We further quantified the extent of catastrophic payments as well as the main coping strategies adopted by patients or their families.th century. The per capita income increased from US$ 1,010 per capita in 2011 [Laos (6.4 million population) was formerly described as a closed country until it opened up to the market economy in the late 20 in 2011  to US$ 1 in 2011 –42. AbouPublic health services were initially mostly composed of very basic free primary care services. User fees for curative public health services were subsequently introduced in the 2000ies. This was followed by the slow reintroduction of user fee exemption for some target population groups, such as the poor. A nationwide, Revolving Drug Fund (RDF) mechanism was established in order to assure a steady supply of essential medicines from the central level all the way down to the village level through cost-recovery. Four health financing schemes were developed: (1) Social Security Organization (SSO) for salaried private employees since 1999; (2) State Authority for Social Security (SASS) for civil servants since 1993; (3) Community-Based Health Insurance (CBHI) for non-poor workers in the informal sector established in 2002; and (4) a Health Equity Fund (HEF) for the poor. However, population coverage by these four main pre-payment schemes is limited to around 19.6% of the population and the overall participation to each scheme is deemed as poor . ExternaART was first introduced in Laos at the Savannaket provincial public hospital (SVK) with the support of “Médecins sans frontières” (MSF) in 2001. It was then gradually extended to public hospitals in the Capital Vientiane, namely to the Setthathirat Hospital (STT) in 2006, and the Mahosot hospital in 2007, in collaboration with MSF, the national HIV/AIDS program, the Center for HIV/AIDS/STI (CHAS) and a French public interest group “Ensemble pour une solidarité thérapeutique hospitalière en réseau” (ESTHER). In 2013, the estimated HIV prevalence among 15 to 49 years old was 0.2%.  A total This study was conducted in SVK hospital in Savannaket province and in STT hospital in Vientiane Capital from March to June 2009. These two hospitals provide ART and treatment for opportunistic infections as well as clinical examinations needed for the follow up treatment . Viral load testing was not available at the time of the study . TranspoWe enrolled PLWHA attending an outpatient HIV clinic and HIV inpatients at the infectious disease unit. PLWHA were eligible if they were aged 16 years or above, HIV-positive, and under ART for less than 24 months or awaiting ART. Inpatients were included if it was possible to enroll them at the beginning of their hospitalization period. PLWHA with mental issues or unable to answer questions were excluded.A list of outpatient attending the HIV clinic was established every day during the survey. From this list of outpatients five patients were selected using a table of random numbers. The number of interviewees was limited to five per day for feasibility reasons.The procedure differed for inpatients due to the small number of new patient admissions. Newly hospitalized patients in the infectious disease service were subsequently enrolled until a number of 40 inpatients was reached.We prospectively recorded all OOPs supported by these HIV patients during their outpatient/inpatient period.All patients were included after informed written consent was obtained.An 82-item, pre-tested structured questionnaire was administered to all study participants. The questionnaire addressed the following issues: socioeconomic characteristics, individual and family income and data relevant to expenses during the survey period , coping strategies used to face the recurrent expenses of HIV care  and the consequences of the disease on employment.All expenditures that involved OOPs were recorded including all health-related expenses and indirect expenses. This included transportation costs, number of lost working days and loss of daily income for the patient and accompanying family if any, accommodation, food, consultation fees, purchase of medications, and hospital bills . The chaFamily income was defined as the total revenue of all family members. Income which was not monetary such as farm products  was converted to monetary value. Family income was calculated using the following information: the number of farmers/professionals in the family, the personal report of  income generated either by farm/shop or production/sales, the number of workers with a salary and the monthly income generated by salaries. The patient income was calculated similarly. From the patient income or the family income we extrapolated the loss of income generated for one day.Necessary expenditures were defined as the monthly expenses per family for accommodation, electricity, phone, food, school and additional necessary expenses including children care or clothing. Patients were asked to report all these different expenses on a monthly basis.Necessary expenditures were calculated adding the expenses for the different categories. Capacity to pay was the difference between available income and the necessary expenditures. Total health expenditure was defined as the entire medical or non-medical HIV related expenditures. The medical expenditures included consultations, drugs, and medical exams while the non-medical expenditures concerned transportation and accommodation. This excludes any loss of income related to HIV.Cost to patients was classified as direct and indirect costs . Direct The indirect costs were defined as the consequences related to the treatment for patients such as loss of work income, loss due to illness, and costs incurred, if any, by the accompanying relative.Out of pocket payments (OOPs) were defined as all the direct and indirect expenses related to HIV care supported by the patients which were not reimbursed. All financial support/reimbursements received by the patient were recorded and deducted from the OOPs.Catastrophic costs were defined as OOPs greater than or equal to 40% of the capacity-to-pay .Data collection was done in Lao language by one Lao doctor (AF) attending a master course in epidemiology and trained in infectious diseases.The main outcome was the total OOPs. The secondary outcomes were catastrophic expenses, direct and indirect disease costs, costs according to stage of illness, residence, and hospital location, household coping strategies, and impact of the disease on professional activity.As no published data was available on how to calculate the sample size, the sample size was based on the assumption that the frequency of HIV OOPs account occurred for 50% of the HIV patients attending care in Laos. Using Stata software the sample size was estimated at 257 with 10% precision, alpha = 0.05, power 80%. We added 26 patients (10%) to compensate for non-exploitable files raising the total number to 283 which was rounded down to 280 patients.Data was entered in EpiData freeware . All recAssociations between catastrophic spending and patients’ characteristics were initially measured using bivariate analyses  and multivariate analyses . MultinoThis study formed part of a master’s course at “Institut Francophone pour la Médecine Tropicale” . All study participants were informed about the study in Lao language and supplied with an information sheet describing the study. Patients were included in the study only after they gave written informed consent. Agreement was recorded on the consent form. Ethical clearance for the study was obtained from the Lao Medical Ethics Committee of the Ministry of Health.A total of 352 patients were screened, 32 (9.1%) refused to participate in the survey leaving 320 patients included for data analysis . This coThe characteristics of the population per hospital are summarized in Patients differed in STT and SVK on certain characteristics  . SVK patMedian household income, essential expenses and capacity-to-pay were US$ 147.0 (IQR: 86–242) per month, $126 (IQR: 82–192) and $14 (IQR: -19–80), respectively. Up to 60% of patients had to change their profession due to their illness and 102 (31.8%) had to stop working permanently, while 131 (40.9%) became temporary workers, after discovering their HIV status. A total of 132 (41.2%) were defined as poor. To face the expenses of the disease, 141 (44.0%) took out loans, and 127 (39.6%) had to sell some of their assets. A total of 45 (14.1%) had to sell gold; 45 (14.1%) cattle; 28 (8.70%) land and 6 (1.9%) had to sell their house. The median amount of loans was US$117 (IQR: 29.4–235) and was higher for outpatients at STT than at SVK . The median distance from home to hospital was 70 km (IQR: 17–200).Characteristics of patient disease are shown in Almost all patients  were on ART, and 264 (82.5%) were at WHO stage 3 or 4. Median CD4 count at initiation of treatment was cells/mm3 (IQR: 19–181) and 90 cells/mm3 (IQR: 25–249) at the time of survey.Details of household income and of disease related costs are shown in In the inpatients group, 10 (25.0%) had no revenue and 8 (20.0%) earned less than US$100 per month. The average revenue was US$214.2 (95%CI: 161.4–267.1). The total OOPs for each hospitalization period was US$220.3 (95%CI: 150.8–289.8).The mean direct costs for hospitalization at SVK (US$33.8) represented half of the total direct costs of US$68.5 at STT (p<0.1). The total average costs at SVK (US$110.8) represented a third of the costs at STT (US$329.8). The OOPs per day was twice as much in the capital STT than in provincial hospital . Of 40 inpatients, OOPs were considered catastrophic for 36 .The bivariate analyses of factors associated with catastrophic spending are shown in After multivariate analysis, 7 factors were independently associated with catastrophic spending . The folThe groups of 22 people living alone were younger than the others, were mostly businessman or salesmen, . Their income was not different from others but they had lower essential expenditures .This survey, set in a low-resource setting, shows the precarity and high level of catastrophic spending frequently faced by PLWHA. Nearly half of outpatients and a third of inpatients were defined as poor. OOPs expenditure reached a catastrophic level for 41% of outpatients and 90% of inpatients compromising an already fragile economic condition. The impact on the work force was also high with up to 60.6% of patients changing profession and 31.8% losing their job. No patients made reference to any form of insurance system and the level of financial support was low and essentially restricted to SVK within an NGO run ward. In the absence of a comprehensive formal social security/insurance mechanism for chronic and long term and repeated treatments, many Lao patients had to resort to their family and traditional social network for alternative support. Such behavior has also been described in other traditional and custom bound societies such as in India .The results show that HIV is associated with the depletion of savings and productive assets and consequent level of households’ debt . The freTo improve the situation a few strategies have been developed in Laos including equity funds. These approaches remain largely dependent on external sources and hence are of limited sustainability despite the progressive commitment and funding for health care by the Government of Laos . In addiWe evaluated OOPs in the context of two different environments: one urban (STT) and one rural environment (SVK). This was justified by programmatic reasons and the project of scaling up HIV treatment sites to the provincial and districts areas. The assumption behind this comparison was that spending and OOPs differ between the two environments due to the difference of cost of living in Vientiane Capital and in the province. It was important to evaluate and confirm the economic impact for patients in both environments.We used a conservative definition of catastrophic expense with a higher threshold (40%) than in other studies . This prThe impact of OOPs was important not only at the patient level but also at the whole family level, particularly for the inpatient group. Despite differences between the province and capital hospitals, each hospitalization can be classified as a catastrophic expense. Over 90% of inpatients faced health expenditures that were of a catastrophic level and likely to lead to severe economic consequences for the family, as opposed to 41% of families of PLWHA attending consultations. Similar studies in other Asian countries such as in neighboring Vietnam, show catastrophic health expenditures for 35.1% of households [Poor people, unlike people in the 75% quartile of wealth, were mostly associated with catastrophic OOPs. This is a frequently occurring trend. A study in India revealed that poor households spent a higher proportion of their income on care and treatment than the better-off households . This stTransportation costs were associated with extensive OOP costs for the family. They are a major well-known obstacle for access to treatment and patient adherence reported in many other countries such as Burkina Faso, Cameroon and Malawi ,16,45,46The coping strategies for loss of revenue mostly relied on the sale of assets or contracting family loans. A few families  resorted to selling non-monetary valuables . For these families, this suggests that the level of poverty is probably overestimated when using only the daily income of US$1.25 per day, since some families have no revenue but instead non-monetary assets. For other families this suggests that the disease exhausted potential assets and patients had to resort to loans. However it shows the presence of a traditional net of resource that can be used in the case of an emergency. The origin of loans was not investigated and probably need further investigation and we did not know how much of the assets were still left available for the households. These are usually exhausted after the first year of treatment . A similThe total OOPs for inpatients were three times more expensive in the capital than in the province, while only a small difference was observed for outpatients. The cost of para-clinical tests and medicines for hospitalization was much higher in the capital (US$35.5) compared to the province (US$3.6). The duration of hospitalization was also longer in the capital (24.4 days) compared to the province (14.7 days), which would further add to the cost of treatment. This is partially explained by the support for patients by local NGOs in the province  and by more sophisticated level of analysis performed in the capital hospital. This supports the recommendation to alleviate indirect OOPs for PLWHA. Similar observations were done in China where the cost of hospitalization was estimated in two provinces ,34. HereThe reported level of financial support was lower than expected and variable with patients and sites. This needs to be monitored. In fact, exemptions for the poor and other groups including civil servants and their families as well as monks have been established in Laos . It is lTo protect HIV households from catastrophic spending the most straightforward approach suggested by this study is to reduce major out of pocket expenses including transportation and hospitalization costs. Increasing early access to testing and ART would decrease hospitalization costs since here, most patients presented with very low CD4 levels and there is still a need to scale up ART coverage in the country ,49.To date, seven main centers and two satellite centers have been gradually established: another one in Vientiane , 3 in the North  and another in the South (Pakse). Due to In addition mechanisms to subsidize, through social health protection schemes, indirect costs such as transportation, and compensation for loss of income including of accompanying relatives, such as health equity fund for the poor, are crucial elements to alleviate the burden of the disease faced by PLWHA and their families. To date these mechanisms are not yet in place in Laos .Decreasing patient expenses through the development of social insurance or funding through general taxes is also recommended ,33. TotaOf concern is the low coverage of the Lao health insurance system and the issue of how to improve its efficiency through better defining the people in need, improved access, and how to avoid impoverished families from facing the huge burden of chronic disease such as HIV but also non communicable diseases such as cancers in the country. A positive aspect is the public and private commitment to improve the situation in the country. This study showed that support for items such as transportation and food, which do not represent a large proportion of health costs, could effectively contribute to help alleviate catastrophic expenses and subsequent impoverishment of families.The study has several limitations. Common limitations are related to memory bias and self reporting. Some respondents may have under- or overestimated the costs. To reduce this potential bias, only the costs of the last outpatient visit were recorded and for the inpatient visits, the expenses were prospectively recorded. The study did not investigate in-depth coping strategies among the household .In Laos, the majority of PLWHA households face catastrophic OOPs that are not attributable to the cost of ART or routine follow-up tests. Distance to care, transportation and hospitalizations are the major causes of OOPs. Being on ART and attending the provincial hospital were associated with a lower risk of catastrophic spending. Decentralization of care, access to ART and alleviation of OOPs are crucial factors to successfully decrease the household burden of HIV-AIDS expenses.S1 Dataset(XLSX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 TableLogistic regression using Odd ratios.(DOCX)Click here for additional data file.