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Background Treatment of HCV with direct-acting antivirals has enabled the discussion of HCV eradication worldwide. Envisioning this aim requires implementation of mass screening in resource-limited areas, usually constrained by testing costs. Methods We validated a low-cost, rapid diagnosis test (RDT) for HCV in three different continents in 141 individuals. Results The HCV RDT showed 100% specificity and sensitivity across different samples regardless of genotype or viral load (in samples with such information, 90%). Conclusions The HCV test validated in this study can allow for HCV screening in areas of need when properly used. [ABSTRACT FROM AUTHOR]

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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Smith, Sawe, Matthay, Murray, Reynolds and Kortz.)

Background: We hypothesized that knowledge regarding obstetric anal sphincter injuries amongst healthcare workers in our setting is limited. A lack of knowledge would result in worsened clinical outcomes and proving this knowledge deficiency would allow us to institute educational programs to improve outcomes., Objective: This study aimed to assess the knowledge and perceptions of healthcare workers regarding obstetrical anal sphincter injuries in a resource-limited setting., Study Design: Questionnaires assessing the knowledge in classification, diagnosis, and management of obstetrical anal sphincter injuries were completed by 290 doctors and nurses involved in conducting vaginal deliveries at various levels of care (primary, district, regional, tertiary) in a resource-limited setting. Moreover, confidence in managing obstetrical anal sphincter injuries was assessed., Results: Although the healthcare workers' knowledge of anatomy was poor, most healthcare workers knew how to define obstetrical anal sphincter injuries and classify these injuries. Most healthcare workers considered obstetrical anal sphincter injuries serious complications and perceived that patients with obstetrical anal sphincter injuries were best managed at a regional- or tertiary-level hospital. There was variation in choice of suture material and methods of repair, with most healthcare workers lacking confidence in managing obstetrical anal sphincter injuries and 96.9% of healthcare workers indicating a need for further training. Most healthcare workers felt that perineal support was the best intrapartum preventative strategy against obstetrical anal sphincter injuries., Conclusion: Here, it was likely that knowledge and confidence in managing obstetrical anal sphincter injuries in most resource-limited settings were suboptimal, highlighting a need for ongoing training., (© 2021 The Authors.)

The need for viral load (VL) monitoring of HIV patients receiving antiretroviral therapy (ART) in resource-limited settings (RLS) has become apparent with studies showing the limitations of immunological monitoring. We compared the Abbott m2000 Real-Time (Abbott) HIV-1 assay with the Roche AMPLICOR Monitor v1.5 (Roche) HIV-1 assay over a range of VL concentrations. Three hundred and eleven plasma samples were tested, including 164 samples from patients on ART ⩾ six months and 147 from ART-naïve patients. The Roche assay detected ⩾400 copies/mL in 158 (50.8%) samples. Of these, Abbott produced 145 (91.8%) detectable results ⩾400 copies/mL; 13 (8.2%) samples produced discrepant results. Concordance between the assays for detecting HIV-1 RNA ⩾400 copies/mL was 95.8% (298/311). The sensitivity, specificity, positive predictive value and negative predictive value of Abbott to detect HIV-1 RNA ⩾400 copies/mL were 91.8%, 100%, 100% and 92.2%, respectively. For the 151 samples with HIV-1 RNA ⩾400 copies/mL for both assays, a good linear correlation was found (r = 0.81, P< 0.0001; mean difference, 0.05). The limits of agreement were 20.97 and 1.07 log10 copies/mL (mean±2 SD). The Abbott assay performed well in our setting, offering an alternative methodology for HIV-1 VL for laboratories with realtime polymerase chain reaction (PCR) capacity. [ABSTRACT FROM AUTHOR]

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., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Purpose: A considerable barrier to global pediatric oncology efforts has been the scarcity and even absence of trained professionals in many low- and middle-income countries, where the majority of children with cancer reside. In 2013, no dedicated pediatric hematology-oncology (PHO) programs existed in Ethiopia despite the estimated annual incidence of 6000-12000 cases. The Aslan Project initiative was established to fill this gap in order to improve pediatric cancer care in Ethiopia. A major objective was to increase subspecialty PHO-trained physicians who were committed to practicing locally and empowered to lead programmatic development., Methods: We designed and implemented a PHO training curriculum to provide a robust educational and clinical experience within the existing resource-constrained environment in Ethiopia. Education relied on visiting PHO faculty, a training attachment abroad, and extraordinary initiative from trainees., Results: Four physicians have completed comprehensive PHO subspecialty training based primarily in Ethiopia, and all have remained local. Former fellows are now leading two PHO centers in Ethiopia with a combined capacity of 64 inpatient beds and over 800 new diagnoses per year; an additional former fellow is developing a pediatric cancer program in Nairobi, Kenya. Two fellows currently are in training. Program leadership, teaching, and advocacy are being transitioned to these physicians., Conclusions: Despite myriad challenges, a subspecialty PHO training program was successfully implemented in a low-income country. PHO training in Ethiopia is approaching sustainability through human resource development, and is accelerating the growth of dedicated PHO services where none existed 7 years ago., (© 2020 Wiley Periodicals LLC.)

Currently diagnosis and management of patients in Clinical Practice is very much dependent on laboratory diagnostics. Laboratory Medicine, like any other branch of Medicine, is therefore, mandated with ethical usage of materials and data obtained from patients. Several countries, professional societies and the have developed policies and guidance materials on ethical issues related to laboratory medicine. However, ethical standards and practices vary between different cultures, geographies, legal architecture and according to available resources. In this article, we try to understand the challenges presented in terms of Ethics, where there are constraints of resources., (Copyright © 2020 International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). All rights reserved.)

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  < .05). Chart reviews demonstrated significant improvement in documentation of seizure description ( P  = .008), seizure frequency ( P  = .00), and possible causes of seizures/epilepsy ( P  = .034). Discussion . Key elements of success to this program included hands on clinical skills building and case-based teaching, development of a program with direct and ongoing input from the target audience, and inclusion of assessments to monitor impact on clinical practice. Future studies looking at health outcomes are necessary to determine sustained impact., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Background: One of the major challenges associated with nursing education in this 21st century is the practice preparation of student nurses to serve in complex healthcare environments and to ensure their fitness to practise in these environments. Clinical mentoring has shown promise in providing clinical learning support for student nurses. Most approaches are, however, biased towards higher-income settings without giving due consideration to the resources, culture and structures of health systems in resource-limited settings. It is also unclear how qualified nurses who act as nurse teachers experience the clinical mentoring of student nurses in resource-limited settings., Aim: This study aimed to explore and describe the experiences of qualified nurses regarding the clinical mentoring of nursing students in resource-limited settings., Setting: The study took place in Mauritius, a developing country., Methods: A qualitative, exploratory, descriptive approach was used with a purposive sample of eight nurses. Data were collected through face-to-face interviews and thematically analysed., Results: The findings indicated that mentoring per se was not practised, but rather general support, supervision or coaching. This resulted in the practice being less effective for its original purpose. Possible explanations included a lack of policy directives. Additionally, the mentoring practice was informal with unclear role expectations. Poor material and personal resources further compounded the challenges. An absence of buy-in and involvement of management along with a lack of monitoring clinical mentoring by the nursing school concludes the picture., Conclusion: Effective clinical mentoring requires an understanding of the mentoring process from a broader perspective. Mentors should be equipped with core competencies. Successful mentoring outcomes are dependent on a conducive clinical learning environment and a clear mentoring approach., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2020. The Authors.)

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, naïve, 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 naïve/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 naïve/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., (Copyright © 2020 Payne, Lawrie, Nieuwoudt, Cotton, Gibb, Babiker, Glencross and Klein.)

Background: Short-term medical missions prevail as the most common form of international medical volunteerism, but they are ill-suited for medical education and training local providers in resource-limited settings. Objective: The purpose of this study is to evaluate the effectiveness of a longitudinal educational program in training clinicians how to perform point-of-care ultrasound (POCUS) in resource-limited clinics. Design: A retrospective study of a four-month POCUS training program was conducted with clinicians from a rural hospital in Haiti. The model included one-on-one, in-person POCUS teaching sessions by volunteer instructors from the United States and Europe. The Haitian trainees were assessed at the start of the program and at its conclusion by a direct objective structured clinical examination (OSCE), administered by the visiting instructors, with similar pre- and post- program ultrasound competency assessments. Results: Post-intervention, a significant improvement in POCUS competency was observed across six different fundamental areas of ultrasound (p < 0.0001). According to our objective structured clinical examination (OSCE), the mean assessment score increased from 0.47 to 1.68 out of a maximum score of 2 points, and each trainee showed significant overall improvement in POCUS competency independent of the initial competency pre-training (p < 0.005). There was a statistically significant improvement in POCUS application for five of the six medically relevant assessment categories tested. Conclusion: Our results provide a proof-of-concept for the longitudinal education-centered healthcare delivery framework in a resource-limited setting. Our longitudinal model provides local healthcare providers the skills to detect and diagnose significant pathologies, thereby reducing avoidable morbidity and mortality at little or no addition cost or risk to the patient. Furthermore, training local physicians obviates the need for frequent volunteering trips, saving costs in healthcare training and delivery., Competing Interests: The authors have no conflicts of interest to disclose., (Author(s) retain the copyright for their work.)

Background: Distal sensory peripheral neuropathy (DSPN) is a complication of human immunodeficiency virus (HIV). We estimate DSPN prevalence in 7 resource-limited settings (RLSs) for combination antiretroviral therapy (cART)-naive people living with HIV (PLWH) compared with matched participants not living with HIV and in PLWH virally suppressed on 1 of 3 cART regimens., Methods: PLWH with a CD4+ count <300 cells/mm3 underwent standardized neurological examination and functional status assessments before and every 24 weeks after starting cART. Matched individuals not living with HIV underwent the same examinations once.Associations between covariates with DSPN at entry were assessed using the χ2 test, and virally suppressed PLWH were assessed using generalized estimating equations., Results: Before initiating cART, 21.3% of PLWH had DSPN compared with 8.5% of people not living with HIV (n = 2400; χ2(df = 1) = 96.5; P < .00001). PLWH with DSPN were more likely to report inability to work [χ2(df = 1) = 10.6; P = .001] and depression [χ2(df = 1) = 8.9; P = .003] than PLWH without DSPN. Overall prevalence of DSPN among those virally suppressed on cART decreased: 20.3%, week 48; 15.3%, week 144; and 10.3%, week 192. Incident DSPN was seen in 127 PLWH. Longitudinally, DSPN was more likely in older individuals (P < .001) and PLWH with less education (P = .03). There was no significant association between cART regimen and DSPN., Conclusions: Although the prevalence of DSPN decreased following cART initiation in PLWH, further research could identify strategies to prevent or ameliorate residual DSPN after initiating cART in RLSs., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: The inability to identify individuals with acute fever at risk of death is a barrier to effective triage and management of severe infections, especially in low-resource settings. Since endothelial and immune activation contribute to the pathogenesis of various distinct life-threatening infections, we hypothesized that measuring mediators of these pathways at clinical presentation would identify febrile adults at risk of death., Methods: Plasma concentrations of markers of endothelial (angiopoetin-1/2, soluble fms-like tyrosine kinase-1, soluble vascular cell adhesion molecule-1, soluble intercellular adhesion molecule-1) and immune (soluble triggering receptor expressed on myeloid cells [sTREM-1], interleukin-6, interleukin-8, chitinase-3-like protein-1, soluble tumor necrosis factor receptor-1, procalcitonin [PCT], C-reactive protein [CRP]) activation pathways were determined in consecutive adults with acute fever (≥38°C) at presentation to outpatient clinics in Dar es Salaam, Tanzania. We evaluated the accuracy of these mediators in predicting all-cause mortality and examined whether markers could improve the prognostic accuracy of clinical scoring systems, including the quick sequential organ failure assessment (qSOFA) and Glasgow coma scale (GCS)., Results: Of 507 febrile adults, 32 died (6.3%) within 28 days of presentation. We found that sTREM-1 was the best prognostic marker for 28-day mortality (area under the receiver operating characteristic [AUROC] 0.87, 95% confidence interval [CI] 0.81-0.92) and was significantly better than CRP (P < .0001) and PCT (P = .0001). The prognostic accuracy of qSOFA and the GCS were significantly enhanced when sTREM-1 was added (0.80 [95% CI 0.76-0.83] to 0.91 [95% CI 0.88-0.94; P < .05] and 0.72 [95% CI 0.63-0.80] to 0.94 [95% CI 0.91-0.97; P < .05], respectively)., Conclusions: Measuring sTREM-1 at clinical presentation can identify febrile individuals at risk of all-cause febrile mortality. Adding severity markers such as sTREM-1 to simple clinical scores could improve the recognition and triage of patients with life-threatening infections in resource-limited settings., (© Crown copyright 2019.)

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of manifestations and potential to affect several organ systems. Complications arise from both disease and medications especially glucocorticoids, significantly contributing to overall morbidity and mortality. SLE predominantly affects patients during their prime productive years resulting in substantial economic burden on the patient, caregivers, and society due to direct, indirect, and intangible costs. This illness burden is compounded in developing countries with limited resources due to various disparities in healthcare delivery. Physician education and practical referral and endorsement guidelines adapted to the local setting reinforce continuity and coordinated care. Likewise, patient education, self-help programs, and shared decision-making are essential best practice in the clinics. Both physician education and patient education improve overall outcomes in chronic diseases like SLE. As a developing country with very few rheumatologists and/or lupus specialists, efficient healthcare delivery for most Filipino lupus patients remains elusive. We describe our experience in confronting these challenges through development of strategies which focus on physician and patient education. KEY POINTS: • Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a highly variable course, requiring specialized, individualized, and coordinated care by a healthcare team. • Health disparities and limited resources significantly contribute to illness burden on the patient, family, and society. • Physician education on SLE must commence at undergraduate medical school, be integrated in Internal Medicine and Pediatrics, and reinforced through specialized training in Rheumatology and related specialties. • Patient education and empowerment are integral to improving healthcare outcomes especially in a resource-limited setting.

Purpose: There was limited study available on successful intervention for central-line-associated bloodstream infection (CLABSI) done at nonintensive care unit (ICU) and resources-limited setting. The objective of this study was to design, implement and evaluate a strategy to reduce CLABSI rate in non-ICU settings at general medical wards of Hospital Tuanku Ja'afar Seremban., Design/methodology/approach: Preinterventional study was conducted in one-month period of January 2019, followed by intervention period from February to March 2019. Postintervention study was conducted from April to July 2019. The CLABSI rates were compared between pre and postintervention periods. A multifaceted intervention bundle was implemented, which comprised (1) educational program for healthcare workers, (2) weekly audit and feedback and (3) implementation of central line bundle of care., Findings: There was a significant overall reduction of CLABSI rate between preintervention and postintervention period [incidence rate ratio (IRR) of 0.06 (95 percent CI, 0.01-0.33; P  = 0.001)]., Practical Implications: CLABSI rates were reduced by a multifaceted intervention bundle, even in non-ICU and resource-limited setting. This includes a preinterventional study to identify the risk factors followed by a local adaption of the recommended care bundles. This study recommends resources-limited hospitals to design a strategy that is suitable for their own local setting to reduce CLABSI., Originality/value: This study demonstrated the feasibility of a multifaceted intervention bundle that was locally adapted with an evidence-based approach to reduce CLABSI rate in non-ICU and resource-limited setting., (© Emerald Publishing Limited.)

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. [ABSTRACT FROM AUTHOR]

Objective: Critical care capabilities needed for the management of septic patients, such as continuous vital sign monitoring, are largely unavailable in most emergency departments (EDs) in low- and middle-income country (LMIC) settings. This study aimed to assess the feasibility and accuracy of using a wireless wearable biosensor device for continuous vital sign monitoring in ED patients with suspected sepsis in an LMIC setting., Methods: This was a prospective observational study of pediatric (≥2 mon) and adult patients with suspected sepsis at the Kigali University Teaching Hospital ED. Heart rate, respiratory rate and temperature measurements were continuously recorded using a wearable biosensor device for the duration of the patients' ED course and compared to intermittent manually collected vital signs., Results: A total of 42 patients had sufficient data for analysis. Mean duration of monitoring was 32.8 h per patient. Biosensor measurements were strongly correlated with manual measurements for heart rate (r = 0.87, p  <   0.001) and respiratory rate (r = 0.75, p  <   0.001), although were less strong for temperature (r = 0.61, p  <   0.001). Mean (SD) differences between biosensor and manual measurements were 1.2 (11.4) beats/min, 2.5 (5.5) breaths/min and 1.4 (1.0)°C. Technical or practical feasibility issues occurred in 12 patients (28.6%) although were minor and included biosensor detachment, connectivity problems, removal for a radiologic study or exam, and patient/parent desire to remove the device., Conclusions: Wearable biosensor devices can be feasibly implemented and provide accurate continuous heart rate and respiratory rate monitoring in acutely ill pediatric and adult ED patients with sepsis in an LMIC setting., (© The Author(s) 2019.)

Rwanda's ambitious Human Resources for Health (HRH) program comes to an end this year, having made great strides towards achieving its aim to create a large, diverse and competent health workforce, and will have graduated over 4,500 healthcare professionals since its inception in 2012. The HRH program was based on strong collaborative relationships between Rwandan and United States academic institutions and faculty and now stands poised to enter a new phase focused on sustaining the many gains achieved. Fostering career development of new Rwandan faculty and building health research capacity are key components to sustaining the mutually beneficial partnerships that have been forged over the past seven years, with the goal of creating strong Rwandan health researchers that can advance knowledge of best practices for patient care and public health, appropriate to the Rwandan context and other resource-limited settings.

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.

Background: Since 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., Aim: This 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 & Setting: A mixed-methods evaluation of a postgraduate diploma in Gaza Palestine., Method: The 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., Results: All 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., Conclusion: Where 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., (Copyright © 2019, The Authors.)

Adult cancer patients (ACPs) in resource-limited settings disproportionately suffer from inadequate pain control despite advancements in pain management. Family caregivers (FCGs) can support optimal pain control for ACPs in these settings if they are knowledgeable and confident about the needed care. However, the status of FCGs' knowledge and self-efficacy (SE) for pain management in developing countries is not well established., Purpose: To assess the FCGs' knowledge and SE levels for pain management among ACPs while at home in a resource-limited setting., Methods: Using a questionnaire that comprised a Family Pain Questionnaire and Chronic Pain Self-efficacy Scale, data were collected from 284 FCGs of ACPs receiving care from two cancer care centres., Results: The FCGs had moderate knowledge (mean = 41.70 ± 14.1) and SE (mean = 795.95 ± 301.3) levels for pain management at home for ACPs. Majority of the FCGs had low knowledge (52.1%), but expressed higher SE (52.5%). Poor self-rated health among FCGs was significantly associated with low knowledge levels (OR = 1.75; 95% CI 1.024-2.978, p = 0.041). SE was significantly associated with perceiving a low impact of caregiving on health (OR = 1.55; 95% CI 1.074-2.239, p = 0.019), hours of caregiving per week (OR = 0.52; 95% CI 0.315-0.854; p = 0.01) and receiving organisational support (OR = 0.388; 95% CI 0.222-0.679; p = 0.001)., Conclusion: The results show a need for deliberate interventions to enhance FCG knowledge and SE for pain management at home as one of the ways of improving cancer pain management in resource-limited settings.

Background: AIDS Clinical Trial Group 5199 compared neurological and neuropsychological test performance of human immunodeficiency virus type 1 (HIV-1)-infected participants in resource-limited settings treated with 3 World Health Organization-recommended antiretroviral (ART) regimens. We investigated the impact of tuberculosis (TB) on neurological and neuropsychological outcomes., Methods: Standardized neurological and neuropsychological examinations were administered every 24 weeks. Generalized estimating equation models assessed the association between TB and neurological/neuropsychological performance., Results: Characteristics of the 860 participants at baseline were as follows: 53% female, 49% African; median age, 34 years; CD4 count, 173 cells/μL; and plasma HIV-1 RNA, 5.0 log copies/mL. At baseline, there were 36 cases of pulmonary, 9 cases of extrapulmonary, and 1 case of central nervous system (CNS) TB. Over the 192 weeks of follow-up, there were 55 observations of pulmonary TB in 52 persons, 26 observations of extrapulmonary TB in 25 persons, and 3 observations of CNS TB in 2 persons. Prevalence of TB decreased with ART initiation and follow-up. Those with TB coinfection had significantly poorer performance on grooved pegboard (P < .001) and fingertapping nondominant hand (P < .01). TB was associated with diffuse CNS disease (P < .05). Furthermore, those with TB had 9.27 times (P < .001) higher odds of reporting decreased quality of life, and had 8.02 times (P = .0005) higher odds of loss of productivity., Conclusions: TB coinfection was associated with poorer neuropsychological functioning, particularly the fine motor skills, and had a substantial impact on functional ability and quality of life., Clinical Trials Registration: NCT00096824., (© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Familiarity with principles of palliative care, supportive care, and palliative oncological treatment is essential for providers caring for cancer patients, though this may be challenging in global communities where resources are limited. Herein, we describe the scope of literature on palliative oncological care curricula for providers in resource-limited settings. A systematic literature review was conducted using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Med Ed Portal databases, and gray literature. All available prospective cohort studies, case reports, and narratives published up to July 2017 were eligible for review. Fourteen articles were identified and referenced palliative care education programs in Argentina, Uganda, Kenya, Australia, Germany, the USA, or multiple countries. The most common teaching strategy was lecture-based, followed by mentorship and experiential learning involving role play and simulation. Education topics included core principles of palliative care, pain and symptom management, and communication skills. Two programs included additional topics specific to the underserved or American Indian/Alaskan Native community. Only one program discussed supportive cancer care, and no program reported educational content on resource-stratified decision-making for palliative oncological treatment. Five programs reported positive participant satisfaction, and three programs described objective metrics of increased educational or research activity. There is scant literature on effective curricula for providers treating cancer patients in resource-limited settings. Emphasizing supportive cancer care and palliative oncologic treatments may help address gaps in education; increased outcome reporting may help define the impact of palliative care curriculum within resource-limited communities.

Objectives: Diarrhea is one of the most common and deadly conditions affecting children, causing over 525,000 deaths annually, largely in resource-limited settings. Appropriate treatment depends on accurate determination of dehydration status. This study evaluated the accuracy of a new model using clinical and ultrasound measurements for predicting dehydration status in children with acute diarrhea., Methods: The Dehydration: Assessing Kids Accurately (DHAKA) study was a prospective cohort study of children under 5 years of age with acute diarrhea presenting to the International Centre for Diarrhoeal Disease Research in Dhaka, Bangladesh. Clinical signs and sonographic measurements of the aorta-to-inferior vena cava ratio were recorded. Percent weight change with rehydration was used to classify dehydration severity. Logistic regression was used to create a combined DHAKA-US model based on clinical and sonographic measurements. Area under the curve and calibration slope were used to assess the model's accuracy and compare it to the original DHAKA score model., Results: A total of 850 children were enrolled, with 736 included in the final analysis. The combined DHAKA-US model showed equivalent discrimination with the original DHAKA score, with an area under the curve of 0.79 for both models for severe dehydration (95% confidence interval, 0.74-0.84), as well as similar classification (48% versus 50% correctly classified) and calibration (calibration slopes of 0.900 versus 0.904 for presence of any dehydration)., Conclusion: Adding sonographic measurements to the DHAKA score had no effect on discrimination, classification, or calibration when compared to the original DHAKA score. Clinical signs alone may be the most important predictors of dehydration status in children with diarrhea in limited resource settings., (© 2018 by the American Institute of Ultrasound in Medicine.)

Objectives: Ultrasound (US) is increasingly used in settings where commercial US gel is unavailable. This study evaluated noncommercial gel recipes compared to commercial gel., Methods: A search for US gel formulations revealed 6 recipes. Half-strength commercial gel and a modified glucomannan recipe were also tested. Nine gels, including commercial gel, were tested in Liberia and the United States. In each session, 2 physician sonologists evaluated 9 gels on 2 models, obtaining videos from the hepatorenal space with a curvilinear transducer, the cardiac parasternal long view with a phased array transducer, and the left basilic vein with a linear transducer. The sonologists and models, who were blinded to gel identity, made independent quantitative and qualitative gel evaluations comparing the test gel to commercial gel. Two physician sonologists who were blinded to the gel identities and a US operator reviewed the images and rated their quality. An analysis of variance in repeated measures was performed to test for differences in the overall score, real-time quality, and other characteristics. Post hoc pairwise comparisons to commercial gel were performed with a Tukey-Kramer adjustment. Inter- and intra-rater reliability was calculated for the image review., Results: Commercial gel earned a perfect score. Compared to commercial gel, xanthine gum gel scored highest, followed by half-strength commercial gel. Hot concentrated glucomannan and cold glucomannan gel were found to be significantly worse than commercial gel. No significant difference was found between images based on the gel used on the image review., Conclusions: No significant difference in image quality was found between commercial and noncommercial gels on US image review., (© 2018 by the American Institute of Ultrasound in Medicine.)

Vehicular networks are becoming increasingly dense due to expanding wireless services and platooning has been regarded as a promising technology to improve road capacity and on-road safety. Constrained by limited resources, not all communication links in platoons can be allocated to the resources without suffering interference. To guarantee the quality of service, it is required to determine the set of served services at which the scale of demand exceeds the capability of the network. To increase the number of guaranteed services, the resource allocation has to be adjusted to adapt to the dynamic environment of the vehicular network. However, resource re-allocation results in additional costs, including signal overhead and latency. To increase the number of guaranteed services at a low-cost in a resource-limited vehicular network, we propose a time dynamic optimization method that constrains the network re-allocation rate. To decrease the computational complexity, the time dynamic optimization problem is converted into a deterministic optimization problem using the Lyapunov optimization theory. The simulation indicates that the analytical results do approximate the reality, and that the proposed scheme results in a higher number of guaranteed services as compared to the results of a similar algorithm. [ABSTRACT FROM AUTHOR]

The author reflects on the increased awareness of the significance of critical care as more available dedicated intensive care units (ICUs) are seen in low-middle-income and middle-income countries but explores the higher fatalities in ICUs in such settings than in higher income countries. Topics discussed include the "Surviving Sepsis Campaign" guidelines for severe sepsis and septic shock management, what hinders the guidelines and the benefits of ICU registries in monitoring ICU performance.