Principles of patient-centred, person-centred and problem-solving approaches.
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"52",leadTitle:null,fullTitle:"Wave Propagation",title:"Wave Propagation",subtitle:null,reviewType:"peer-reviewed",abstract:"The book collects original and innovative research studies of the experienced and actively working scientists in the field of wave propagation which produced new methods in this area of research and obtained new and important results.\nEvery chapter of this book is the result of the authors achieved in the particular field of research. The themes of the studies vary from investigation on modern applications such as metamaterials, photonic crystals and nanofocusing of light to the traditional engineering applications of electrodynamics such as antennas, waveguides and radar investigations.",isbn:null,printIsbn:"978-953-307-275-3",pdfIsbn:"978-953-51-4908-8",doi:"10.5772/584",price:159,priceEur:175,priceUsd:205,slug:"wave-propagation",numberOfPages:582,isOpenForSubmission:!1,isInWos:1,hash:null,bookSignature:"Andrey Petrin",publishedDate:"March 16th 2011",coverURL:"https://cdn.intechopen.com/books/images_new/52.jpg",numberOfDownloads:58656,numberOfWosCitations:82,numberOfCrossrefCitations:33,numberOfDimensionsCitations:67,hasAltmetrics:0,numberOfTotalCitations:182,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 19th 2012",dateEndSecondStepPublish:"July 10th 2012",dateEndThirdStepPublish:"October 6th 2012",dateEndFourthStepPublish:"November 5th 2012",dateEndFifthStepPublish:"December 5th 2012",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,editors:[{id:"7760",title:"Dr.",name:"Andrey",middleName:"Borisovich",surname:"Petrin",slug:"andrey-petrin",fullName:"Andrey Petrin",profilePictureURL:"https://mts.intechopen.com/storage/users/7760/images/1036_n.jpg",biography:"Andrey B. Petrin was born in 1961. He graduated from the Moscow Institute of Physics and Technology, \r\nMoscow, Russia, in 1983 and received the Ph.D. degree in physics and mathematics in 1988.\r\nIn 1983, he joined the S. P. Korolev Space Corporation “Energy,†Russia, where he has participated in \r\nseveral research projects on antennas and EM propagation. \r\nIn 1990, he joined the Moscow State University of Forestry, Russia, as a Lecturer of General Physics. \r\nSince 1996, he has been with the Joint Institute for High Temperatures of Russian Academy of Sciences, \r\nMoscow, as a Leading Scientific Researcher of Theoretical Department. \r\nHis scientific interests include propagation of electromagnetic waves, electrodynamics of plasma, \r\ngasdynamics, ECR microwave gas discharges, electrowetting phenomena, electric field singularities on \r\ngeometric singularities such as microtips and microwedges, electric field induced instabilities of free fluid \r\nsurface, nanofocusing of light energy, heat transfer in nanoscale. He is the author of more than 45 papers in \r\nscientific journals and 4 U.S. patents: www.petrin.nm.ru.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Joint Institute for High Temperatures",institutionURL:null,country:{name:"Russia"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1234",title:"Optoelectronics",slug:"quantum-mechanics-optoelectronics"}],chapters:[{id:"14153",title:"Wave Propagation Inside a Cylindrical, Left Handed, Chiral World",doi:"10.5772/13703",slug:"wave-propagation-inside-a-cylindrical-left-handed-chiral-world",totalDownloads:1451,totalCrossrefCites:1,totalDimensionsCites:1,signatures:"Pierre Hillion",downloadPdfUrl:"/chapter/pdf-download/14153",previewPdfUrl:"/chapter/pdf-preview/14153",authors:[{id:"7426",title:"Dr.",name:"Pierre",surname:"Hillion",slug:"pierre-hillion",fullName:"Pierre Hillion"}],corrections:null},{id:"14154",title:"Microwave Sensor Using Metamaterials",doi:"10.5772/14459",slug:"microwave-sensor-using-metamaterials",totalDownloads:3820,totalCrossrefCites:19,totalDimensionsCites:32,signatures:"Ming Huang and Jingjing Yang",downloadPdfUrl:"/chapter/pdf-download/14154",previewPdfUrl:"/chapter/pdf-preview/14154",authors:[{id:"17613",title:"Dr.",name:"Ming",surname:"Huang",slug:"ming-huang",fullName:"Ming Huang"},{id:"18836",title:"Dr.",name:"Jingjing",surname:"Yang",slug:"jingjing-yang",fullName:"Jingjing Yang"}],corrections:null},{id:"14155",title:"Electromagnetic Waves in Crystals with Metallized Boundaries",doi:"10.5772/13912",slug:"electromagnetic-waves-in-crystals-with-metallized-boundaries",totalDownloads:1481,totalCrossrefCites:1,totalDimensionsCites:0,signatures:"V.I. 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\r\n\tTo accomplish the objectives of the Smart grid, Smart metering is the main dynamism. Smart Grids solve necessitous complications like balancing of renewables, customer operations, peak management, and many more. Incontrovertibly, Smart metering helps to dwindle the commercial Losses, monitor energy(real-time or near real-time), detect energy theft(Cybersecurity), enhance reliability in Grid and lead to better revenue as well as tariff management. Additionally, it introduces innovative tariff structures, dispatches accurate bills based on meter data, thus reduces the annoyance of customers and uplifts customer constancy. It will motivate consumers to change behavior and optimize energy consumption, even by generating their own electricity and sell it back to the grid, which will boost the business turnover in the later stage. So, Smart metering technology plays a major role to accomplish the objectives of a smart grid. Undoubtedly, Control Systems, Automations, FACTS devices, Smart Sensors, Wireless sensors, Cybersecurity, Communication Networks, Data acquisition, Signal processing and processing, Energy Conservation and Management, Renewable energy resources, Grid integration play important roles for making reliable smart metering technologies.
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With nearly 23 years of dynamic experience, she brings ideas to life with my technical skills as an Engineer, train students and impart knowledge as an educationist, and search for ways to build a smarter life, simply as a Human Being. She is a member of IEEE, ISTE, OSI, IEI. She is in the committee of Reviewers in National and International Journals. She regularly contributes in various \nJournals, Magazines, and Conferences. 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by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"68935",title:"A Spirituality Discourse in Treating Substance Use Disorders with Marginalised Persons",doi:"10.5772/intechopen.89073",slug:"a-spirituality-discourse-in-treating-substance-use-disorders-with-marginalised-persons",body:'Similar to international trends, substance abuse is a huge concern and growing phenomenon in South Africa. Similarly more and more persons seeking treatment for substance use disorders (SUDs) present with dual diagnoses of which mental health problems are significantly high [1]. Treatment for SUDs thus has become more complex in that diagnoses and expectations of clients are multifaceted [1, 2]. Equally complex is treating clients with SUDs while paying due diligence to their ethnic, cultural and religious orientation. This chapter presents examples from a research study conducted in South Africa that supports the urgency for an integrated approach that incorporates spirituality in treating coloured persons with SUDs. It needs to point out that coloured people are not part of a minority group as described in conventional terms. However, they are marginalised and at a disadvantage in terms of their low socioeconomic status largely due to the remnants of apartheid,1 laws in which the wealth and resources of the country were qualitatively and quantitatively unequally distributed to benefit a minority group in the country at the time [5]. The narratives that will be shared in this chapter are that of persons whose families were forcefully removed from urbanised towns to the outskirts of these towns to areas known as townships in terms of the then South African Group Areas Act of 1950 [3, 4]. While these township communities were characterised by social cohesion and a spirit of Ubuntu2 [6], often still prevalent today, there were high crime rates and excessive use of alcohol and other drugs (AOD).
Today, 25 years after apartheid has been abolished in South Africa, townships continue to be plagued by poverty, unemployment and a high prevalence of SUDs [4, 7, 8]. As such treatment services offered by community-based non-profit organisations (NPOs) to coloured persons with SUDs are complex firstly, because people have deep psychosocial problems (such as previous disadvantage and high prevalence of poverty), and secondly, these township communities lack resources, such as clinics and hospitals that are overcrowded). Adding to these challenges is the fact that social workers rarely delve into the spiritual and religious (S&R) needs and well-being of clients leaving a gap in addressing the holistic needs of clients [8]. However, there is a growing body of literature that supports working with clients’ spirituality, as an effective strategy in treating SUDs [8, 9, 10, 11, 12, 13]. The literature also indicates an acknowledgement to facilitate ethnic minority groups’ need for inclusion of their spirituality in treating SUDs [8, 14, 15, 16]. Such an approach calls for a broader perspective that pays equal attention to the biological, psychological, social and spiritual needs of people with SUDs. Furthermore one cannot look at such an integrated approach without considering mindfulness techniques which is an integral part of such spiritual conventions. It is against this backdrop that this chapter is presented.
There is no singular practice model in social work and/or SUD treatment that can be applied in all contexts. As such the intervention model that counsellors, such as social workers, select is unique to the setting and client often culminating in an eclectic approach [17]. Eclecticism is commonly used in social work and SUD treatment. It is the use of a wide range of theories and techniques regardless of its theoretical origins and orientation as long as the client, a group or a community’s needs are met [18, 19]. In other words a social worker drawing on eclectic knowledge therefore uses a wide range of theories and techniques that are appropriate for a particular case. Similarly, an integrated approach is also the use of a combination of theories and techniques to address complex needs of individuals, groups and communities. The difference is that eclecticism does not necessarily result in the emergence of a new theory or model, while this is certainly the case with an integrated approach [18, 20].
There are approximately 400 new approaches that have evolved as a result of the integrationist movement, referred to as ‘an ubiquitous process of conjunction that comes from relationship and conflict’ [20]. Two perspectives that are important to understanding an integrated approach are chaos and complexity science and contiguous integration. Chaos and complexity science is driven by relational dynamics and systems theory, while contiguous integration holds that a person is understood in relation to larger groups, organisations or society, a perspective based on a metasystem view of the integration phenomenon [20]. This phenomenon is similar to the concept of Ubuntu in South Africa that holds that a person’s worth and dignity is engrained and embedded in relation to others; therefore the saying in Ubuntu: ‘I am because you are’ [6].
The term integrated approach seems to have replaced the term eclectic approach [18, 19]. However, the two should not be confused and used interchangeably because it means different things. While an eclectic approach is more focused on the techniques used, an integrated approach focused on the theories and techniques and the emergence of a new theory [18]. There is, however, ‘no technical eclectic that can totally disregard theory and no theoretical integrationist can totally ignore technique’ [18, 20]. For example, social workers often use a biopsychosocial approach to treating SUDs. When social workers are confronted by clients to integrate clients’ S&R, social workers are required to explore clients’ S&R. Hence a fourth dimension, namely, spirituality, is necessary in an existing model or approach such as in a biopsychosocial model. This would involve not only knowledge of diverse S&R but also interrogating one’s own S&R as a therapist.
It is appropriate to link what has been said thus far to the integrated relational model which places emphasis on the relationship of the client/patient and counsellor/doctor. Clients’ response to treatment is the best indicator of treatment outcomes. An empathic counsellor/doctor improves and enhances treatment outcomes [21] especially when a strengths-based and problem-solving approach is adopted [22]. The integrated relational approach combines and has several principles in common with patient-centred, person-centred and problem-solving approaches.
A patient-centred approach is a commonly used approach in health settings and takes into consideration the patient’s choices and decisions for accepting or declining medical care or procedures [23, 24]. Often a patient’s S&R determines and affects his/her choices and decisions for medical intervention. Patient-centredness is often used interchangeably with person-centredness; however, the two are different [24, 25]. Similar to the patient-centred approach, this approach places the focus of intervention on developing relationships and care plans based on the client’s preference [24, 26, 27]. However, a person-centred approach goes further and takes into consideration the ethical and legal rights of clients as important factors when providing holistic service [27]. A person-centred approach is therefore more holistic than a patient-centred approach [28]. Adding to the two aforementioned approaches is the problem-solving approach which is a generalist approach in social work that consists of distinct steps for effective problem-solving ([27, 28] Mc and Mc 2015). In short, the steps that a social worker will follow are: (1) Determining the exact nature of the problem—If the problem seems too complex, break it up into smaller manageable parts that can be managed one at a time. (2) Finding as many solutions to the problem as possible—Ask for input from clients and colleagues. (3) Narrowing down solutions—Anticipate possible outcomes of each choice, both negative and positive, and list anticipated consequences. (4) Making decision—Mutually decide with the client on what do. (5) Implementing the plan—Be cognizant of the outcome and use the success and challenges to improve and reassess the intervention goals [17]. The three approaches share similar principles worth exploring when working with persons having SUDs.
The common principles in the three approaches are summed up in Table 1 as follows:
Table 1 presents the principles embedded in patient-centred [24, 25], person-centred [27, 28] and problem-solving [17] approaches. For the purpose of this chapter and since references to persons with SUDs do not only refer to such persons in medical or health settings but also in community-based settings, I will use the terms client (as in service user) and worker (as in service provider) whether in health or community-based setting. The client-worker relationship forms the foundation of the treatment process [17, 24, 27, 28]. The responsibilities and commitment of the worker is the second layer in the treatment process because an emphatic worker encourages clients’ motivation for change. The last layer is the clients’ role and responsibility as the ‘expert’ in his/her own life. The principles are not static but interlinked and fluid. The similarities of the principles in these approaches compliment an integrated eclectic model. While the principles may not specifically address spirituality per say, the inference to respect for the client’s worldview, beginning where the client is at, honing in on the client’s strengths and working in the client’s frame of reference could be linked to clients’ S&R.
Originally developed for the medical sciences, George Engel (1933–1999) first introduced the biopsychosocial model in the health sciences. Engel [23] laid the foundation for a biopsychosocial model in healthcare. He argued that there is a distinctive interaction between the biological, psychological and social needs of patients that determine the cause, effects and outcomes of disease and well-being [23].
The concept of biopsychosocial model is eloquently described by Borrell-Carrió et al. [29] who propose that the model is a philosophy of clinical care and a practical guide for health practitioners. These authors argue that the model is philosophical on the one hand because it is a means of understanding how multiple levels of organisation, from the societal to the molecular, affect disease, illness and suffering. They further contend that the biopsychosocial model is practical in that it is a way of understanding the patient’s subjective experience as an essential contributing factor to accurate diagnosis, health and humane care [29]. White, Williams and Greenberg [30] took this approach even further by introducing an ecological model of care that added the person in his/her environment context. White et al.’s model thus proposes that the biological, psychological and interpersonal relationships that surround a person require equal attention to achieve a state of health and well-being [30]. The two models, however, did not address the person’s spirituality.
The addition of a spiritual dimension to define health was tabled at the 52nd Assembly of the World Health Organization (WHO). The 1948 WHO definition is ‘Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity’. Thus the proposed definition would be: ‘Health is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity’. Despite the latter being approved at the 1999, the 52nd WHO Assembly, it was not implemented [30]. Katerndahl [12] and Sulmasy, [31] while in favour of the spiritual dimension to the biopsychosocial model, however, warn that spirituality is a complex phenomenon and therefore should be approached critically when practitioners adopt a biopsychosocial-spiritual model in any context.
In the current milieu of treating ethnic minorities with SUDs, the reductionist scientific model is inadequate to meet the holistic needs of clients [32]. Therefore, a biopsychosocial-spiritual model for treating ethnic minorities with SUDs which utilises mindfulness techniques is proposed. Mindfulness approaches in treating persons with mental health and related conditions are rooted in Buddhist Vipassana meditation, which was introduced by Kabat-Zinn in 1979 [33]. Mindfulness approaches involves ‘paying attention in a particular way; on purpose in the present moment’ in a non-judgemental way [34, 35]. It involves being aware of and accepting of thoughts and acknowledging and accepting livid experiences, thoughts and feelings instead of modifying and/or suppressing such experiences, thoughts and feelings [35]. In other words clients are encouraged to practise ‘reperceiving’ (think of SUD, e.g. differently, as an issue externalised rather than internalised) and ‘attentional control’ (how to externalised SUD) which could facilitate a more mindful response to SUD [33]. So, mindfulness is the practice and process of beginning where the client is at, being cognizant of the ‘here and now’ and ‘being in the present moment’ [33, 34, 35, 36]. Furthermore, focusing on the here and now could help the client to enhance and improve focus, have a greater awareness and gain perspective regarding the SUD and the adverse consequences associated with it. Using mindfulness techniques could assist the client in recognising risks associated with relapse and could thus assist in avoiding relapse [36]. Skills to facilitate mindfulness techniques can be taught to diverse people regardless of cultural S&R backgrounds and can be used in a variety of intervention approaches such as biopsychosocial-spiritual models [34, 35, 37].
While the need for a biopsychosocial-spiritual model utilising mindfulness techniques in SUDs has been well established [34, 35, 36, 37], it is not clear how this new model can be integrated within the reductionist scientific conception of the client. Several empirical studies and systematic literature reviews [9, 20, 29, 31] are drawn on explaining how a biopsychosocial-spiritual model for treatment in SUDs is worth perusing as a feasible approach for working with ethnic minorities. But first it is imperative to explain the distinction between spirituality and religion.
Spirituality and religion (S&R) is often used interchangeably as if it means the same thing. What is more, there is not a universal definition for either mainly because the two respective constructs are so diverse [8, 38, 39, 40]. S&R has to do with one’s beliefs, emotional state of mind experiences and conduct associated with the search for the sacred [10, 39]. At the same time, it can be described as a worldview that places emphasis on the divine, a higher power or being whose followers promote spiritual and human well-being in which care and compassion for others take a centre stage as apposed to self-centred materialistic gains [13, 39, 41]. In this chapter, however, briefly, I differentiate between spirituality and religion (see Table 2).
Client | The ‘expert’ in his/her own life | Has the freedom to make his/her own choices | ||
---|---|---|---|---|
Counsellor |
|
|
|
|
Professional relationship | Fundamental to the therapeutic progress | Cooperation rather than confrontation | Goals and expectations for treatment are clearly articulated |
Principles of patient-centred, person-centred and problem-solving approaches.
Spirituality | Religion |
---|---|
|
|
Spirituality vs. religion.
In reference to Table 2, religion for most part is about a set of beliefs about the moral code governing human conduct, while spirituality is not constrained by theological barriers and/or any particular ideology [38]. Rather it is characterised as the quest to understand and find answers to definitive questions about life, about meaning and about relationship to the divine, sacred or God and may (or may not) emanate from or lead to the development of religious rituals and rules [39]. Spirituality is thus a more holistic and inclusive approach as apposed to religion. Spirituality is rooted in multiculturalism and is therefore diverse in terms of cultures and beliefs [38]. The search for meaning, purpose and morality and fulfilling relations with self, others, the universe and ultimately with reality are central to spirituality [40, 41]. Ubuntu shares similar principles. Spirituality (however a person understands it) has always been part of indigenous and culturally sensitive substance abuse counselling [29]; consider, for example, Alcoholics Anonymous (AA) programmes. I propose that the spiritual dimension (which includes religiosity) should be recognised and incorporated in treatment models regardless of the field of practice.
“What treatment, by whom, is more effective for this individual with that specific problem and under which set of circumstances?” [42]
Social workers treating ethnic minorities with SUDs are confronted with complex challenges experienced by clients. Never has Paul’s [42] provocative question been more valid than in the current milieu of SUDs. Understanding the spiritual needs of persons with SUD is important if we are truly holistic in our approach to service delivery and should thus not be perceived as separate from attending to biopsychosocial needs. To holistically assess people with complex challenges associated with SUDs, knowledge about their spirituality is important [43, 44, 45] and can thus not be avoided, especially when client themselves raise the need to delve into their S&R.
Several qualitative studies [14, 38, 40, 43, 44, 46] that investigated religious coping and spirituality in relation to SUDs indicate that positive religious coping and dimensions of spirituality protect against SUDs. In a qualitative study [47] that focused on barriers and facilitators to successful transition from long-term residential substance abuse treatment, the researchers found that clients having faith in the Divine as a facilitator for transitioning from in-patient treatment to reintegration back into the family and community played a pivotal role during the reintegration process. Various studies [8, 45, 46, 47, 48] indicate the value of addressing S&R as a factor that enhances and aids treatment for SUDs. However, several studies with ethnic minorities [8, 46, 48, 49] have found that the S&R needs of clients are not generally addressed by counsellors (such as social workers), and instead this role is more likely to be facilitated by clergy and/or recovering addicts. This raises the question though: who should be facilitating this role if clients make explicit their need for S&R well-being? If such high value is placed on the S&R of clients, a counsellor will require some understanding of S&R albeit at a theoretical level in order to effectively provide treatment services. It stands to reason therefore that a biopsychosocial-spiritual approach requires the counsellor to reflect and interrogate his/her own S&R as well as his/her own ambivalence for not wanting to venture into clients’ S&R.
Employing a spiritual dimension in treating SUDs is not a new phenomenon. The complexity of dual diagnoses and the multifaceted challenges associated with SUDs necessitated a need to intervene beyond the biological, psychological and social needs of clients with SUDs [1, 2, 8, 10, 15].
South Africans are not averse to managing complex life challenges through prayer, meditation and rituals as coping measures. Such practices are often embedded in people’s spirituality which is commonly rooted in their religion and/or culture [6, 9, 16]. The reflections shared next is that of participants in a recent qualitative research study conducted in the Western Cape of South Africa on the experiences of coloured adults seeking substance abuse services at non-profit organisations (NPOs) [8].
John*3, 32, has been in and out of rehab since he was 14 years old. Most of the rehabs he has been to in the past were what he refers to as secular rehabs, meaning that it did not have a spiritual component in its treatment model. According to the facility manager, this is the longest that John has been sober and attributes this to the fact that John is in a faith-based rehab that employs a biopsychosocial-spiritual model. This is John’s narrative of his experience of S&R coping:
I started using when I was very young, I must have been like fourteen years old. I went to an organisation that was an out-patient programme where they basically counseled me on a weekly basis. This time is different because there is a strong focus on the spiritual side of the addict. Because of my religious background I am more at home at this rehab and I know if I keep to the programme I will stay sober.
John’s situation is indeed complex as SUD cases generally are. Apart from the SUD, he experienced marital problems and homelessness, and his estranged wife refused to grant him visitations with their children. The complexity of SUDs often leaves people discouraged, and many, such as in the case of John, acknowledged drawing strength from God, a higher power, and being part of a religious group that meets on a weekly basis [49]. Like many people with SUDs, John felt that delving into S&R of clients provides a more holistic treatment approach than secular approaches that avoid S&R completely [49, 50, 51, 52].
While mindfulness theories originate from Buddhism, people of different religious affiliations have become more open to use these techniques because of its usefulness especially in treating SUDs. The use of meditation is a common practice in mindfulness techniques [34, 35, 37, 48]. A case example of a client with dual diagnoses explains the use of prayer as a form of mindfulness technique.
James*, 26, admits being addicted to drugs and sex. He says the sex craving started when he was rehabilitated and during his first treatment programme completion. He believed that when he gave up methamphetamine, the craving for smoking cigarettes started. While in the programme which was an in-patient treatment programme for adults with SUDs, James gave up cigarettes and methamphetamine. However, when he reintegrated back into his community, his cravings for sex started, something according to him that was never an issue in his life before being treated for SUDs. He related that he started smoking after having sex and then later reverted back to using methamphetamine to the point where he felt that he could not cope without using methamphetamine on a daily basis. He explained that he felt that his cravings for methamphetamine were worse than before because he failed God in falling back into drugs. He explains: ‘The righteous will fall seven times…’ which is a Bible first quoted from Proverbs 24:16–18. Making reference to the quoted scripture, he explained his relapse as follows:
…I didn’t believe at first but I have experienced it firsthand. I was worse off in a space of a few months after beating my addiction to meth. … I first started stealing. I sold my personal belongings. In a space of a few months I lost so much weight. I knew where it was going to end, because my mind was constantly on how to get my next fix. My family did not confront me, but they could clearly see that I was back on drugs again. I told my sister that the addiction was out of my control and that I wanted to go back to the rehab.
James was reflecting and had a greater sense of spiritual mindfulness regarding the SUD and relapse because he described himself as follows:
I am a child of God, but I didn’t work on all aspects of my life. I had to work on it [referring to his spiritual life]. So I did not equip myself adequately with the word [referring to the Bible] of God. So I am back [at the rehab] to work on a view aspects that I neglected before. So I can give people advice and can share the word of God to the people in my community. I can also refer them to a place for rehabilitation if they want help. But the best thing is to proclaim the Word of the Lord. You do not need a [rehabilitation] program. You can change your life just by adhering to the Word of God. It is easier said than done, but it can be done.
James attributes his recovery to his spiritual awakening more than the intervention by social workers.
It is not uncommon that the need for close relationships with others and/or an encounter with a divine being or higher power is a motivating factor for maintained sobriety in people with SUDs [53]. Whatever the client’s reason for wanting to maintain sobriety, the social worker should tap into the motivating factors and amplify it as strengths [54, 55]. Motivation is a state of readiness to change in which a predictable course is followed. This is where client-centred approaches such as motivational interviewing (MI) and motivational enhancement therapy (MET) are appropriate models because it is aimed at bringing about and enhancing change in the problem situation. These methods emphasise resolving clients’ ambivalence [54, 55]. Honing in on client’s motivating factors such as restoring relationships with significant others is important in enhancing motivation and resolving ambivalence. When clients are treated as partners, they are more likely to respond to the counsellor.
MI and MET do not represent any particular theoretical perspective and are thus useful to contextualise in terms of an integrated eclectic approach. Furthermore MI and MET are brief treatment strategies that can be as short as four sessions but can be prolonged depending on the client’s level of motivation [53, 54, 55]. Thus intervention is time limited and goal directed, when the client reaches a level of high motivation where he/she is able to take responsibility for his/her own recovery.
Many community-based organisations in South Africa offer a dual focus, meaning the treatment service includes both a secular social work intervention approach and a spiritual approach. However, the spiritual component is mostly offered by volunteers who are religious leaders in the communities where the organisations are situated. During the course of the day, most of the programmes make provision for meditation and prayer. So clients gather in groups in separate venues or those who preferred to meditate on their own would find a private space in the organisation to engage in prayer and meditation [8].
Strategies employed in self-help groups [56, 57] that focus on the cognitive, spiritual and behaviour changes of the persons with SUDs are more accessible because they are found across communities and are free of charge [52]. However, organisations should caution against whom and what such rituals entail so as not to exploit and/or impose religion or spirituality on clients. Therefore general training should be available for all people involved in substance abuse services including volunteers. It is imperative for such persons to have basic standards and knowledge for practice to avoid possible harm to clients. With the review and implementation of the current White Paper on Health (NHI) [58] and the norms and standards for social welfare services in South Africa, this type and methods of interventions are worth pursuing as services become more expensive and therefore inaccessible to the clients who come from disadvantaged communities, are unemployed and have low incomes.
Social worker rarely set out to gage clients about their spirituality. However, this topic more often than not emerges during interviews and thus requires social workers to be knowledgeable not necessarily on every spiritual and/or religious practice out there, but at least being able to engage client’s expression of his/her S&R needs [59, 60]. This unconventional way of looking at treating SUDs is particularly important in the South African context, where spirituality is ingrained in the culture and value systems of many South Africans and more so in the light of current policy and legislation in South Africa calling for evidence-based, culturally sensitive and indigenous practice and research [8]. As counsellors treating ethnic minorities with SUDs, social workers are encouraged to interrogate their own spirituality, as clients more often than not express their own spiritual needs during treatment services [61, 62].
It is not uncommon that group work offered by NPOs is generally facilitated by laypersons such as spiritual counsellors [8, 63, 64]. In some instances these would be trained clergy [63]; however, in most cases these would be recovering addicts [8, 51, 57] who have had some ‘supernatural’ experience. This is similar to approaches used in self-help groups such as Alcoholics Anonymous. The focus of such programmes is that most of the group work interventions are on spiritual growth and life skills [8, 65]. For example, in a study conducted by carelse [8] that focused on ethnic minority groups in treatment for methamphetamine, all the participants reported on the important role played by religious clergy and recovering addicts. This is what they had to say:
We have two spiritual counsellors …They focus more on the spiritual things like the Christian principles.
And then we have a lot of ministers and pastors, and … priests, since the organisation is a faith-based organisation. We do spiritual growth which is run by pastors.
These narratives concur with studies conducted [50, 57, 63] that focused on professionals and laypersons’ contention with issues of power, oppression and privilege in service delivery. These authors conclude that there must be differentiating functions of professionals such as social workers and laypersons such as recovering addicts in the helping relationship. As a general rule, training should be available for all people involved in services to people with SUDs including volunteers, in particular training on how to engage the service user’s spirituality [60, 61]. Therefore it is imperative for clergy and recovering addicts in treatment in SUDs to have basic standards and knowledge with regard to spiritual intervention to avoid possible harm to clients. More importantly service providers will have to interrogate their own spirituality (however they perceive it) in order to engage meaningfully with the spirituality of others.
In pursuing a state of equilibrium, clients feel that it was important for them to take the first step of the 12-step programme [57, 62] and admit that they were powerless over SUDs and that their lives had become unmanageable. In particular, clients in the 12-step programmes believed that a power greater than themselves could restore their emotional and spiritual well-being [62] where spirituality and a connection to a higher power are pivotal to their recovery process. These are some of their perspectives in this regard from a study on the coping resources of a minority group of adults in a low socioeconomic community on the outskirts of Cape Town, South Africa [8]:
It brought me closer to my higher father and relying on him and to acknowledge that he took me out of, how can I say, I was lost totally.
I believe it’s prayer that God is opening for me. And I never prayed when I was using … my mind was all over the place but now I pray with sincerity and without any mind-altering.
The clients’ livid experiences are confirmed in the study by Miller and Rollnick [55] that explored the role of spirituality in the intervention outcomes after a 12-step programme. As Miller and Rollnick [55] points out, clients experienced an increased spiritual awareness and growth after completing the treatment programme. The findings also suggest that spirituality may have a positive effect on maintained sobriety if the person continues to engage in mindfulness strategies. In a study by Amaro and Black on the role of spirituality in helping Black women with histories of trauma and substance abuse, healing and recovery of participants also expressed more hope and motivation to maintain their sobriety because of their spiritual awareness and growth after their involvement in a programme incorporating mindfulness strategies linked to spirituality during treatment [35].
Treatment services for SUDs sometimes involve alternative therapies too [34, 37, 62]. For ethnic minorities in low socioeconomic community, alternative therapies such as reflexology are not common [8]. Participants could experience being overwhelmed with such unfamiliar strategies as one client indicated [8]: ‘I could not believe that someone so decent touched me. Me, I am an addict. People normally treat us as dirty and filth, the low lives of society’. Therefore clients must be introduced to such new methods in a client-centred manner that respects their S&R and cultural believes.
The social worker’s personal religiosity, training and sensitivity to the client’s spirituality help in using an integrative approach that includes clients’ alternative therapies [10, 20, 23, 64]. Therefore, educating and sensitising social workers in terms of S&R and alternative therapies are of paramount importance [23, 40, 44, 50, 55, 63, 65]. Ongoing training and intrinsic spirituality on the part of the social worker offering services to people with SUDs could be a catalyst when using an integrated approach [60, 63, 64, 65].
There is a growing body of literature on spiritual complementary or alternative therapies; however, there is a dearth of research of its efficacy for treating ethnic minorities with SUDs [?]. Still, an integrated body, mind and spirit approach to intervention in social work practice that is researched- and therefore evidence-based can be an advantage in treating such groups [62]. A combination of Eastern and Western philosophies as well as current research in integrated practice approach offering guidelines for assessment and intervention and not limited to spiritual beliefs appears to be a viable approach.
The role of the social worker in any setting is to provide support and guidance. Participants in Carelse’s study [8] reported that the counselling, interest and compassion from the social workers motivated them to stay in the programme and to pursue their recovery goals. They described the service provided as very good work, noting that all the things they had learnt would help to prevent relapse, to stay positive and to keep their focus on their recovery goals. Participants’ views about the benefits of utilising social work services provided by the NPOs offering treatment to adults with SUDs from low socioeconomic backgrounds are summed up as follows:
The drugs strip you of all that [dignity] and I think that’s a big part of a social worker’s duty in individual counselling. They do very good work and even after I finished [the drug counselling programme] the one lady called and she wasn’t even my therapist, and she called and followed up. She called to my mom’s because she couldn’t get a hold of me, how am I doing and that. And at that time, I relapsed already so I felt guilty … So that for me played a big role, the interest. And I think that’s a major role; the compassion with which you do your work.
All the things you learn there and the chance to express yourself. The information is vital, what they [social workers] put in place, a plan to prevent relapse and I still have all my papers [literature/material on coping resources] at home. And the homework that they give you, it keeps you positive, it keeps you focused on your goal to stay clean. So that helps a lot.
I started praying again. I prayed Wednesday and Thursday and felt better spiritually. Even though I’m not on the place, I know I won’t fool myself to think that now that I am praying I am recovered. Friday a lady called me and said she’s got a job for me so everything is coming together. So things are starting to fall in place for me and I believe its prayer that God is opening doors for me.
I never prayed when I was using, because I was constantly under the influence [of drugs] and I felt unworthy. Not that I feel worthy now but at least I now don’t have drugs in my system. My mind is all over the place but I pray to make myself feel better. Now I pray with sincerity and without any mind-altering [drugs].
The benefits of prayer and meditation seem to have developed the client’s problem-solving techniques and efforts to manage triggers for relapse. Coping with stress and stressors such as in the case of SUDs involves deliberate efforts such as in mindfulness strategies, which in this study were prayer and meditation to combat and deter SUDs by influencing the environment and using the resources such as mindfulness strategies in the form of prayer and meditation [34, 35, 37, 62]. Therefore it can be deduced that maintained sobriety is largely dependent on the nature and scope of the treatment programme and more so when mindfulness strategies in a biopsychosocial-spiritual approach is embedded in treatment. Incorporating spirituality in the treatment programmes challenges clients to reflect on their quality of life, for example, learning new ways of dealing with SUDs enhances their self-worth and dignity as they gain higher levels of person: environment fit or a state of equilibrium.
There is a growing demand for integrated approaches to treating minority and marginalised people with SUDs. Such treatment requires a continuous process of interrogating theories and related approaches to suit clients’ needs. Social work services have evolved from a generalist approach to a person-centred approach over the past 20 years. In this process, the spiritual dimension to persons with SUDs gained progressively more prominence. Currently, a biopsychosocial-spiritual approach has paramount importance for offering integrated and holistic treatment for ethnic minority persons with SUDs. Thus a biopsychosocial-spiritual approach is proposed particularly in the South African context where spirituality is ingrained in the culture and value systems of coloured people. This chapter highlighted the importance of an integrated eclectic approach and the feasibility of a biopsychosocial-spiritual model in treating SUDs in marginalised communities in South Africa. Lessons could be learnt from the experiences shared for integrating spirituality in SUDs in similar contexts. What is clear is that the value of a biopsychosocial-spiritual approach in substance abuse treatment in South Africa cannot be ignored. By no means, this is the only model that can be used with marginalised communities, but it is one that is emerging strongly in treating SUDs when working with such ethnic minorities. The value of spirituality as it relates to person-centredness, in treating SUDs in minority groups, is a topic worth pursuing for future research.
The inclusion of a person-centred approach and mindfulness strategies in treating SUDs should also be further investigated. Similarly, the Bachelor of Social Work (BSW) as well as continued professional development training should incorporate aspects of students’ and practitioners’ personal spiritual beliefs, the role this has on the professional relationship, as well as the impact of spirituality on the intervention process. Therefore it will be imperative that due diligence is given to the personal S&R beliefs (whether they believe in the transcendent, a higher power or not) of students and practitioners because it is as important as that of the clients that they serve.
The biopsychosocial-spiritual model is indeed a modern humanistic and holistic perspective that is truly person-centred and therefore worth perusing for treatment services with marginalised persons with SUDs, such as ethnic minorities.
The author declares no conflict of interest.
Enterococci are Gram-positive, non-spore forming and facultative anaerobic cocci. They are indigenous flora of the intestinal tract, oral cavity and vagina in healthy persons. The genus comprises 54 species which are ubiquitously present in nature [1]. Enterococci have emerged as an important nosocomial pathogens second to Staphylococci which is the leading cause of nosocomial infections worldwide [2]. Enterococci are important nosocomial pathogens causing up to 10% of all infections in the hospitalized patients [3]. In these Enterococci infections approximately 60% of infections are caused by Enterococcus faecalis and Enterococcus faecium causes the remaining [4]. In the last decade both E. faecalis and E. faecium have emerged as important nosocomial pathogens. Other Enterococcal species causing nosocomial human infections are E. avium, E. gallinarum, E. casseliflavus, E. durans, E. raffinosus and E. mundtii. Majority of clinical isolates (63–81%) are identified as E. faecalis, around 13–23% as E. faecium and other enterococcal species comprise around 3–4% of the clinical isolates [5].
\nNosocomial infections particularly by vancomycin resistant Enterococci (VRE) have become a major problem since last few years though VRE are organisms of low virulence and pathogenicity. Nosocomial infections caused by VRE are highly prevalent in intensive care units of hospitals. These infections are particularly high in presence of underlying health factors like diabetes, liver transplantation, neutropenia, diabetes mellitus and renal dysfunction. Recently it has also been seen that VRE bloodstream infections have higher mortality rates as compared to vancomycin susceptible Enterococci (VSE) [6, 7]. Data from countries like Germany shows an increase of VRE from less than 5% in 2001 to 14.5% in 2013 mainly vancomycin resistant E. faecium [8]. In Europe of all the nosocomial infections reported 9.6% were of Enterococci [9]. In USA 3% of the nosocomial infections are due to VRE [10]. VRE nosocomial infections cause greater number of invasive treatment resulting in extended stay in hospital and cost [11]. Hospitals in some countries have now established VRE screening in high risk areas and isolation of patients to prevent spread of the resistant pathogen [12]. A study has shown the prevalence of VRE colonization in patients who had history of previous administration of antibiotics for more than 2 weeks were 10 times more likely of getting VRE colonization [13]. Other studies have also reported similar findings which show antibiotic exposure can cause colonization of VRE in hospital settings because of their resistance to commonly used antibiotics, virulence factors and ability to acquire genes [14].
\nThe genes Van A, Van B, Van C, Van D and Van E are responsible for vancomycin resistance in Enterococci. Van M has been identified which is also an important vancomycin resistant determinant among different E. faecium lineages in hospitals in Shanghai, China [15]. Each Van operon has different ecological origin, Van A has originated from soil organisms, van B, Van G and Van D from gut microbiota [16]. Vancomycin resistance in Enterococci is of two types (a) Intrinsic resistance—Enterococci spp. like E. gallinarum and E. casseliflavus show an inherent low level resistance to Vancomycin. They have Van C genes that produce Vancomycin minimum inhibitory concentration (2–32 μg/ml) [17] A hospital wide outbreak of vancomycin resistant E. gallinarum has been reported in Colombia showing that uncommon species of Enterococci are capable of spreading in the hospital environment and producing nosocomial infections [18]. The second type is (b) acquired resistance—Enterococci species acquire resistance genes and become resistant to vancomycin. This is seen in E. faecium and E. faecalis and to some extent in E. raffinosus, E. avium, E. durance and other enterococcal species. The most common isolated Enterococci species which is VRE in hospital settings is E. faecium. It has been seen that E. faecium produces high vancomycin minimum inhibitory concentration (64–1000 μg/ml) [19]. There has been a significant increase in VRE prevalence. The emergence and rapid spread of VRE has led to the use of new antibiotics like linezolid, daptomycin and tigecycline. Linezolid is a oxazolidinone antibiotic. An oxazolidinone resistance gene optr A has been identified in E. faecalis and E. faecium isolates of human and animal origin [20] .Linezolid resistance is still less prevalent reported as 1.1 and 1.8% in E. faecium and E. faecalis isolates from 19 US hospitals [21]. Daptomycin resistance is more prevalent in E. faecium than E. faecalis isolates. Around 3.9 and 0.2% of E. faecium and E. faecalis isolates have been reported in various hospital settings [22]. Tigecycline is a semisynthetic derivative of tetracycline. Tigecycline resistance in E. faecium and E. faecalis is rare and reported as 0.3%. It is being used to treat bacteremia caused by MDR enterococci. The increased use of antibiotics in hospitals is causing gut dysbiosis and enterococci possess surviving ability take over the niche in the gastrointestinal tract and this could be the primary source of enterococcal infections [23].
\nThe ability of E. faecium to exchange mobile genetic elements carrying antimicrobial resistance genes and virulence determinants has resulted in hospital adapted clones [24]. Esp was the first adaptive element found in hospital strains of E. faecium. The E. faecium esp. gene has been linked to biofilm formation, UTI and endocarditis [24]. New determinants have been now linked to hospital isolates of E. faecium. A genomic analysis study of E. faecium hospital strains identified gain and loss of gene clusters in clinical and non-clinical isolates of E. faecium [25]. Genomic studies of nosocomial E. faecium infection have confirmed the transmission of E. faecium Clad A115. Recently it has been seen a significant presence of hospital associated VRE fm lineages in the wastewater and need of controlling healthcare associated dissemination of VRE fm [26]. However studies on E. faecalis ecotypes have shown no appearance of distinct E. faecalis strains over a significant period of time. Virulence factors like antibiotic resistance and virulence genes, esp., capsule polysaccharide genes and genes determining gelatinase, aggregation factor, cytolysin and ace are identified in E. faecalis isolates [27]. The non-emergence of distinct ecotypes of E. faecalis and multiplicity of closely related ecotypes is not seen in E. faecalis as compared to E. faecium. A genomic analysis of 168 E. faecalis hospital isolates showed no genes and non-synonymous single nucleotide polymorphisms in the three lineages of hospital strains [28]. A recent study has also demonstrated that the acquisition of mobile genetic elements in E. faecalis V583, makes it unable to coexist with commensal enterococci in humans [29].
\nNosocomial infections by Enterococci are Urinary tract infection, endocarditis, bacteremia, catheter related infections, wound infections, intra- abdominal and pelvic infections and recently even oral infections have been reported.
\nEnterococci cause both uncomplicated and complicated health care associated UTI. E. faecalis. Vancomycin resistant E. faecalis and vancomycin resistant E. faecium have been mainly implicated in Enterococcal UTI. VRE is fast becoming a major cause of health care associated UTI. The treatment of UTI involves the use of broad spectrum antibiotics which is a major cause of resistant strains to vancomycin (VRE). The complications range from uncomplicated cystitis, pyelonephritis, perinephric abscess, and prostatitis. These organisms are responsible for nosocomial infection of urinary tract particularly in intensive care units (ICU). Enterococci have been particularly reported in catheter associated urinary tract infections, CAUTI (28.4%). Enterococci species are capable of producing biofilms, which are a population of cells attached irreversibly on various biotic and abiotic surfaces. CAUTI are associated with multispecies biofilms. Biofilms are difficult to remove and result in many chronic infections. Bacteria in biofilms colonize medical devices such as catheters, pacemakers, prosthetic heart valves and orthopedic appliances [30]. These multispecies biofilms have synergistic or antagonistic effects of interspecies interaction. Many studies have shown the association of biofilm producing enterococci and urinary catheter [31, 32]. Enterococci biofilms which are formed on catheter in CAUTI are resistant to immune clearance, urination force and even antibiotics. These enterococci utilize fibrinogen formed on catheter surface and form resistant biofilms. E. faecalis attachment in biofilm formation seen in vitro is partially inhibited by uropathogenic E. coli (UPEC) but biofilm formation by K. pneumoniae or UPEC are not affected by E. faecalis but E. faecalis increased E. coli biofilm mass accumulation and it has been seen that co-culture of an E. faecium probiotic strain with enteropathogenic E. coli increased the antibiotic sensitivity of E. coli to aminoglycosides, B-lactams and quinolones [33]. Biofilm formation confers the organism resistance to phagocytosis and antimicrobial agents. UTI by E. faecalis is mediated by virulence factors of the genes esp., srtC, ebp A, ebpC, ace, epaB, msrA, msr B, sigV, efbA, and grvR/etaR. E. faecium also displays similar genes related to virulence. Both E. faecalis and E. faecium isolated from nosocomial UTIs show kidney tropism. It is important to study factors in enterococcal causing pyelonephritis [33].
\nThere is a high prevalence of blood stream infections caused by Gram-positive bacteria and 45% are caused by Enterococci. Bacteremia is a common manifestation of vancomycin resistant Enterococci. Due to use of intravascular and urinary catheters these nosocomial infections are acquired. E. faecium in the blood stream is associated with increased mortality due to high levels of resistance. Risk factors identified with VRE bacteremia include intestinal colonization, long term antibiotic use, severity of illness, bone marrow transplant, hematologic malignancy, indwelling urinary catheters, corticosteroid treatment, chemotherapy and parenteral nutrition [34]. Studies have shown that bacteremia caused by vancomycin resistant Enterococci strains carry higher mortality rates (2.5-fold increase) as compared to bacteremia caused by vancomycin sensitive strains. In one such study the prognosis of VRE bacteremia was not much changed even with the availability of antimicrobial agents with greater potency. E. faecalis sigma factor Sig V that regulates gene expression in response to stress conditions has been implicated in enterococci survival and colonization in systemic infection. Absence of sig V in systemic infection in mice resulted in attenuation of bacterial translocation reducing colonization of kidney and liver. Virulence factors like Bgs A and Bgs B have also been implicated in colonization of endocarditic lesions and bacteremia. BgsA and Bgs B are now being used to treat enterococcal infections by using them as drug targets [35]. Similarly gene Asr has been implicated in E. faecium pathogenesis in systemic infections. Nosocomial enterococcal bacteremia have been associated with urinary catheters, intra-abdominal, burn wound, pelvic, biliary and bone sources. VRE bacteremia results in 2.5-fold increase in mortality as compared to vancomycin sensitive (VSE) bacteremia [18].
\nEnterococci are the second most cause of infective endocarditis. Endocarditis caused by VRE faecalis causes GI or GU manipulation, damaged mitral or aortic valve infections, liver transplantation whereas VRE faecium endocarditis is associated with infection of tricuspid valve [36]. E. faecalis is also associated with community acquired endocarditis. Characteristic signs of infection include fever or a new murmur. Typical stigmata of endocarditis like petechiae, osler spots are rare and occur with sub-acute infections. Genitourinary infection or instrumentation often precedes the onset of enterococcal endocarditis. In published series of enterococcal endocarditis men often outnumber women and mostly it occurred in elderly individuals. In the current therapeutic regimes, the mortality rate of enterococcal endocarditis remains around 20%.
\nVRE has been isolated from intra-abdominal and pelvic infections. The usual infections include abscesses wounds or peritonitis. Often it is a part of polymicrobial infection with Gram negative or anaerobic organisms. Usually infecting strains originate from patients intestinal flora and cause intra-abdominal infection. Enterococci are able to cause monomicrobial peritonitis infections particularly in patients undergoing chronic peritoneal dialysis or liver cirrhosis.
\nGI related enterococcal infections are opportunistic infections particularly occurring during colorectal surgery and colorectal cancer. Pre-colonization with VRE in patients can result in bacteremia following antibiotic induced disruption of gut microbiota [37]. Reg IIIy, a c type lectin is secreted by intestinal epithelial and paneth cells that removes Gram positive bacteria from the gut. Antibiotic treatment causes Reg IIIy down-regulation [38]. Therapeutic strategies have been devised to prevent intestinal colonization of resistant enterococci, introducing probiotic E. faecalis pheromone induced killing of drug resistant E. faecalis reactivating Reg IIIy introducing obligate anaerobic commensal bacteria containing Barnesiella species which prevents E. faecium gut colonization and bacteremia [39]. High collagenase producing E. faecalis strains have been found to be associated with colorectal anastomotic leak by activating tissue matrix metalloproteinase 9 that cleaves host extracellular matrix [40]. Enterococci produce menaquinone and extracellular superoxide in intestine. This results in high oxidative stress which is linked with colorectal cancer as high genomic instability of intestinal tumor cells as around 80% of colon cancers are caused due to genetic mutations.
\nAlthough CNS infections have been reported rarely with VRE but occur in elderly patients having underlying health issues like malignancies, pulmonary and cardiac complications [41]. In them VRE faecium is reported at 82% and less so of VRE faecalis. These infections present as fever, mental disorientation, focal CNS deficits and petechial rash. CSF investigations show pleocytosis, low glucose and increased protein levels.
\nEnterococci are part of polymicrobial infections which are found to be associated with SSSE [42]. Enterococci are frequently isolated from diabetic foot ulcers and 2–5% of patients undergoing inpatient surgery. In studies using animal models it has been seen that E. faecalis capsular polysaccharide in SSSI predominantly is related to the persistence of the organism. A gene cpsI encodes the carbohydrate for capsular polysaccharide.
\nEnterococci are inhabitants of the oral cavity and as opportunistic pathogen cause oral diseases like caries, endodontic infections, periodontitis and peri-implantitis. In endodontic infections the failure of root canal treatment by endodontic infections is now well evidenced. Enterococci have high resistance to endodontic medicaments and forms resistant biofilms. This is implicated in root canal treatment failure [43, 44]. Enterococci prevalence is also seen in gingivitis and periodontitis (3.7–35%) [45]. Oral Enterococci constitute the highest percentage of virulent genes and ability to form resistant biofilms. The oral cavity may hence be an important reservoir of virulent antibiotic resistant enterococci strains. VRE colonization occurs mainly in GI tract, skin, genitourinary tract and oral cavity. Enterococci can persist from months to years. The hands of health care workers are the most common source of transmission in nosocomial infections [46]. The need of oral care is particularly important in nosocomial settings. The spread of the nosocomial VRE occurs and when the immunity is lowered VRE multiply to cause disease. Few studies have shown that antibiotic resistant enterococci is transmitted by food [47, 48, 49] but recently Vidana et al. [50] have said there is no food related transmission of enterococci. Enterococci are now showing a high degree of resistance to tetracycline, chloramphenicol, erythromycin besides vancomycin pose a threat for spread of nosocomial infection particularly in patients of ICUs and on mechanical ventilators [51]. Vancomycin resistance is an independent predictor for the overall increase of hospital costs for the patient but also for the individual hospital [52].
\nVRE and have now become an important nosocomial pathogen globally. VRE causes range of infections from UTI, bacteremia, infective endocarditis, intra-abdominal and pelvic infections, central nervous system infections and even oral infections. The ability of enterococci to form recalcitrant biofilms, colonize and express virulence factors, genome plasticity, resistant to antibiotics, survival ability makes it an important nosocomial pathogen to which new therapeutic strategies have to be devised for the treatment of VRE. A periodic surveillance of VRE in hospitals is essential for limiting the spread of antibiotic resistance. Future therapy should be targeted to prevent VRE colonization of patients with immunosuppression.
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I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). 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