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Background: Tele-rehabilitation after stroke holds promise for under-resourced settings, especially sub-Saharan Africa (SSA), with its immense stroke burden and severely limited physical therapy services., Objective: To preliminarily assess the feasibility and outcomes of mobile technology-assisted physical therapy exercises for stroke survivors in Ghana., Methods: We conducted a prospective, single arm, pre-post study involving 20 stroke survivors recruited from a tertiary medical center, who received a Smartphone with the 9zest Stroke App® to deliver individualized, goal-targeted 5-days-a-week exercise program that was remotely supervised by a tele-therapist for 12 weeks. Outcome measures included changes in stroke levity scale scores (SLS), Modified Rankin score (MRS), Montreal Cognitive Assessment (MOCA), and feasibility indicators., Results: Among study participants, mean ± SD age was 54.6 ± 10.2 years, 11 (55%) were men, average time from stroke onset was 6 months. No participants dropped out. Compared with baseline status, mean ± SD scores on SLS improved from 7.5 ± 3.1 to 11.8 ± 2.2 at month 1 (p < 0.0001) and 12.2 ± 2.4 at month 3 (p < 0.0001), MOCA scores improved from 18.2 ± 4.3 to 20.4 ± 4.7 at month 1 (p = 0.14), and 22.2 ± 7.6 at month 3 (p = 0.047). Mean ± SD weekly sessions performed by participants per month was 5.7 ± 5.8 and duration of sessions was 25.5 ± 16.2 min. Erratic internet connectivity negatively affected full compliance with the intervention, although satisfaction ratings by study participants were excellent., Conclusion: It is feasible to administer an m-health delivered physical therapy intervention in SSA, with high user satisfaction. Randomized trials to assess the efficacy and cost-effectiveness of this intervention are warranted., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Malawi is one of the poorest nations in the world, ranked 151st among 195 countries by the World Bank, with an under-5-year mortality rate of 63 per 1000 live births. There are no previous studies describing the spectrum of inpatient pediatric cardiology consultations in sub-Saharan Africa. A descriptive cohort study was performed at Kamuzu Central Hospital (KCH), a tertiary care hospital in Lilongwe, Malawi. Demographic, anthropometric, and clinical information for all cardiology consults patients aged 0-18 years admitted to the children's wards over a period of 1 month was reviewed. Seventy-three consults and 69 echocardiograms were performed on 71 patients (35 males, 38 females). The median (IQR) age was 3.1 years (9 months-10.5 years). About 53% (39/73) had failure to thrive, 4.1% (3/73) were sero-reactive for HIV and 100% (73/73) were fully immunized for age per the Expanded Program on Immunization schedule. Seventy-four percent of the echocardiograms were abnormal, with 34.8% (24/69) having congenital heart disease (CHD) and 18.8% (13/69) having acquired heart disease (AHD) with preserved cardiac function. Among CHD, 10.1% (7/69) had cyanotic CHD and 24.6% (17/769 had acyanotic CHD. Among AHD, 10.1% (7/69) had rheumatic heart disease with preserved cardiac function. Symptomatic systolic heart failure (HF) with ejection fraction <50%, was found in 20.3% (14/69), and pulmonary hypertension was diagnosed in 10.1% (7/69). Overall admission mortality was 5.5% (4/73). Three patients left the hospital against medical advice. None of the patients with systolic HF had CHD. There was no significant association of HIV, gender, or failure to thrive on presence of systolic HF. This is the first report describing the spectrum of pediatric cardiology consults in an inpatient setting in Malawi. There was an unexpectedly high proportion of CHD and systolic HF. Further studies should be conducted to explore the implications and potential causes of these findings., (© 2018 Wiley Periodicals, Inc.)

This article describes a 3D microfluidic paper-based analytical device that can be used to conduct an enzyme-linked immunosorbent assay (ELISA). The device comprises two parts: a sliding strip (which contains the active sensing area) and a structure surrounding the sliding strip (which holds stored reagents-buffers, antibodies, and enzymatic substrate-and distributes fluid). Running an ELISA involves adding sample (e.g. blood) and water, moving the sliding strip at scheduled times, and analyzing the resulting color in the sensing area visually or using a flatbed scanner. We demonstrate that this device can be used to detect C-reactive protein (CRP)-a biomarker for neonatal sepsis, pelvic inflammatory disease, and inflammatory bowel diseases-at a concentration range of 1-100ng/mL in 1000-fold diluted blood (1-100µg/mL in undiluted blood). The accuracy of the device (as characterized by the area under the receiver operator characteristics curve) is 89% and 83% for cut-offs of 10ng/mL (for neonatal sepsis and pelvic inflammatory disease) and 30ng/mL (for inflammatory bowel diseases) CRP in 1000-fold diluted blood respectively. In resource-limited settings, the device can be used as a part of a kit (containing the device, a fixed-volume capillary, a pre-filled tube, a syringe, and a dropper); this kit would cost ~ $0.50 when produced in large scale (>100,000 devices/week). This kit has the technical characteristics to be employed as a pre-screening tool, when combined with other data such as patient history and clinical signs., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

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 to 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 to September 30, 2016). Outcomes included: in-hospital mortality (primary), EMD mortality, and hospital length of stay. We report descriptive statistics using means and SDs, medians and interquartile ranges, and counts and percentages as appropriate. Predictive abilities of SIRS criteria, the Alert-Verbal-Painful-Unresponsive (AVPU) score and the Lambaréné Organ Dysfunction Score (LODS) for in-hospital, early and late mortality were tested., Results: Of the 2,232 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., Conclusion: 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, the perspectives 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., Competing Interests: There are no conflicts of interest.

Background: The variety and complexity of dermatologic diseases in Afghanistan and the associated diagnostic resource constraints have not been previously studied. Moreover, the utility of store-and-forward teledermatopathology in this resource-limited setting has not been investigated., Methods: A retrospective analysis was conducted of 150 store-and-forward teledermatopathology cases that were composed of a clinical history, clinical images, and histologic images that were sent from an academic teaching hospital in Kabul to a dermatology-trained dermatopathologist at Emory University in the United States between November 2013 and June 2017. For each case, the histologic impression of the Emory dermatopathologist was compared with that of the Kabul-based general pathologist and the clinical differential diagnosis and histologic impression of the Kabul-based dermatologist., Results: Eighty-one of the cases that were analyzed were from female patients. The diagnosis after telepathology consultation differed from the first entity in the clinical differential diagnosis in 34.7% of cases. The telepathology consultation refined the Afghan general pathologist's histologic impression 45.5% of the time and the Kabul-based dermatologist's histologic impression 24.3% of the time. A clinically significant difference in care was made in 19.3% of cases for which an analysis could take place between the histologic impressions of the Emory dermatopathologist and U.S.-trained dermatologist. The most common resource constraints that limited a definitive diagnosis were the inability to perform infectious stains and cultures to identify specific pathogens (19.3% of cases) and immunofluorescence studies to confirm autoimmune bullous disease (6.7% of cases)., Conclusions: These results highlight the important diagnostic role that teledermatopathology can serve in resource-limited settings such as in Afghanistan.

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., (© 2017 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.)

Purpose: The World Health Organization (WHO) has developed a simplified algorithm specific to resource-limited settings for the treatment of severe sepsis emphasizing early fluids and antibiotics. However, this protocol's clinical effectiveness is unknown. We describe patient outcomes before and after implementation of an adapted WHO severe sepsis protocol at a community hospital in Haiti., Materials and Methods: Using a before-and-after study design, we retrospectively enrolled 99 adult Emergency Department patients with severe sepsis from January through March 2012. After protocol implementation in January 2014, we compared outcomes to 67 patients with severe sepsis retrospectively enrolled from February to April 2014. We defined sepsis according to the WHO's Integrated Management of Adult Illness guidelines and severe sepsis as sepsis plus organ dysfunction., Results: After protocol implementation, quantity of fluid administered increased and the physician's differential diagnoses more often included sepsis. Patients were more likely to have follow-up vital signs taken sooner, a radiograph performed, and a lactic acid tested. There were no improvements in mortality, time to fluids or antimicrobials., Conclusions: Use of a simplified sepsis protocol based primarily on physiologic parameters allows for substantial improvements in process measures in the care of severely septic patients in a resource-constrained setting., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Scrub typhus is endemic in rural Southeast Asia. The district of Umphang in northwestern Thailand is a prototype environment for this disease. We report the clinical manifestations and outcomes of patients diagnosed with scrub typhus in this area., Methodology: Patients diagnosed with scrub typhus between 2011 and 2014 were analyzed. Diagnosis was based on clinical symptoms in conjunction with a positive rapid test or a pathognomonic eschar lesion., Results: A total of 857 patients were included, of which 488 were adults and 369 were children. Most patients (728; 84.9%) were included via a positive serology on rapid test, 86 patients (10.0%) had eschar only, and 43 patients (5.0%) had both sero-confirmation and presence of eschar. The most common symptom was fever (93.8%), followed by headache (48.1%) and cough (33.1%). Eschars were reported in 129 patients, with a significantly higher percentage in children (p < 0.001), and a different anatomical distribution was found when adults and children were compared. Common complications were elevated transaminases, acute kidney injury, and pneumonia. Most patients recovered from the disease., Conclusions: Scrub typhus in Umphang district is common. Patients can present with a variety of clinical symptoms, regardless of the presence of fever. Standard treatment led to a favorable outcome in most patients., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2017 Tobias Brummaier, Chatporn Kittitrakul, Vorada Choovichian, Saranath Lawpoolsri, Chayadol Namaik-larp, Yupaporn Wattanagoon.)

Purpose: Developing countries carry the greatest burden of sepsis, yet few descriptive data exist from the Western Hemisphere. We conducted a retrospective cohort study to elucidate the presentation, treatment, and outcomes of sepsis at an urban referral hospital in Port-au-Prince, Haiti., Materials and Methods: We studied all adult emergency department patient encounters from January through March 2012. We characterized presentation, management, and outcomes using univariable and multivariable analyses., Results: Of 1078 adult patients, 224 (20.8%) had sepsis and 99 (9.2%) had severe sepsis. In-hospital mortality for severe sepsis was 24.2%. Encephalopathy was a predictor of intravenous fluid administration (adjusted odds ratio [OR], 5.63; 95% confidence interval [CI], 1.46-21.76; P=.01), and lower blood pressures predicted shorter time to fluid administration. Increasing temperature and lower blood pressures predicted antibiotic administration. Encephalopathy at presentation (adjusted OR, 6.92; 95% CI, 1.94-24.64; P=.003), oxygen administration (adjusted OR, 15.96; 95% CI, 3.05-83.59; P=.001), and stool microscopy (adjusted OR, 45.84; 95% CI, 1.43-1469.34; P=.03) predicted death in severe sepsis patients., Conclusions: This is the first descriptive study of sepsis in Haiti. Our findings contribute to the knowledge base of global sepsis and reveal similarities in independent predictors of mortality between high- and low-income countries., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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 < 0.0001). In multivariate analyses, female patients (HR = 0.79, 95% CI: 0.65-0.95; p = 0.02), older patients (HR = 0.73 per 10 years, 95% CI: 0.64-0.84; p < 0.0001) and patients with a higher pre-ART CD4 cell count (HR = 0.64 per 100 cells/mm 3 , 95% CI: 0.54-0.75; p < 0.0001) had a lower incidence of virological failure after adjusting for adherence to ART. No difference in failure rate between the two randomised monitoring strategies was observed (p= 0.25)., Conclusions: The long-term durability of virological suppression on dual-class NRTI-NNRTI first-line ART without virological monitoring is remarkable and is enabled by high-quality clinical management and a consistent drug supply. To achieve higher rates of virological suppression viral-load-informed differentiated care may be required., Trial Registration: Prospectively registered on 18/10/2000 as ISRCTN13968779 .

Pediatric HIV remains a significant global health dilemma, especially in resource-constrained nations. As access to ART increases around the world, areas of concern in pediatric HIV treatment include age-appropriate disclosure of HIV status to children and development of adherence habits over time. This review was conducted to synthesize quantitative associations reported between disclosure and adherence among children living with HIV in resource-limited settings. An electronic database search of PubMed, MEDLINE and Cochrane returned 1348 results after removal of duplicates, 14 of which were found to meet inclusion criteria. Review of these reports showed conflicting results regarding the impact of disclosure on adherence, with 5 showing no association, 4 showing a negative impact of disclosure on adherence, and 5 showing positive benefits of disclosure for adherence habits. Thus, there was no clear consensus on the effect, if any, that disclosure has on medication adherence. Longitudinal, prospective research needs to be conducted to evaluate further impacts that disclosure may have on adherence habits over time, and interventions must be structured to link the two processes together in order to maximize health benefit to the child or adolescent.

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.

Severe sepsis and septic shock continue to cause major morbidity and mortality among children, especially in the resource-limited areas. Guidelines that focus on these entities, such as "Surviving Sepsis" and "Paediatric Advanced Life Support" guidelines, are revised and updated on regular basis to incorporate new evidence based medicine. There is ongoing need to review these updated guidelines, and address potentially best available solutions for adapting them into suitable practical steps for paediatricians worldwide, especially those working in resource-limited areas. The available recommendations may help to improve sepsis management in middle- and low-income countries; however, guidelines must be wisely implemented according to the available resources, with follow up auditing to ensure appropriate implementation.