Search

While important advances have been made in the prevention and treatment of Human Immunodeficiency Virus (HIV) infection, limited expertise and resource constraints to effectively manage rollout of HIV programs often contribute to poor treatment outcomes in Sub-Saharan Africa. In 1998, the University of Zimbabwe (UZ) and the University at Buffalo, State University of New York (UB), developed a collaborative clinical pharmacology capacity building program in Zimbabwe to train the next generation of HIV researchers and support rollout of the national HIV program. The collaboration was funded by research and training grants that were competitively acquired through United States of America government funding mechanisms, between 1998 and 2016. Thirty-eight research fellows were trained and a specialty clinical pharmacology laboratory was established during this period. Knowledge and skills transfer were achieved through faculty and student exchange visits. Scientific dissemination output included sixty-two scholarly publications that influenced three national policies and provided development of guidelines for strategic leadership for an HIV infection—patient adherence support group. The clinical pharmacology capacity building program trained fellows that were subsequently incorporated into the national technical working group at the Ministry of Health and Child Care, who are responsible for optimizing HIV treatment guidelines in Zimbabwe. Despite serious economic challenges, consistent collaboration between UZ and UB strengthened UZ faculty scholarly capacity, retention of HIV clinical research workforce was achieved, and the program made additional contributions toward optimization of antiretroviral therapy in Zimbabwe.

Background: Over 40% of the global burden of sepsis occurs in children under 5 years of age, making pediatric sepsis the top cause of death for this age group. Prior studies have shown that outcomes in children with sepsis improve by minimizing the time between symptom onset and treatment. This is a challenge in resource-limited settings where access to definitive care is limited.Methods: A secondary analysis was performed on data from 1,803 patients (28 days−14 years old) who presented to the emergency department (ED) at Muhimbili National Hospital (MNH) from July 1, 2016 to June 30, 2017 with a suspected infection and ≥2 clinical systemic inflammatory response syndrome criteria. The objective of this study was to determine the relationship between delayed presentation to definitive care (>48 h between fever onset and presentation to the ED) and mortality, as well as the association between socioeconomic status (SES) and delayed presentation. Multivariable logistic regression models tested the two relationships of interest. We report both unadjusted and adjusted odds ratios and 95% confidence intervals.Results: During the study period, 11.3% (n = 203) of children who presented to MNH with sepsis died inhospital. Delayed presentation was more common in non-survivors (n = 90/151, 60%) compared to survivors (n = 614/1,353, 45%) (p ≤ 0.01). Children who had delayed presentation to definitive care, compared to those who did not, had an adjusted odds ratio for mortality of 1.85 (95% CI: 1.17–3.00).Conclusions: Delayed presentation was an independent risk factor for mortality in this cohort, emphasizing the importance of timely presentation to care for pediatric sepsis patients. Potential interventions include more efficient referral networks and emergency transportation systems to MNH. Additional clinics or hospitals with pediatric critical care may reduce pediatric sepsis mortality in Tanzania, as well as parental education programs for recognizing pediatric sepsis.

Background Antimicrobial resistance (AMR) is a global public health threat and is increasingly prevalent among enteric pathogens in low- and middle-income countries (LMICs). However, the burden of multidrug-resistant organisms (MDROs) in older children, adults, and elderly patients with acute diarrhea in LMICs is poorly understood. This study’s aim was to characterize the prevalence of MDR enteric pathogens isolated from patients with acute diarrhea in Dhaka, Bangladesh, and assess a wide range of risk factors associated with MDR. Methods This study was a secondary analysis of data collected from children over 5 years, adults, and elderly patients with acute diarrhea at the International Centre for Diarrhoeal Disease Research, Bangladesh Dhaka Hospital between March 2019 and March 2020. Clinical, historical, socio-environmental information, and a stool sample for culture and antimicrobial susceptibility testing were collected from each patient. Univariate statistics and multiple logistic regression were used to assess the prevalence of MDR among enteric pathogens and the association between independent variables and presence of MRDOs among culture-positive patients. Results A total of 1198 patients had pathogens isolated by stool culture with antimicrobial susceptibility results. Among culture-positive patients, the prevalence of MDR was 54.3%. The prevalence of MDR was highest in Aeromonas spp. (81.5%), followed by Campylobacter spp. (72.1%), Vibrio cholerae (28.1%), Shigella spp. (26.2%), and Salmonella spp. (5.2%). Factors associated with having MDRO in multiple logistic regression included longer transport time to hospital (>90 min), greater stool frequency, prior antibiotic use prior to hospital presentation, and non-flush toilet use. However, pseudo-R2 was low 0.086, indicating that other unmeasured variables need to be considered to build a more robust predictive model of MDR. Conclusions MDR enteric pathogens were common in this study population with clinical, historical, and socio-environmental risk factors associated with MDROs. These findings may help guide clinical decision-making regarding antibiotic use and selection in patients at greatest risk of complications due to MDROs. Further prospective research is urgently needed to determine what additional factors place patients at greatest risk of MDRO, and the best strategies to mitigate the spread of MDR in enteric pathogens.

ICUs worldwide are facing resource shortages including increased need for provision of invasive mechanical ventilation during the current coronavirus disease 2019 pandemic. Fearing shortage of ventilators, many private companies and public institutions have focused on building new inexpensive, open-source ventilators. However, designing and building new ventilators is not sufficient for addressing invasive mechanical ventilation needs in resource-limited settings. In this commentary, we highlight additional interdependent constraints that should be considered and provide a framework for addressing these constraints to ensure that the increasing stockpile of open-source ventilators are easily deployable and sustainable for use in resource-limited settings.

Introduction Giant ovarian cysts are rarely described in the literature, owing to the availability of advanced imaging technologies in developed countries leading to early treatment. In resource-limited settings, various factors lead to late presentation. Case presentation We present a case of a 48-year-old black African woman with a giant mucinous cystadenoma who presented to a tertiary hospital with massive abdominal distention 5 years after being referred from a district hospital for the same problem. Surgical management resulted in fatal complications. Conclusions The surgical management of these huge tumors is associated with many life-threatening complications. Transvaginal ultrasound should be used in resource-limited settings to delineate ovarian masses. Community health workers must be involved in scouting and follow up of community members with unusual abdominal swellings in developing countries to avoid delays in care.

Background Anesthesia in lactating women is frequently indicated for time-sensitive procedures such as postpartum tubal ligation. Ketamine and diazepam are two of the most commonly used anesthetic agents in low resource settings, but their safety profile in lactating women has not been established. Methods Medical records of post-partum tubal ligations between 2013 and 2018 at clinics of the Shoklo Malaria Research Unit were reviewed for completeness of key outcome variables. Logistic regression identified presence or absence of associations between drug doses and adverse neonatal outcomes: clinically significant weight loss (≥95th percentile) and neonatal hyperbilirubinemia requiring phototherapy. Results Of 358 records reviewed, 298 were lactating women with singleton, term neonates. There were no severe outcomes in mothers or neonates. On the first postoperative day 98.0% (290/296) of neonates were reported to be breastfeeding well and 6.4% (19/298) had clinically significant weight loss. Phototherapy was required for 13.8% (41/298) of neonates. There was no association between either of the outcomes and increasing ketamine doses (up to 3.8 mg/kg), preoperative oral diazepam (5 mg), or increasing lidocaine doses (up to 200 mg). Preoperative oral diazepam resulted in lower doses of intraoperative anesthetics. Doses of intravenous diazepam above 0.1 mg/kg were associated with increased risk (adjusted odds ratio per 0.1 mg/kg increase, 95%CI) of weight loss (1.95, 95%CI 1.13–3.35, p = 0.016) and jaundice requiring phototherapy (1.87, 95%CI 1.11–3.13, p = 0.017). Conclusions In resource-limited settings ketamine use appears safe in lactating women and uninterrupted breastfeeding should be encouraged and supported. Preoperative oral diazepam may help reduce intraoperative anesthetic doses, but intravenous diazepam should be used with caution and avoided in high doses in lactating women.

Background: Despite the exceptional burden of burns in low- and middle-income countries (LMIC) and the importance of adequate analgesia in burn care, there is a lack of analgesia protocol developed in resource-scarce settings. This necessitates the development of an analgesia protocol applicable to the resource-scarce setting. This study presents the findings of a modified Delphi study aimed at achieving consensus by a panel of experts in the management of burn injuries from low- and middle-income settings across Africa. Methods: A two-round Delphi survey was conducted to achieve consensus on an analgesia protocol for paediatric burn patients for a resource- limited setting. The Delphi panel consisted of nine experts with experience in management of burn injuries in low-income settings. Results: Consensus was determined by an a priori threshold of 80% of agreement for a drug to be included in the analgesia protocol. There was a largely overarching agreement with regard to the background analgesia protocol and strong agreement regarding the use of an initial dose of ketamine and midazolam for procedural sedation. Conclusion: A modified Delphi method was used to obtain expert consensus for a recently adopted analgesia protocol for burn-injured children in a resource-limited setting, with experts in the management of burn injuries in low- and middle-income settings. The expert consensus leads to the rigour and robustness of the protocol. Delphi methods are exceptionally valuable in healthcare research and the aim of such studies is to find converging expert opinions.&nbsp

Background Grenada is a small, resource‐limited Caribbean country with a high incidence of sickle cell disease (SCD). Since little is known about the challenges facing individuals living with SCD in the West Indies, we sought to assess barriers to healthcare and the impact of SCD on quality of life in Grenada. Methods Both adults aged 18+ (n = 19) and caregivers of children aged 2–17 (n = 26) completed validated survey measures regarding barriers to care and quality of life, along with a genetics knowledge questionnaire. Caregivers also completed a caregiver burden scale. Survey scores were calculated, and responses were analyzed for an association between demographic variables. Results The Barriers to Care Questionnaire, in which lower scores indicate more barriers, revealed that both adults (mean = 69.9) and children (mean = 75.5) with SCD experienced reduced access to care. The Adult Sickle Cell Quality of Life Measurement Information System indicated increased depression and loneliness in adults, with the lowest scores in the Emotional subscale. However, the Pediatric Quality of Life Inventory answered by caregivers of children with SCD showed the lowest scores in the Physical Functioning subscale. Further analysis using the Caregiver Burden Scale‐Zarit Burden Interview revealed that 53.8% of caregivers of children with SCD indicated “little to no burden,” which may reflect a difference in cultural expectations of a caregiver between high‐income countries and Grenada. Finally, ~80% of respondents knew that SCD was a genetic condition; however, 61%–84% could not correctly indicate recurrence risks, demonstrating a need for additional education. Conclusion These data provide new insights regarding the experience of living with SCD in Grenada and support the need for further investigations into specific barriers to healthcare delivery, which could also improve education and well‐being for those affected by SCD in Grenada and in the broader Caribbean community., Grenada is a small, resource‐limited Caribbean country with a high incidence of sickle cell disease (SCD). Despite the prevalence, little is known about the challenges facing individuals living with SCD. In this study, caregivers of children with SCD and adults with SCD reported a variety of barriers to care and reduced quality of life that highlight the need for improvements to infrastructure, including education, facilities, and personnel, to facilitate earlier diagnosis and improved lifelong therapeutic management for individuals with SCD.

Background Rural parts of Mali carry a disproportionate burden of the country’s high under-five mortality rate. A range of household factors are associated with poor under-five health in resource-limited settings. However, it is unknown which most influence the under-five mortality rate in rural Mali. We aimed to describe household factors associated with under-five mortality in Bankass, a remote region in central Mali. Methods We analysed baseline household survey data from a trial being conducted in Bankass. The survey was administered to households between December 2016 and January 2017. Under-five deaths in the five years prior to baseline were documented along with detailed information on household factors and women’s birth histories. Factors associated with under-five mortality were analysed using Cox regression. Results Our study population comprised of 17,408 under-five children from 8322 households. In the five years prior to baseline, the under-five mortality rate was 152.6 per 1000 live births (158.8 and 146.0 per 1000 live births for males and females, respectively). Living a greater distance from a primary health center was associated with a higher probability of under-five mortality for both males (adjusted hazard ratio [aHR] 1.53 for ≥10 km versus Conclusions U5 mortality is very high in Bankass and is associated with living a greater distance from healthcare and several other household factors that may be amenable to intervention or facilitate program targeting.

Background: Typically, African healthcare providers use immunological reference intervals adopted from Europe and the United States (US). This may be inappropriate in a setting with many differences including exposure to different environmental stimuli and pathogens. We compared immunological reference intervals for children from Europe and the US with South African children to explore whether healthy children living in settings with high rates of infectious diseases have different baseline immunological parameters. Methodology: Blood was taken from 381 HIV-uninfected children aged between 2 weeks and 13 years of age from a Child Wellness Clinic in an informal settlement in Cape Town to establish local hematological and lymphocyte reference intervals for South African children. Flow-cytometry quantified percentage and absolute counts of the B-cells, NK-cells, and T-cells including activated, naive, and memory subsets. These parameters were compared to three separate studies of healthy children in Europe and the US. Results: Increased activated T-cells, and natural killer cells were seen in the younger age-groups. The main finding across all age-groups was that the ratio of naive/memory CD4 and CD8 T-cells reached a 1:1 ratio around the first decade of life in healthy South African children, far earlier than in resource-rich countries, where it occurs around the fourth decade of life. Conclusions: This is the largest data set to date describing healthy children from an African environment. These data have been used to create local reference intervals for South African children. The dramatic decline in the naive/memory ratio of both CD4 and CD8 T-cells alongside increased activation markers may indicate that South African children are exposed to a wider range of environmental pathogens in early life than in resource-rich countries. These marked differences illustrate that reference intervals should be relevant to the population they serve. The implications for the developing pediatric immune system requires further investigation.

Purpose Adequate cancer pain management (CPM) is challenging in resource-limited settings, where current international guideline recommendations are difficult to implement owing to constraints such as inadequate availability and accessibility of opioids, limited awareness of appropriate opioid use among patients and clinicians, and lack of guidance on how to translate the best evidence into clinical practice. The multinational and multidisciplinary CAncer Pain managEment in Resource-limited settings (CAPER) Working Group proposes a two-step initiative to bridge clinical practice gaps in CPM in resource-limited settings. Methods A thorough review of the literature, a steering committee meeting in February 2017, and post-meeting teleconference discussions contributed to the development of this initiative. As a first step, we developed practical evidence-based CPM algorithms to support healthcare providers (HCPs) in tailoring treatment according to availability of and access to resources. The second part of the initiative proposes a framework to support an effective implementation of the CPM algorithms that includes an educational program, a pilot implementation, and an advocacy plan. Results We developed CPM algorithms for first-line use, breakthrough cancer pain, opioid rotation, and refractory cancer pain based on the National Comprehensive Cancer Network guidelines and expert consensus. Our proposed educational program emphasizes the practical elements and illustrates how HCPs can provide optimal CPM according to evidence-based guidelines despite varied resource limitations. Pilot studies are proposed to demonstrate the effectiveness of the algorithms and the educational program, as well as for providing evidence to support a draft advocacy document, to lobby policymakers to improve availability and accessibility of analgesics in resource-limited settings. Conclusions These practical evidence-informed algorithms and the implementation framework represent the first multinational step towards achieving optimal CPM in resource-limited settings. Electronic supplementary material The online version of this article (10.1007/s00520-018-4471-z) contains supplementary material, which is available to authorized users.

Background Prehospital (ambulance) care can reduce morbidity and mortality from trauma. Yet, there is a dearth of effective evidence-based interventions and implementation strategies. Emergency Medical Services Traumatic Shock Care (EMS-TruShoC) is a novel bundle of five core evidence-based trauma care interventions. High-Efficiency EMS Training (HEET) is an innovative training and sensitization program conducted during clinical shifts in ambulances. We assess the feasibility of implementing EMS-TruShoC using the HEET strategy, and feasibility of assessing implementation and clinical outcomes. Findings will inform a main trial. Methods We conducted a single-site, prospective cohort, multi-methods pilot implementation study in Western Cape EMS system of South Africa. Of the 120 providers at the study site, 12 were trainers and the remaining were eligible learners. Feasibility of implementation was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Feasibility of assessing clinical outcomes was assessed using shock indices and clinical quality of care scores, collected via abstraction of patients’ prehospital trauma charts. Thresholds for progression to a main trial were developed a priori. Results The average of all implementation indices was 83% (standard deviation = 10.3). Reach of the HEET program was high, with 84% learners completing at least 75% of training modules. Comparing the proportion of learners attaining perfect scores in post- versus pre-implementation assessments, there was an 8-fold (52% vs. 6%) improvement in knowledge, 3-fold (39% vs. 12%) improvement in skills, and 2-fold (42% vs. 21%) increase in self-efficacy. Clinical outcomes data were successfully calculated—there were clinically significant improvements in shock indices and quality of prehospital trauma care in the post- versus pre-implementation phases. Adoption of HEET was good, evidenced by 83% of facilitator participation in trainings, and 100% of surveyed stakeholders indicating good programmatic fit for their organization. Stakeholders responded that HEET was a sustainable educational solution that aligned well with their organization. Implementation fidelity was very high; 90% of the HEET intervention and 77% of the implementation strategy were delivered as originally planned. Participants provided very positive feedback, and explained that on-the-job timing enhanced their participation. Maintenance was not relevant to assess in this pilot study. Conclusions We successfully implemented the EMS-TruShoC educational intervention using the HEET training strategy in a single-site pilot study conducted in a low-resource international setting. All clinical outcomes were successfully calculated. Overall, this pilot study suggests high feasibility of our future, planned experimental trial.

Introduction: The term acute abdomen refers to a clinical syndrome of sudden onset, severe abdominal pain. The differential diagnosis for this presentation is broad, but most cases require emergent medical or surgical management. Especially in cases of ischaemic bowel, time to diagnosis can mean the difference between survival and death. As a result, mortality remains high in resource-limited settings. Case report: We describe the case of a 28-year-old male who presented to an urban Ethiopian emergency centre with three days of vomiting, bloody diarrhoea, and abdominal pain. He collapsed in triage with weak pulses and an undetectable blood pressure. Point-of-care ultrasound revealed a hyperechoic, mobile mass in the left ventricle of the heart. Small bowel dilation and thickening was visualised throughout the abdomen. Mesenteric ischaemia was rapidly identified as the working diagnosis, prompting early surgical consultation and aggressive, goal-directed resuscitation. Discussion: Short of elucidating a definitive diagnosis, ultrasound narrowed the focus of an undifferentiated presentation and supported mobilisation for exploratory laparotomy. Ultimately, this circumvented several hours of time which is conventionally required to obtain computed tomography at this institution. As demonstrated in this case, point-of-care ultrasound can be life-saving in resource-limited settings where acquisition time for definitive imaging is often prohibitive. Keywords: Point-of-care, Ultrasound, Acute abdomen, Mesenteric ischaemia, Bowel necrosis, Resource-limited, Thromboembolism

Objective: To assess the prevalence and clinical manifestations of lymphatic filariasis among inhabitants of the study area. Methods: A total of 1 069 persons of different age groups were examined using immunochromatographic test which detected Wuchereria bancrofti (W. bancrofti) antigens by finger prick blood collection. Physical examinations of the subjects were also carried out to check for signs of the infection on the individuals. Results: Of these, 36 (3.4%) were infected with W. bancrofti. Males showed a higher prevalence than females (4.0% vs. 2.8%, P < 0.05). Those that fell in the age group of 70 years and above were the most infected (23.8%). Regarding signs and symptoms of the disease, periodic fever was reported the most by the subjects (7.5%) followed by crawling sensation (4.9%). Periodic fever and crawling sensation tended to appear much earlier in life, while tenderness of limbs, elephantiasis and hydrocele were symptoms that showed up from the fifth decade of life. Conclusions: Our study showed that lymphatic filariasis was caused by W. bancrofti as a serious health problem in irrigation communities of Nigeria. Realistic and sustained health interventions are required to effectively control the disease in this community and other related areas of Nigeria.

Background: Telemedicine, or healthcare delivery from a distance, has evolved over the past 50 years and helped alter health care delivery to patients around the globe. Its integration into numerous domains has permitted high quality care that transcends obstacles of geographic distance, lack of access to health care providers, and cost. Ultrasound is an effective diagnostic tool and its application within telemedicine ("tele-ultrasound") has advanced substantially in recent years, particularly in high-income settings. However, the utility of tele-ultrasound in resource-limited settings is less firmly established. Objective: To determine whether remote tele-ultrasound is a feasible, accurate, and care-altering imaging tool in resource-limited settings. Data Sources: PubMed, MEDLINE, and Embase. Study Eligibility Criteria: Twelve original articles met the following eligibility criteria: full manuscript available, written in English, including a direct patient-care intervention, performed in a resource-limited setting, images sent to a remote expert reader for interpretation and feedback, contained objective data on the impact of tele-ultrasound. Study Appraisal and Synthesis Methods: Abstracts were independently screened by two authors against inclusion criteria for full-text review. Any discrepancies were settled by a senior author. Data was extracted from each study using a modified Cochrane Consumers and Communication Review Group's data extraction template. Study bias was evaluated using the ROBINS-I tool. Results: The study results reflect the diverse applications of tele-ultrasound in low-resource settings. Africa was the most common study location. The specialties of cardiology and obstetrics comprised most studies. Two studies primarily relied on smartphones for image recording and transmission. Real-time, rather than asynchronous, tele-ultrasound image interpretation occurred in five of the 12 studies. The most common outcome measures were image quality, telemedicine system requirements, diagnostic accuracy, and changes in clinical management. Limitations: The studies included were of poor quality with a dearth of randomized control trials and with significant between study heterogeneity which resulted in incomplete data and made cross study comparison difficult. Conclusions and Implications of Key Findings: Low-quality evidence suggests that ultrasound images acquired in resource-limited settings and transmitted using a telemedical platform to an expert interpreter are of satisfactory quality and value for clinical diagnosis and management.

Background We sought to develop a low-fidelity simulation-based curriculum for pediatric residents in Rwanda utilizing either rapid cycle deliberate practice (RCDP) or traditional debriefing, and to determine whether RCDP leads to greater improvement in simulation-based performance and in resident confidence compared with traditional debriefing. Methods Pediatric residents at the Centre Hospitalier Universitaire de Kigali (CHUK) were randomly assigned to RCDP or traditional simulation and completed a 6 month-long simulation-based curriculum designed to improve pediatric resuscitation skills. Pre- and post- performance was assessed using a modified version of the Simulation Team Assessment Tool (STAT). Each video-taped simulation was reviewed by two investigators and inter-rater reliability was assessed. Self-confidence in resuscitation, pre- and post-simulation, was assessed by Likert scale survey. Analyses were conducted using parametric and non-parametric testing, ANCOVA and intra-class correlation coefficients (ICC). Results There was a 21% increase in pre- to post-test performance in both groups (p

The emergence and spread of multidrug-resistant tuberculosis (MDR-TB) poses a major threat to the global targets for TB control. In recent years, an evolving science and evidence base for MDR-TB has led to much needed changes in international guidelines promoting the use of newer TB drugs and regimens for MDR-TB, however, there remains a significant implementation gap. Due to the complexity of treating MDR-TB, management of cases is often supported by an expert multidisciplinary team, or clinical expert group. This service is often centralized, and may be delivered through a telemedicine platform. We have implemented a Web-based “store-and-forward” telemedicine service to optimize MDR-TB patient care in Daru, a remote and resource limited setting in Papua New Guinea (PNG). From April 2016 to February 2019, 237 cases were discussed using the service. This encompassed diagnostic (presumptive) and treatment cases, and more recently, support to the scale up of preventative therapy for latent TB infection. There were 75 cases in which the use of Bedaquiline was discussed or mentioned, with a high frequency of discussions occurring in the initial period (26 cases in the first 12 months), which has appeared to decrease as clinicians gained familiarity with use of the drug (15 cases in the last 12 months). This service has supported high quality clinical care and fostered collaboration between clinicians and technical experts in a shared learning environment.

Treatment of HCV with direct-acting antivirals has enabled the discussion of HCV eradicationworldwide. Envisioning this aim requires implementation of mass screening in resource-limited areas, usuallyconstrained by testing costs. We validated a low-cost, rapid diagnosis test (RDT) for HCV in three different continents in 141individuals. The HCV RDT showed 100% specificity and sensitivity across different samples regardless of genotypeor viral load (in samples with such information, 90%). The HCV test validated in this study can allow for HCV screening in areas of need when properly used. Fil: Leathers, James S.. Vanderbilt University; Estados Unidos Fil: Pisano, María Belén. Universidad Nacional de Cordoba. Facultad de Medicina. Instituto de Virología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Ré, Viviana Elizabeth. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Cordoba. Facultad de Medicina. Instituto de Virología; Argentina Fil: van Oord, Gertine. Erasmus Medical Center; Países Bajos Fil: Sultan, Amir. Addis Ababa University; Etiopía Fil: Boonstra, Andre. Erasmus Medical Center; Países Bajos Fil: Debes, Jose D.. Universidad de Minnesota; Estados Unidos

BackgroundSince 2007, Gaza Palestine has been subject to blockade affecting over 1.9 million people. This denies health professionals access to continuing professional development (CPD). In Gaza, family physicians are scarce, and their level of training does not meet the needs of United Nations Relief and Works Agency’s (UNRWA) Family Health Team (FHT) model for better population health.AimThis study sought to develop a postgraduate training programme for Gazan doctors via a Diploma in Family Medicine (FM PG), and evaluate its impact on physicians and patients.Design & settingA mixed-methods evaluation of a postgraduate diploma in Gaza Palestine.MethodThe programme was delivered over 1 year, to 15 primary care doctors. The impact was evaluated through focus group discussions and patient feedback questionnaire survey comparing FM PG graduate doctors and doctors without the FM PG Diploma.ResultsAll participating doctors graduated successfully and found the experience extremely positive. Trainees felt that the Diploma helped them take more individualised approach to patients; have a better understanding of psychosocial elements affecting patient health; feel more inclined towards team-working and collaborative approaches to health care; and more insight into non-verbal communication such as active listening and tactile gestures. Statistical analysis of patients’ feedback showed significantly improved patient-reported outcomes and satisfaction when treated by course diplomates compared to non-diplomates.ConclusionWhere there are limited training opportunities, investment in a structured postgraduate diploma training programme can improve quality of health service delivery. UNRWA’s experience in Gaza demonstrates the value of a scalable model in resource-limited settings.

Background Strong laboratory capacity is essential for detecting and responding to emerging and re-emerging global health threats. We conducted a quantitative laboratory assessment during 2014–2015 in two resource-limited provinces in southern China, Guangxi and Guizhou in order to guide strategies for strengthening core capacities as required by the International Health Regulations (IHR 2005). Methods We selected 28 public health and clinical laboratories from the provincial, prefecture and county levels through a quasi-random sampling approach. The 11-module World Health Organization (WHO) laboratory assessment tool was adapted to the local context in China. At each laboratory, modules were scored 0–100% through a combination of paper surveys, in-person interviews, and visual inspections. We defined module scores as strong (> = 85%), good (70–84%), weak (50–69%), and very weak (

Context: The epidemiology and outcome of critical illness in Mongolia remain undefined. Aim: The aim of this study was to evaluate the epidemiology and outcome of critical illness in Mongolia. Settings and Design: This is a multicenter, prospective, observational cohort study including 19 Mongolian centers. Materials and Methods: Demographic, clinical, and outcome data of patients >15 years admitted to the Intensive Care Units (ICUs) were collected during a 6-month period. Statistical Analysis: Descriptive methods, Mann–Whitney-U test, Fisher's exact or Chi-square test, and logistic regression analyses were used for statistical analysis. Results: Two thousand and thirty-two patients (53.6% male) with a median age of 49 years (36–62 years) were included. The most frequent ICU admission diagnoses were stroke (17.4%), liver failure (9.2%), heart failure (9%), infection (8.3%), severe trauma (7.5%), traumatic brain injury (7.1%), acute abdomen (7%), pre-eclampsia/eclampsia (5.8%), renal failure (3.9%), and postoperative care following elective and emergency surgeries (3.2%). ICU mortality was 23.5% in the study population and 26.6% when maternal cases were excluded. The five ICU admission diagnoses with the highest ICU mortality were lung tuberculosis (51.9%), traumatic brain injury (42.1%), liver failure (33.7%), stroke (31.9%), and infection (30.8%). The five ICU admission diagnoses causing most death cases were stroke (n = 113), liver failure (n = 63), traumatic brain injury (n = 61), infection (n = 52), and acute abdomen (n = 38). Conclusion: Critical illness in Mongolia affects younger patients compared to high-income countries. ICU admission diagnoses are similar with a particularly high incidence of stroke and liver failure. ICU mortality is approximately 25% with most deaths caused by stroke, liver failure, and traumatic brain injury.

Introduction. The developing world continues to face challenges in closing the large treatment gap for epilepsy, due to a high burden of disease and few experienced providers to manage the condition. Children with epilepsy are susceptible to higher rates of developmental impairments and refractory disease due to delays or absence of appropriate management as a result. We demonstrated that a structured education intervention on pediatric epilepsy can improve knowledge, confidence, and impact clinical practice of first level providers in Zambia. Methods. Three first-level facilities across Zambia were included. After initial pilot versions and revisions, the final course was implemented at each site. Pre- and post-intervention knowledge and confidence assessments were performed. Additionally, chart reviews were conducted prior to intervention and 4 months after completion of training at each site to assess change on management. Results. Twenty-three of the original 24 participants from all 3 sites completed the training; 48% clinical officers, 43% nurses, 9% other expertise. Of the 15 concepts tested by knowledge assessment, 12 showed trends in improvement, 7 of which were significant ( P

Background In many resource-limited settings, emergency medicine (EM) is underdeveloped and formal EM training limited. Residencies and fellowships are an ideal long-term solution but cannot meet immediate needs for emergency providers, while short-term programs are often too limited in content. We describe a third method successfully implemented in Haiti: a medium-duration certificate program to meet the immediate need for emergency specialists. Methods In conjunction with the Haitian Ministry of Health and National Medical School, we developed and implemented a novel, 6-month EM certificate program to build human resources for health and emergency care capacity. The program consisted of didactic and supervised clinical components, covering core content in EM. Didactics included lectures, simulations, hands-on skill-sessions, and journal clubs. Supervised clinical time reinforced concepts and taught an EM approach to patient care. Results Fourteen physicians from around Haiti successfully completed the program; all improved from their pre-test to post-test. At the end of the program and 9-month post-program evaluations, participants rated the program highly, and most felt they used their new knowledge daily. Participants found clinical supervision and simulation particularly useful. Key components to our program’s success included collaboration with the Ministry of Health and National Medical School, supervised clinical time, and the continual presence of a course director. The program could be improved by a more flexible curriculum and by grouping participants by baseline knowledge levels. Conclusion Medium-duration certificate programs offer a viable option for addressing immediate human resource gaps in emergency care, and our program offers a model for implementation in resource-limited settings. Similar options should be considered for other emerging specialties in resource-limited settings.

Background: Pediatric sepsis causes significant global morbidity and mortality and low- and middle-income countries (LMICs) bear the bulk of the burden. International sepsis guidelines may not be relevant in LMICs, especially in sub-Saharan Africa (SSA), due to resource constraints and population differences. There is a critical lack of pediatric sepsis data from SSA, without which accurate risk stratification tools and context-appropriate, evidence-based protocols cannot be developed. The study’s objectives were to characterize pediatric sepsis presentations, interventions, and outcomes in a public Emergency Medicine Department (EMD) in Tanzania. Methods: Prospective descriptive study of children (28 days-14 years) with sepsis (suspected infection with >2 clinical Systemic Inflammatory Response Syndrome [SIRS] criteria) presenting to a tertiary EMD in Dar es Salaam, Tanzania (July 1-September 30, 2016). Outcomes included: in-hospital mortality (primary), EMD mortality, and hospital length of stay. We report descriptive statistics using means and standard deviations, medians and interquartile ranges, and counts and percentages as appropriate. Predictive abilities of SIRS criteria, the Alert-Verbal-Painful-Unresponsive (AVPU) score and the Lambarene Organ Dysfunction Score (LODS) for in-hospital, early and late mortality were tested. Results: Of the 2232 children screened, 433 (19.4%) met inclusion criteria, and 405 were enrolled. There were 247 (61%) subjects referred from an outside facility. Approximately half (54.1%) received antibiotics in the EMD, and some form of microbiologic culture was collected in 35.8% (n=145) of subjects. In-hospital and EMD mortality were 14.2% and 1.5%, respectively, median time to death was 3 days (IQR 1-6), and median length of stay was 6 days (IQR 1-12). SIRS criteria, the AVPU score, and the LODS had low positive (17-27.1%, 33.3-43.9%, 18.3-55.6%, respectively) and high negative predictive values (88.6-89.8%, 86.5-91.2%, 86.8-90.5%, respectively) for in-hospital mortality. Conclusions: This pediatric sepsis cohort had high and early in-hospital mortality. Current criteria and tested clinical scores were inadequate for risk-stratification and mortality prediction in this population and setting. Pediatric sepsis management must take into account the local patient population, etiologies of sepsis, healthcare system, and resource availability. Only through studies such as this that generate regional data in LMICs can accurate risk stratification tools and context-appropriate, evidence-based guidelines be developed.

Objective The objective of this study is to describe the characteristics of in‑hospital cardiopulmonary resuscitation (CPR) attempts, theperspectives of junior doctors involved in those attempts and the use of do not attempt resuscitation (DNAR) orders. Methods A cross‑sectional telephone survey aimed at intern doctors working in all medical/surgical wards in government hospitals. Interns were interviewed based on the above objective. Results A total of 42 CPR attempts from 82 hospitals (338 wards) were reported, 3 of which were excluded as the participating doctor was unavailable for interview. 16 (4.7%) wards had at least 1 patient with an informal DNAR order. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt, of which 6 occurred on wards with an informal DNAR order in place. 39 resuscitations were attempted. Survival at 24 h was 2 (5.1%). In 5 (13%) attempts, CPR was the only intervention reported. On 25 (64%) occasions, doctors were “not at all” or “only a little bit surprised” by the arrest. Conclusions CPR attempts before death in hospitals across Sri Lanka is prevalent. DNAR use remains uncommon.

Background Few low-income countries have virological monitoring widely available. We estimated the virological durability of first-line antiretroviral therapy (ART) after five years of follow-up among adult Ugandan and Zimbabwean patients in the DART study, in which virological assays were conducted retrospectively. Methods DART compared clinically driven monitoring with/without routine CD4 measurement. Annual plasma viral load was measured on 1,762 patients. Analytical weights were calculated based on the inverse probability of sampling. Time to virological failure, defined as the first viral load measurement ≥200 copies/mL after 48 weeks of ART, was analysed using Kaplan-Meier plots and Cox regression models. Results Overall, 65% of DART trial patients were female. Patients initiated first-line ART at a median (interquartile range; IQR) age of 37 (32–42) and with a median CD4 cell count of 86 (32–140). After 240 weeks of ART, patients initiating dual-class nucleoside reverse-transcriptase inhibitor (NRTI) -non-nucleoside reverse-transcriptase (NNRTI) regimens containing nevirapine + zidovudine + lamivudine had a lower incidence of virological failure than patients on triple-NRTI regimens containing tenofovir + zidovudine + lamivudine (21% vs 40%; hazard ratio (HR) =0.48, 95% CI:0.38–0.62; p

Background The HIV prevalence among men who have sex with men (MSM) in Peru (12.4 %) is 30 times higher than in the general adult population (0.4 %). It is critical for community-based organizations to understand how to provide HIV services to MSM while maximizing limited resources. This study describes the HIV prevalence and risk profiles of MSM seeking HIV services at a community-based organization in Lima, Peru. It then compares HIV prevalence between those who found out about the HIV services through different sources. Methods A cross-sectional study of MSM seeking HIV services at Epicentro Salud in Lima, Peru for the first time between April 2012 and October 2013. We compared HIV prevalence among MSM who found out about Epicentro via online sources of information (N = 419), those using in-person sources (friends, partners) (N = 907), and sex workers (N = 140) using multivariable logistic regression models. Results HIV prevalence was 18.3 % overall: 23.2 % among MSM using online sources, 19.3 % among sex workers, and 15.9 % among MSM using in-person sources. However, when compared to the in-person group, sexual risk behaviors were not statistically higher among MSM using online sources. For the sex worker group, some behaviors were more common, while others were less. After adjusting for confounders, the odds of having HIV was higher for the online group (Odds Ratio = 1.61; 95 % Confidence Interval: 1.19–2.18), but not for the sex worker group (OR = 1.12; 95 % CI: 0.68–1.86), compared to the in-person group. Conclusion Internet-based promotion appears to successfully reach MSM at high risk of HIV in Peru. Outreach via this medium can facilitate HIV diagnosis, which is the critical first step in getting infected individuals into HIV care. For community-based organizations working in resource-limited settings, this may be an effective strategy for engaging a subset of high-risk persons in HIV care.

Background Chorea is a rare complication of uncontrolled type II diabetes. We report for the first time in Tanzania a case of type II diabetes presenting with a hyperglycaemia-induced hemichorea. Case presentation A 58-year-old Tanzanian chagga by tribe with a body mass index of 28 kg/m2 and newly diagnosed type II diabetes presented with polydipsia and involuntary movements of the right upper limb for 4 days. His plasma glucose was 549 mg/dl and glycated haemoglobin was 18.9 %. His movements were exaggerated by attempts to use his right hand. The rest of his neurological assessment was unremarkable. Other laboratory findings including calcium were within the normal range. A computed tomography scan of the brain was essentially normal except for age-related atrophy. There was no significant ketonuria on urine dipstick testing. We treated the patient’s hyperglycaemia with intravenous insulin and the dystonia disappeared within 5 days. Conclusion Hemichorea is among the rare complications of hyperglycaemia-induced involuntary movements. Hyperglycaemia should be considered as a differential diagnosis for patients with type II diabetes mellitus presenting with hemichorea upon clinical assessment.

Background The diagnosis and management of acutely dyspneic patients in resource-limited developing world settings poses a particular challenge. Focused cardiopulmonary ultrasound (CPUS) may assist in the emergency diagnosis and management of patients with acute dyspnea by identifying left ventricular systolic dysfunction, pericardial effusion, interstitial pulmonary edema, and pleural effusion. We sought to assess the accuracy of emergency providers performing CPUS after a training intervention in a limited-resource setting; a secondary objective was to assess the ability of CPUS to affect change of clinician diagnostic assessment and acute management in patients presenting with undifferentiated dyspnea. Methods and results After a training intervention for Haitian emergency providers, patients with dyspnea presenting urgently to a regional referral center in Haiti underwent a rapid CPUS examination by the treating physician. One hundred seventeen patients (median age of 36 years, 56 % female) were prospectively evaluated with a standardized CPUS exam. Blinded expert review of ultrasound images was performed by two board certified cardiologists and one ultrasound fellowship trained emergency physician. Inter-observer agreement was determined using an agreement coefficient (kappa). Sensitivity and Specificity with confidence intervals were calculated. Pre-test and post-test clinician impressions and management plans were compared to assess for a change. We enrolled 117 patients with undifferentiated dyspnea. Upon expert image review, prevalence of left ventricular systolic dysfunction was 40.2 %, and in those with systolic dysfunction, the average EF was 14 % (±9 %). The parasternal long axis (PLAX) single view was predictive of an overall abnormal echo with PPV of abnormal PLAX 95 % and NPV 93 % of normal PLAX. Weighted kappa for pericardial effusion between the Haitian physicians and two cardiology reviewers was 0.81 (95 % CI 0.75–0.87, p value

Background Adequate pain control through sedation and anesthesia for emergency procedures is a crucial aspect of pediatric emergency care. Resources for administering such anesthesia are extremely limited in many low-income settings. Methods Non-anesthetist providers in Western Kenya were trained in the use of a ketamine-based sedation and anesthesia package for non-anesthetists, Every Second Matters for Mothers and Babies-Ketamine™ (ESM-Ketamine). Data on use and safety of this package for emergent and urgent pediatric procedures was collected. Providers were surveyed as to what they would have done for similar procedures if the ESM-Ketamine package were unavailable. Results Ninety procedures were completed for 77 pediatric patients utilizing the ESM-Ketamine package. Of these, 29 (32.2 %) cases were orthopedic reductions, 19 (21.1 %) were incision and drainage, and 19 (21.1 %) were debridement and irrigation of burns. Remaining cases included cesarean section, repair of perineal tear, foreign body removal, arthrocentesis, laceration repair, exploratory laparotomy, excision of mass, paracentesis, and circumcision. There were no serious adverse events in any of the cases, 17 % experienced minor adverse events including hypersalivation, hallucinations, or brief, self-resolving, oxygen desaturations. Providers were surveyed for 80 of the 90 cases as to what they would have done in the absence of the ESM-Ketamine package: in 26 cases (32.5 %), they reported they would proceed with the procedure without any anesthesia or analgesia; in 15 (18.75 %), they reported they would significantly delay the procedure while waiting for an anesthetist; in 13 (16.25 %), they reported they would attempt referral to another facility; and in 26 (32.5 %), they reported they would try using an alternate form of analgesia, primarily acetaminophen, ibuprofen, diclofenac, and/or diazepam. All surveyed providers reported they would use the ESM-Ketamine package again in similar cases. Conclusions The ESM-Ketamine package, through the use of a simplified protocol and checklist, allows for safe analgesia and anesthesia in children by non-anesthetists in a resource-limited setting for selected emergent and urgent procedures. This package addresses a significant gap in the availability of anesthesia services in low-income settings that would otherwise result in significant delays to procedures or proceeding with painful procedures with inadequate analgesia.

BACKGROUND: The World Health Organization recommends adding bedaquiline or delamanid to multi drug-resistant tuberculosis (MDR-TB) regimens for which four effective drugs are not available, and delamanid for patients at high risk of poor outcome. OBJECTIVE: To identify patients at risk of unfavourable outcomes who may benefit from the new drugs. METHODS: Retrospective cohort study of treatment outcomes involving four to five effective drugs for 1524 months in programmes in Uzbekistan, Georgia, Armenia, Swaziland and Kenya between 2001 and 2011. RESULTS: Of 1433 patients, 48.5% had body mass index (BMI)

Strong international mobilization and political will drove a golden decade for global health. Key initiatives over the last decade include setting of health-related Millennium Development Goals; the Commission on Macroeconomics and Health; the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Doha Declaration on the TRIPS Agreement and Public Health affirming countries’ rights to protect public health when implementing patent rules; and the creation of product development partnerships to address neglected areas of research and development. Significant progress was made in reducing the incidence of and morbidity and mortality from human immunodeficiency virus (HIV), tuberculosis (TB), and malaria, with a major impact made through increased access to medicines. Antiretroviral treatment for HIV was expanded to 6.6 million people, and medication prices were reduced significantly through generic competition. However, donor support has started to decline at a time when many patients still wait for treatment and the prices of needed newer medicines are on the increase due to patent protection. TB incidence has started to decrease, but progress in diagnosis and treatment of multi-drug-resistant TB has been slow due to complexity of treatment and high drug costs. Promising new TB drugs in development need to be introduced rapidly and appropriately while treatment is being expanded. The introduction of more affordable artemisinin combination therapies for malaria contributed to significantly reducing malaria incidence and mortality, but challenges remain in ensuring that the latest recommendations for treating severe malaria are implemented. Looking to the next decade, there is a worrisome mismatch between additional health priorities accompanied by shifting burdens of disease that need to be addressed and dwindling political attention and financial support. Difficulties in producing and guaranteeing access to affordable medicines are expected from a changing pharmaceutical market where an appropriate balance between trade and health has not been found. Systematic changes through a global framework for research and development and access are needed to support increased innovation and access to the health tools of the next decade.

Introduction The success of HIV treatment programmes globally has resulted in children with perinatally acquired HIV reaching adolescence in large numbers. The number of adolescents living with HIV is growing further due to persisting high HIV incidence rates among adolescents in low‐ and middle‐income settings, particularly in sub‐Saharan Africa. Although expanding access to HIV viral load monitoring is necessary to achieve the 90‐90‐90 targets across the HIV care continuum, implementation is incomplete. We discuss the rationale for prioritizing viral load monitoring among adolescents and the associated challenges. Discussion Adolescents with HIV are a complex group to treat successfully due to extensive exposure to antiretroviral therapy for those with perinatally acquired HIV and the challenges in sustained medication adherence in this age group. Given the high risk of treatment failure among adolescents and the limited drug regimens available in limited resource settings, HIV viral load monitoring in adolescents could prevent unnecessary and costly switches to second‐line therapy in virologically suppressed adolescents. Because adolescents living with HIV may be heavily treatment experienced, have suboptimal treatment adherence, or may be on second or even third‐line therapy, viral load testing would allow clinicians to make informed decisions about increased counselling and support for adolescents together with the need to maintain or switch therapeutic regimens. Conclusions Given scarce resources, prioritization of viral load testing among groups with a high risk of virological failure may be required. Adolescents have disproportionately high rates of virological failure, and targeting this age group for viral load monitoring may provide valuable lessons to inform broader scale‐up.

Introduction First-line antiretroviral therapy (ART) failure often results from the development of resistance-associated mutations (RAMs). Three patterns, including thymidine analogue mutations (TAMs), 69 Insertion (69Ins) and the Q151M complex, are associated with resistance to multiple-nucleoside reverse transcriptase inhibitors (NRTIs) and may compromise treatment options for second-line ART. Methods We investigated patterns and factors associated with multi-NRTI RAMs at first-line failure in patients from The TREAT Asia Studies to Evaluate Resistance – Monitoring study (TASER-M), and evaluated their impact on virological responses at 12 months after switching to second-line ART. RAMs were compared with the IAS-USA 2013 mutations list. We defined multi-NRTI RAMs as the presence of either Q151M; 69Ins; ≥2 TAMs; or M184V+≥1 TAM. Virological suppression was defined as viral load (VL) 2 years (OR=6.25, 95% CI [2.39–16.36], p

There have been impressive gains in public health in low- and middle-income countries in recent decades, which are contributing to significant reductions in infant mortality, malaria attributable mortality and a general improvement in life expectancy in these countries. With basic public health needs better addressed, improvements in curative care, in particular for the critically ill, are becoming more important for saving lives. The recent and continuing outbreaks of severe acute respiratory infections due to emerging infections give further political and media attention to critical care. Increased awareness of the importance of critical care is reflected in an increase in availability of dedicated intensive care units (ICUs) in low-middle-income and middle-income countries. However, with the scarce data available, it appears that severity adjusted case fatality in ICUs in these settings remains much higher than in higher income countries.3,4 Improving these outcomes will require evaluation of setting specific factors adversely affecting performance and identification of investments and interventions to address them. In general, ICUs in low- and middle-income countries have to function with important limitations in material and human resources, although improving in some countries.1,2,5 Laboratory support is limited, supplies of consumables and medication can be unpredictable, and proper maintenance of crucial equipment for monitoring and treatment is often a challenge. Nevertheless, many of the basic principles of good critical care are as applicable (or are even more so) to resource poor settings, but are often not practiced. These include management and organizational aspects, such as regular ward rounds, empowerment of nurses, proper and frequent documentation of vital signs, structured handover to the next shift of doctors and nurses, admission and discharge policies, the use of both short-term and long-term treatment plans, and adherence to strict hygiene rules. The ‘Surviving Sepsis Campaign’ guidelines for severe sepsis and septic shock management6 have been implemented widely in ICUs in high-income countries and have, together with timely administration of essential therapies, contributed to improved survival. Part of these recommendations can be applied to more resource-limited settings at low or no extra costs. These include the use of low tidal volumes for mechanical ventilation, prompt start of appropriate empirical antibiotic treatment, restricted use of fluid therapy after the initial phase in septic shock and restricted use of sedation. From the limited data available, these practices are often not implemented.7 An important drawback of the ‘Surviving Sepsis Campaign’ guidelines is that the evidence for the recommendations has been mainly gathered from studies in high-income countries. Often this evidence cannot be directly translated to the resource-poor setting.8 The causes of severe sepsis are different in tropical countries and often require different approaches for their management. Examples are severe falciparum malaria and severe dengue, which require more restricted fluid therapy than recommended for bacterial sepsis.8,9 Also, some of the widely accepted recommendations for well-equipped ICUs can be dangerous in a resource-poor setting. An example is the early start of enteral feeding, including in sedated and comatose patients. In resource-poor settings, intubation for airway protection in patients with reduced consciousness is commonly not possible because of limited availability of mechanical ventilation. Early start of enteral feeding through a nasogastric tube in this group of patients results in aspiration pneumonia in an unacceptably large proportion of patients10 and should be reconsidered. Thus, many guidelines will require careful setting-adjusted re-evaluation. A basic requirement for improving critical care in resource-poor settings are tools for evaluation of baseline ICU facilities, practices and performance, which also facilitates assessment of improvement over time when changes are implemented. In rich countries, ICU registries have proven to be critical tools for monitoring ICU performance. These registries can be adjusted to the more resource-limited setting and can be implemented at relatively low costs.2 A limited number of low- and middle-income countries are using such registries, and a wider roll-out is clearly warranted. Such registries (local, national or regional across borders) will also enable inventorying existing ICUs and availability of equipment and other resources. Minimum standards for equipment, monitoring and treatment required for critical care adjusted to low- and middle-income countries have not been described and a registry can help make these recommendations. Monitoring of nosocomial infections and antimicrobial resistance patterns in the ICU could be an important part of the registry, but facilities for microbiology are unfortunately underdeveloped in these countries. Training of both doctors and nurses working in the ICU is another important area for sustained improvement of care. Collaboration between countries where ICU medicine has been established, and countries where critical care as a separate specialty is still at its early stages, can facilitate this. International networks and linked registries can help identify priority areas for improvement and training, develop communication channels and contribute to create a critical mass of critical care trainers. It is clear from the multitude of these issues, that research and quality improvement initiatives at different levels targeted towards critical care in resource-limited settings are warranted. The potential gains for the individual, families, ICU, hospital and healthcare systems are likely to be large and potentially of greater magnitude than is currently possible in high-income countries. Currently there is only a limited body of literature available on the topic and the usual funding schemes rarely focus on this important area. At the same time there is widespread interest on the topic of critical care as a global need, as witnessed by an increasing number of professional organizations with active working groups on the topic. We should capitalize on this development and make a concerted effort to make quality care for the critically ill patient a reachable goal for the entire globe.

BACKGROUND: Curaçao is a Dutch Caribbean island with a relatively high aging population, a high prevalence of chronic diseases and a health care system that is driven by cost-containment. In 2009 the development of a new value-based health care (VBHC) system was initiated on the island, and a key role was identified for the St. Elisabeth Hospital as a (model) platform for implementing this initiative. We therefore decided to investigate for the requirements needed to build a health care environment that is conducive for change and capable of facilitating the smooth migration of existent services into an effective and sustainable VBHC system.FINDINGS: Our findings revealed that our chosen approach was well accepted by the stakeholders. We discovered that in order to achieve a new value based health care system based on a reliable and well-organized system, the competencies of health care providers and the quality of the health care system needs to be assured. For this, extra focus needs to be given to improving service and manpower development both during and after formal training.CONCLUSIONS: In order to achieve a VBHC system in a resource-limited environment, the standard of physicians' competencies and of the health care system need to be guaranteed. The quality of the educational process needs to be maintained and safeguarded within an integrated health care delivery system that offers support to all care delivery and teaching institutions within the community. Finally, collaborative efforts with international medical institutions are recommended.

Background The availability of HIV antiretroviral therapy (ART) has been associated with the development of transmitted drug resistance-associated mutations (TDRM). TDRM can compromise treatment effectiveness in patients initiating ART and the prevalence can vary in different clinical settings. In this study, we investigated the proportion of TDRM in treatment-naïve, recently infected HIV-positive individuals sampled from four urban locations across Asia between 2007–2010. Methods Patients enrolled in the TREAT Asia Studies to Evaluate Resistance – Surveillance Study (TASER-S) were genotyped prior to ART initiation, with resulting resistance mutations analysed according to the WHO 2009 list. Results Proportions of TDRM from recently infected individuals from TASER-S ranged from 0% to 8.7% - Hong Kong: 3/88 (3.4%, 95% CI (0.71%-9.64%)); Thailand: Bangkok: 13/277 (4.7%, 95% CI (2.5%-7.9%)), Chiang Mai: 0/17 (0%, 97.5% CI (0%-19.5%)); and the Philippines: 6/69 (8.7%, 95% CI (3.3%-18.0%)). There was no significant increase in TDRM over time across all four clinical settings. Conclusions The observed proportion of TDRM in TASER-S patients from Hong Kong, Thailand and the Philippines was low to moderate during the study period. Regular monitoring of TDRM should be encouraged, especially with the scale-up of ART at higher CD4 levels.

Introduction Adherence to antiretroviral therapy (ART) plays an important role in treatment outcomes. It is crucial to identify factors influencing adherence in order to optimize treatment responses. The aim of this study was to assess the rates of, and factors associated with, suboptimal adherence (SubAdh) in the first 24 months of ART in an Asian HIV cohort. Methods As part of a prospective resistance monitoring study, the TREAT Asia Studies to Evaluate Resistance Monitoring Study (TASER-M) collected patients’ adherence based on the World Health Organization-validated Adherence Visual Analogue Scale. SubAdh was defined in two ways: (i) 14 days. Time was divided into four intervals: 0–6, 6–12, 12–18 and 18–24 months. Factors associated with SubAdh were analysed using generalized estimating equations. Results Out of 1316 patients, 32% ever reported 2 assessments per patient per year had an odds ratio (OR)=0.7 (95% confidence interval (CI) (0.55 to 0.90), p=0.006), compared to sites with ≤2 assessments per patient per year. Compared to heterosexual exposure, SubAdh was higher in injecting drug users (IDUs) (OR=1.92, 95% CI (1.23 to 3.00), p=0.004) and lower in homosexual exposure (OR=0.52, 95% CI (0.38 to 0.71), p

Sepsis represents a continuum of illness due to systemic inflammation caused by an infection that requires prompt recognition and treatment. While sepsis is a significant cause of death worldwide, its mortality is believed to be disproportionately high in low- and middle-income countries (LMICs). Since 1992, its definition has become standardized, and beginning in 2002, an international collaboration has produced a set of consensus guidelines on the optimal management of septic patients. Based on new evidence, significant updates have been made since then. It is known that application of a bundled approach to patient care with the use of specific resuscitation endpoints to guide therapy leads to significant reductions in mortality from sepsis. However, it is also recognized that the implementation of such interventions in LMICs is extremely challenging. Consequently, a body of literature on practical guidelines for sepsis in developing countries has emerged. This article provides a review of the evidence for the best practice of sepsis management, with recommendations for resource-limited settings.

Background In 2010, in the midst of the human immunodeficiency virus (HIV) epidemic in Zimbabwe, 69% of faculty positions in the Department of Medicine of the University of Zimbabwe College of Health Sciences (UZ-CHS) were vacant. To address the ongoing need to train highly skilled HIV clinicians with only a limited number of faculty, we developed and implemented a course for final-year medical students focused on HIV care using team-based learning (TBL) methods. Methods A competency-based HIV curriculum was developed and delivered to final-year medical students in 10 TBL sessions as part of a 12 week clinical medicine attachment. A questionnaire was administered to the students after completion of the course to assess their perception of TBL and self-perceived knowledge gained in HIV care. Two cohorts of students completed the survey in separate academic years, 2011 and 2012. Descriptive analysis of survey results was performed. Results Ninety-six of 120 students (80%) completed surveys. One hundred percent of respondents agreed that TBL was an effective way to learn about HIV and 66% strongly agreed. The majority of respondents agreed that TBL was more stimulating than a lecture course (94%), fostered enthusiasm for the course material (91%), and improved teamwork (96%). Students perceived improvements in knowledge gained across all of the HIV subjects covered, especially in challenging applied clinical topics, such as management of HIV antiretroviral failure (88% with at least a “large improvement”) and HIV-tuberculosis co-infection (80% with at least a “large improvement”). Conclusions TBL is feasible as part of medical education in an African setting. TBL is a promising way to teach challenging clinical topics in a stimulating and interactive learning environment in a low-income country setting with a high ratio of students to teachers.

Background The Ethiopian epidemic is currently on the wane. However, the situation for infected children is in some ways lagging behind due to low treatment coverage and deficient prevention of mother-to-child transmission. Too few studies have examined HIV infected children presenting to care in low-income countries in general. Considering the presence of local variations in the nature of the epidemic a study in Ethiopia could be of special value for the continuing fight against HIV. The aim of this study is to describe the main characteristics of children with HIV presenting to care at a district hospital in a resource-limited area in southern Ethiopia. The aim was also to analyse factors affecting pre-ART loss to follow-up, time to ART-initiation and disease stage upon presentation. Methods This was a prospective cohort study. The data analysed were collected in 2009 for the period January 2003 through December 2008 at Arba Minch Hospital and additional data on the ART-need in the region were obtained from official reports. Results The pre-ART loss to follow-up rate was 29.7%. Older children (10–14 years) presented in a later stage of their disease than younger children (76.9% vs. 45.0% in 0–4 year olds, chi-square test, χ2 = 8.8, P = 0.01). Older girls presented later than boys (100.0% vs. 57.1%, Fisher’s exact test, P = 0.02). Children aged 0–4 years were more likely to be lost to follow-up (40.0 vs. 21.8%, chi-square test, χ2 = 5.4, P = 0.02) and had a longer time to initiate ART (Cox regression analysis, HR: 0.50, 95% CI: 0.25-0.97, P = 0.04, controlling for sex, place of residence, enrolment phase and WHO clinical stage upon presentation). Neither sex was overrepresented in the sample. Tuberculosis prevalence upon presentation and previous history of tubercolosis were 14.5% and 8% respectively. Conclusions The loss to follow-up is alarmingly high and children present too late. Further research is needed to explore specific causes and possible solutions. Electronic supplementary material The online version of this article (doi:10.1186/1471-2431-14-250) contains supplementary material, which is available to authorized users.