U.S. Department of Health & Human Services — Information for those with limited income and resources (those who may qualify for or already have the Low Income Subsidy to lower their prescription drug coverage...
D-R1-76 122 SERCH WITH ’LIMITED RESOURCES(U) DUKE UNIV DURHM NC i/i DEPTOF COMPUTER SCIENCE D C MUTCHLER FEB 83 CS11983-1 USI FE AFOSR-TR-83-i154...over all possible S" g ame trees. How to weight this average has not yet been specified. It is reasonable. glven the lack of additional information, to...complete binary 0-1 tree can be described by two parameters: P a number of goal nodes with value ŕ". and vt = number of goal nodes. This Justifies
An asymmetry in response to rainfall is not surprising in the light of Liebig's law of the minimum, which says that the yield of a crop is determined by the scarcest resource (the so called limiting resource).
Fossil fuels including coal play a key role as crucial energies in contributing to economic development in Asia. On the other hand, its limited quantity and the environmental problems causing from its usage have become a serious global issue and a countermeasure to solve such problems is very much demanded. Along with the pursuit of sustainable development, environmentally-friendly use of highly efficient fossil resources should be therefore, accompanied. Kyushu-university‧s sophisticated research through long years of accumulated experience on the fossil resources and environmental sectors together with the advanced large-scale commercial and empirical equipments will enable us to foster cooperative research and provide internship program for the future researchers. Then, this program is executed as a consignment business from the Ministry of Economy, Trade and Industry from 2007 fiscal year to 2009 fiscal year. The lecture that uses the textbooks developed by this program is scheduled to be started a course in fiscal year 2010.
Schröder, Malte; Araújo, Nuno A. M.; Sornette, Didier; Nagler, Jan
Connectivity, or the lack thereof, is crucial for the function of many man-made systems, from financial and economic networks over epidemic spreading in social networks to technical infrastructure. Often, connections are deliberately established or removed to induce, maintain, or destroy global connectivity. Thus, there has been a great interest in understanding how to control percolation, the transition to large-scale connectivity. Previous work, however, studied control strategies assuming unlimited resources. Here, we depart from this unrealistic assumption and consider the effect of limited resources on the effectiveness of control. We show that, even for scarce resources, percolation can be controlled with an efficient intervention strategy. We derive such an efficient strategy and study its implications, revealing a discontinuous transition as an unintended side effect of optimal control.
Anson, L.W.; Spinney, R.W.
The achievement of excellence in safety of nuclear power plant operation is dependent in part upon establishment of a performance-based training program. Developing such a program can be a laborious, time-consuming, and very expensive effort. Conducting job and task analyses, designing course outlines from learning objectives, developing training materials, evaluating program effectiveness and managing the training process and program through the out-years will exhaust any utility's training budget and staff. Because the achievement of excellence implies that training become in part performance-based, the question arises of how best to attain quality training yet still maintain a reasonable budget and staff workload. The answer lies not just in contracting the support necessary but making use of all available resources - training staff, contractor personnel in INPO
A review of operations in 1998 and financial information from Gulf Canada Resources Limited is provided to keep shareholders abreast of company performance. Gulf Canada Resources Limited explores for, develops, produces and markets conventional and synthetic crude oil, natural gas and natural gas liquids. In 1998, the company's main operating centres were in western Canada (where it owns a nine per cent interest in the Syncrude Joint Venture), Indonesia, the North Sea and Australia. The report summarizes the company's energy resource activities, presents a detailed review of operations, and provides consolidated financial statements, and common share information. Although Gulf Canada Resources sold $ 1.2 billion worth of non-producing assets during the year, year end proved reserves of 838 million barrels of oil equivalent were less than ten per cent lower than a year earlier, reflecting reserve additions of 100 million barrels of oil equivalent. tabs., figs
Garduño Espinosa Armando
Full Text Available Limited resources assignation is fundamental in the development of health services and since they will never be enough, justice is- sues arise. Many distributive justice theories are discussed: liberal, equilable and utilitarian, as well as ethic principles and cost-benefit relation, that is, the consequences. Palliative medicine is suggested as a strategy to reduce the cost of hospitable care and to enhance its designation.
Full Text Available In the view of optimizing regional power supply and demand, the paper makes effective planning scheduling of supply and demand side resources including energy efficiency power plant (EPP, to achieve the target of benefit, cost, and environmental constraints. In order to highlight the characteristics of different supply and demand resources in economic, environmental, and carbon constraints, three planning models with progressive constraints are constructed. Results of three models by the same example show that the best solutions to different models are different. The planning model including EPP has obvious advantages considering pollutant and carbon emission constraints, which confirms the advantages of low cost and emissions of EPP. The construction of progressive IRP models for power resources considering EPP has a certain reference value for guiding the planning and layout of EPP within other power resources and achieving cost and environmental objectives.
Nikolov, Rumen; Sendova, Evgenia
Describes experiences of the Research Group on Education (RGE) at the Bulgarian Academy of Sciences and the Ministry of Education in using limited computer resources when teaching informatics. Topics discussed include group projects; the use of Logo; ability grouping; and out-of-class activities, including publishing a pupils' magazine. (13…
Dohlman, Lena E
The article reviews the reality of anesthetic resource constraints in low and middle-income countries (LMICs). Understanding these limitations is important to volunteers from high-income countries who desire to teach or safely provide anesthesia services in these countries. Recently published information on the state of anesthetic resources in LMICs is helping to guide humanitarian outreach efforts from high-income countries. The importance of using context-appropriate anesthesia standards and equipment is now emphasized. Global health experts are encouraging equal partnerships between anesthesia health care providers working together from different countries. The key roles that ketamine and regional anesthesia play in providing well tolerated anesthesia for cesarean sections and other common procedures is increasingly recognized. Anesthesia can be safely given in LMICs with basic supplies and equipment, if the anesthesia provider is trained and vigilant. Neuraxial and regional anesthesia and the use of ketamine as a general anesthetic appear to be the safest alternatives in low-resource countries. Environmentally appropriate equipment should be encouraged and pulse oximeters should be in every anesthetizing location. LMICs will continue to need support from outside sources until capacity building has made more progress.
Santos, A.; Gunnarsen, Lars Bo
This report presents experimental data and models for optimisation of the indoor climate parameters temperature, noise, draught and window opening. Results are based on experiments with human subjects performed in climate chambers at University of the Philippines. The report may assist building...... designers to balance attention and resources between the parameters of the indoor climate when resources are less than optimal....
Full Text Available In traditional economics and finance the notion of value creation is virtually synonymous with the net present value of cash flows. Such a characterization implies that all of the uses of resource inputs, such as raw material and energy, are known and that their value is priced into commodities markets. It also fails to allow for the opportunity cost associated with the depletion of resources which, with advancing technology, might reasonably have future uses far greater in value than can be achieved at present with current technology. Stated differently, in traditional valuation analysis the option value associated with scarce resources—when new technology or knowledge can be applied to them—is not addressed. In the present work, we define technology leverage as representative of this effect. We then address the problem of sustainability of organizations by stating four propositions and examining their implications for government policy and for firm governance.
Alfred, Nwofor; Lovette, Lawson; Aliyu, Gambo; Olusegun, Obasanya; Meshak, Panwal; Jilang, Tunkat; Iwakun, Mosunmola; Nnamdi, Emenyonu; Olubunmi, Onuoha; Dakum, Patrick; Abimiku, Alash'le
The light-emitting diode (LED) fluorescence microscopy has made acid-fast bacilli (AFB) detection faster and efficient although its optimal performance in resource-limited settings is still being studied. We assessed the optimal performances of light and fluorescence microscopy in routine conditions of a resource-limited setting and evaluated the digestion time for sputum samples for maximum yield of positive cultures. Cross-sectional study. Facility-based involving samples of routine patients receiving tuberculosis treatment and care from the main tuberculosis case referral centre in northern Nigeria. The study included 450 sputum samples from 150 new patients with clinical diagnosis of pulmonary tuberculosis. The 450 samples were pooled into 150 specimens, examined independently with mercury vapour lamp (FM), LED CysCope (CY) and Primo Star iLED (PiLED) fluorescence microscopies, and with the Ziehl-Neelsen (ZN) microscopy to assess the performance of each technique compared with liquid culture. The cultured specimens were decontaminated with BD Mycoprep (4% NaOH-1% NLAC and 2.9% sodium citrate) for 10, 15 and 20 min before incubation in Mycobacterium growth incubator tube (MGIT) system and growth examined for acid-fast bacilli (AFB). Of the 150 specimens examined by direct microscopy: 44 (29%), 60 (40%), 49 (33%) and 64 (43%) were AFB positive by ZN, FM, CY and iLED microscopy, respectively. Digestion of sputum samples for 10, 15 and 20 min yielded mycobacterial growth in 72 (48%), 81 (54%) and 68 (45%) of the digested samples, respectively, after incubation in the MGIT system. In routine laboratory conditions of a resource-limited setting, our study has demonstrated the superiority of fluorescence microscopy over the conventional ZN technique. Digestion of sputum samples for 15 min yielded more positive cultures.
Heleen A Slagter
Full Text Available The information processing capacity of the human mind is limited, as is evidenced by the so-called "attentional-blink" deficit: When two targets (T1 and T2 embedded in a rapid stream of events are presented in close temporal proximity, the second target is often not seen. This deficit is believed to result from competition between the two targets for limited attentional resources. Here we show, using performance in an attentional-blink task and scalp-recorded brain potentials, that meditation, or mental training, affects the distribution of limited brain resources. Three months of intensive mental training resulted in a smaller attentional blink and reduced brain-resource allocation to the first target, as reflected by a smaller T1-elicited P3b, a brain-potential index of resource allocation. Furthermore, those individuals that showed the largest decrease in brain-resource allocation to T1 generally showed the greatest reduction in attentional-blink size. These observations provide novel support for the view that the ability to accurately identify T2 depends upon the efficient deployment of resources to T1. The results also demonstrate that mental training can result in increased control over the distribution of limited brain resources. Our study supports the idea that plasticity in brain and mental function exists throughout life and illustrates the usefulness of systematic mental training in the study of the human mind.
Bays, Paul M; Husain, Masud
Our ability to remember what we have seen is very limited. Most current views characterize this limit as a fixed number of items-only four objects-that can be held in visual working memory. We show that visual memory capacity is not fixed by the number of objects, but rather is a limited resource that is shared out dynamically between all items in the visual scene. This resource can be shifted flexibly between objects, with allocation biased by selective attention and toward targets of upcoming eye movements. The proportion of resources allocated to each item determines the precision with which it is remembered, a relation that we show is governed by a simple power law, allowing quantitative estimates of resource distribution in a scene.
Park, Se-Moon; Song, Sun-Ja
Women in Nuclear-Korea (WINK) surveyed the public understanding on various energy resources in early September 2006 to offer the result for establishment of the nuclear communication policy. The reason why this survey includes other energy resources is because the previous works are only limited on nuclear energy, and also aimed to know the public's opinion on the present communication skill of nuclear energy for the public understanding. The present study is purposed of having data how public understands nuclear energy compared to other energies, such as fossil fuels, hydro power, and other sustainable energies. The data obtained from this survey have shown different results according to the responded group; age, gender, residential area, etc. Responded numbers are more than 2,000 of general public and university students. The survey result shows that nuclear understanding is more negative in women than in men, and is more negative in young than older age
Desaunay, Cecile; Vidalenc, Eric
Whereas for a decade many experts spoke of an imminent dearth pf hydrocarbons and prices reached record highs, the cost of oil has fallen appreciably over the last two years and talk of shortage has almost disappeared. Does this mean there are no longer grounds for concern about the overall level of consumption of these energy resources? Doubtless not, though these questions of dearth or abundance of energy resources - and, more broadly, of all natural resources -are not solely to be examined in terms of the reserves at our disposal, but also, increasingly, in terms of the limits that ensue from the impact of their consumption on the environment (environmental damage, pollution, climate change etc.), as Cecile Desaunay and Eric Vidalenc show here. Accordingly, they list a series of crucial key questions with regard to the future of our planet's natural resources: is the growth of global resource consumption sustainable? How might energy prices develop? Can we foresee an absolute decoupling of economic growth from material consumption? What are the impacts on our ecosystems of resource degradation; have we passed planetary limits? They go on to stress two deep-seated trends that will have to be taken into account in managing our natural resources sustainably over the coming years: the very great inertia of energy Systems and the possible substitution of alternative energies (and the limits to doing this). The equation is not getting any easier and the lever that is the control of consumption will doubtless have a crucial part to play in the sustainable management of our resources in the medium to long term. (authors)
Bammigatti, Chanaveerappa; Doradla, Saikumar; Belgode, Harish Narasimha; Kumar, Harichandra; Swaminathan, Rathinam Palamalai
Health Care associated Infections (HAI) are the most common complications affecting the hospitalized patients. HAI are more common in developing and under developed countries. However, there are no systematic surveillance programs in these countries. To find out the burden, predisposing factors and multidrug resistant organisms causing HAI in a resource limited setting. This prospective observational study was done at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER). Patients aged 13 years or more with stay of more than 48 hours in a 16 bedded Medical Intensive Care Unit (MICU) between November 2011 and April 2013 were included in the study. Patients were prospectively followed up till discharge or death for the development of HAI. Device associated HAI like Ventilator Associated Pneumonia (VAP), Catheter Related-Blood Stream Infection (CR-BSI) and Catheter Associated-Urinary Tract Infections (CA-UTI) were studied. Standard laboratory methods were used for identification of microorganisms causing HAI and to test their antibiotic sensitivity. A total of 346 patients were included in the study with median age of 38 years. Common indications for admission to Medical Intensive Care Unit (MICU) were poisoning (31.5%); neurological illness (23.4%) like Guillian-Barre syndrome, tetanus, meningitis, encephalitis; respiratory illness (14.5%) like pneumonia, acute respiratory distress syndrome and tropical infections (7.2%) like malaria, scrub typhus, leptospirosis. Fifty percent (174/346) patients developed one or more HAI with VAP being the most common. The rates of HAI per 1000 device days for VAP, CR-BSI, CA-UTI were 72.56, 3.98 and 12.4, respectively. Acinetobacter baumannii was the most common organism associated with HAI. Multidrug resistance was seen in 74% of the isolates. The burden of HAI, especially with MDR organisms, in resource constrained setting like ours is alarming. There is urgent need for infection control and monitoring
Full Text Available Aquatic environments can be restricted with the amount of available food resources especially with changes to both abiotic and biotic conditions. Mosquito larvae, in particular, are sensitive to changes in food resources. Resource limitation through inter-, and intra-specific competition among mosquitoes are known to affect both their development and survival. However, much less is understood about the effects of non-culicid controphic competitors (species that share the same trophic level. To address this knowledge gap, we investigated and compared mosquito larval development, survival and adult size in two experiments, one with different densities of non-culicid controphic conditions and the other with altered resource conditions. We used Aedes camptorhynchus, a salt marsh breeding mosquito and a prominent vector for Ross River virus in Australia. Aedes camptorhynchus usually has few competitors due to its halo-tolerance and distribution in salt marshes. However, sympatric ostracod micro-crustaceans often co-occur within these salt marshes and can be found in dense populations, with field evidence suggesting exploitative competition for resources. Our experiments demonstrate resource limiting conditions caused significant increases in mosquito developmental times, decreased adult survival and decreased adult size. Overall, non-culicid exploitation experiments showed little effect on larval development and survival, but similar effects on adult size. We suggest that the alterations of adult traits owing to non-culicid controphic competition has potential to extend to vector-borne disease transmission.
Using the results of the Global Survey of Physicists, which we conducted in collaboration with the International Union of Pure and Applied Physics Working Group on Women, we document the effect of limited resources and opportunities on women physicists' careers. We find that women respondents are less likely than men to report access to a variety of resources and opportunities that would be helpful in advancing a scientific career. These include access to funding, travel money, lab and office space, equipment, clerical support, and availability of employees or students to help with research. When asked about specific opportunities, women report fewer invited talks and overseas research opportunities. Women who responded are less likely to have been journal editors, acted as bosses or managers, advised graduate students, served on thesis or dissertation committees, and served on committees for grant agencies. We also show the disproportionate effects of children on women physicists' careers. Women who responded are more likely than men to have changed their work situations upon becoming parents. Mothers are more likely than men and women without children to report that their careers have progressed more slowly than colleagues who finished their degrees at the same time. Furthermore, women are more likely than men to report that their careers affected the decisions they made about marriage and children. The results of this survey draw attention to the need to focus on factors other than representation when discussing the situation of women in physics. 15,000 physicists in 130 countries answered this survey, and across all these countries, women have fewer resources and opportunities and are more affected by cultural expectations concerning child care. Cultural expectations about home and family are difficult to change. However, for women to have successful outcomes and advance in physics, they must have equal access to resources and opportunities.
Batandjieva, B.; Warnecke, E.
The number of facilities reaching their lifetime is increasing and drawing the attention of operators, regulators, public and other interested parties (potential users of the site after decommissioning) on the importance of adequate planning, funding and implementation of decommissioning activities in compliance with regulatory requirements and criteria. Specific attention is required for small facilities that have been used for research purposes and in most cases state owned by and dependent on state funding. With the current tendency for expansion of the nuclear industry such small facilities could become less of importance for the operators which can increase the probability that these facilities become abandoned, hazardous and imposing undue burden to future generations. This concern is more related to countries with limited human and financial resources at the operating organizations and the regulatory body. The International Atomic Energy Agency (IAEA) has been working on the; (i) establishment of internationally recognized safety standards on decommissioning and (ii) providing Member States with assistance on the application of these standards. The recent international conference on Lessons Learned from the Decommissioning of Nuclear Facilities and the Safe Termination of Practices (Athens, Greece, 2006) has demonstrated that the set of IAEA standards is almost complete and that the International Action Plan on Decommissioning (2004), that is addressing decommissioning of small facilities, is being successfully implemented. However the need for further assistance on decommissioning of small facilities in countries with limited resources was also recognized and the Agency is planning its future work in this field. The IAEA also addresses the needs of small nuclear countries that have only a limited number of nuclear facilities, e.g. a research reactor, in its R esearch Reactor Decommissioning Demonstration Project (R 2 D 2 P. The Philippine Research Reactor
Alp, E.; Leblebicioglu, H.; Doganay, M.; Voss, A.
Nosocomial infections and their control are a world-wide challenge. The prevalence of nosocomial infections is generally higher in developing countries with limited resources than industrialized countries. In this paper we aimed to further explain the differences with regard to infection control
personnel, and specific drugs. In this paper, through a case managed at Queen Elizabeth Central Hospital (QECH) in. Blantyre, we discuss the challenges of stroke management in resource-limited settings, provide practical tips for general practitioners, and reflect on the potential avenues for short- and long-term action.
Feasibility of Laparoscopic Surgery in a Resource Limited Setting: Cost Containment, Skills Transfer and Outcomes. ... For part three, the notes, materials and schedules used for skills transfer session were reviewed. ... Short but repetitive hands-on training sessions are appropriate for training qualified surgeons on site.
The objective of this study is to audit the processes for the microbiological diagnosis of tuberculosis (TB) in our resource-limited setting. A total of 694 specimens were received from 333 patients. 129 (38.7%) of these patients were positive for TB. 78 (60.5%) were positive on AFB microscopy alone, 13 (10.0%) on culture ...
L'homme, R.F.A.; Muro, E.P.; Droste, J.A.H.; Wolters, L.R.; Ewijk-Beneken Kolmer, E.W.J. van; Schimana, W.; Burger, D.M.
BACKGROUND: We developed a simple and inexpensive thin-layer chromatography (TLC) assay for semiquantitative detection of saliva concentrations of nevirapine in resource-limited settings. The method was validated in an African target population. METHODS: Paired plasma and saliva nevirapine
Tuberculosis diagnosis in resource-limited settings: Clinical use of GeneXpert in the diagnosis of smear-negative PTB: a case report. ... studies are needed to provide evidence to policy makers in order to improve access to GeneXpert. Key words: Tuberculosis; developing countries; molecular diagnostic techniques.
Full Text Available This presentation describes how the present economic situation can be described in terms of the system dynamics models developed in the series of studies that were titled “The Limits to Growth”. The result of this examination is that mineral depletion may be a major factor in causing the slowdown in economic growth in several countries. The effect is not the result of “running out” of any resource, but of the gradual increase in extraction costs which is forcing the economy to dedicate larger and larger resources to the production of mineral commodities.
Siegel, S.M.; Siegel, B.Z.
The environmental consequences of natural processes in a volcanic-fumerolic region and of geothermal resource development are presented. These include acute ecological effects, toxic gas emissions during non-eruptive periods, the HGP-A geothermal well as a site-specific model, and the geothermal resources potential of Hawaii. (MHR)
It is advisable that medical schools have autonomy regarding the number of student-intake, student selection, curriculum ownership, resource allocation including for infrastructure and staff development. Health science and medical curricula should be integrated within and harmonized nationally. An educational evaluation ...
Craig, Nicola; Jones, Stuart E.; Weidel, Brian C.; Solomon, Christopher T.
Food web productivity in lakes can be limited by dissolved organic carbon (DOC), which reduces fish production by limiting the abundance of their zoobenthic prey. We demonstrate that in a set of 10 small, north temperate lakes spanning a wide DOC gradient, these negative effects of high DOC concentrations on zoobenthos production are driven primarily by availability of warm, well-oxygenated habitat, rather than by light limitation of benthic primary production as previously proposed. There was no significant effect of benthic primary production on zoobenthos production after controlling for oxygen, even though stable isotope analysis indicated that zoobenthos do use this resource. Mean whole-lake zoobenthos production was lower in high-DOC lakes with reduced availability of oxygenated habitat, as was fish biomass. These insights improve understanding of lake food webs and inform management in the face of spatial variability and ongoing temporal change in lake DOC concentrations.
Roberts, Drucilla J
The practice of perinatal pathology in much of the world suffers, as do all subspecialties of anatomic pathology, from inadequate resources (equipment, consumables, and both professional and technical personnel), from lack of education (not only of the pathologist but also of the clinicians responsible for sending the specimens, and the technicians processing the specimens), and from lack of appropriate government sector support. Perinatal pathology has significant public health-related utility and should be championing its service by providing maternal and fetal/infant mortality and morbidity data to governmental health ministries. It is with this pathologic data that informed decisions can be made on health-related courses of action and allocation of resources. These perinatal pathology data are needed to develop appropriate public health initiatives, specifically toward achieving the Millennium Developmental Goals as the best way to effectively decrease infant and maternal deaths and to determine causes of perinatal mortality and morbidity. The following overview will focus on the utility of perinatal pathology specifically as related to its public health function and will suggest methods to improve its service in resource-poor settings. This article is offered not as a critique of the current practice that most pathologists find themselves working in globally, but to provide suggestions for improving perinatal pathology services, which could be implemented with the limited available resources and manpower most pathology departments currently have. In addition, we offer suggestions for graded improvements ("ramping up") over time.
National Center for Systemic Improvement at WestEd, 2015
This document provides a list of recommended existing resources for state Part C and Part B 619 staff and technical assistance (TA) providers to utilize to support evaluation planning for program improvement efforts (including the State Systemic Improvement Plan, SSIP). There are many resources available related to evaluation and evaluation…
Howe, G.R.; Abbatt, J.D.
This study has determined the mortality experience of Eldorado Resources Limited employees between 1950 and 1980. This crown corporation is involved in the mining and processing of uranium products. An initial analysis shows significant excesses of lung cancer deaths at Port Raduim and Beaverlodge mines and a smaller, nonsignificant excess at the Port Hope refinery. The lung-cancer mortality has been analyzed as a function of radon-daughter exposure. This initial analysis is currently being refined to further develop estimates of excess risk
Conservation resources have become increasingly limited and, along with social, cultural and political complexities, this shortfall frequently challenges effectiveness in conservation. Because conservation can be costly, efforts are often only initiated after a species has declined below a critical threshold and/or when statutory protection is mandated. However, implementing conservation proactively, rather than reactively, is predicted to be less costly and to decrease a species' risk of extinction. Despite these benefits, I document that the number of studies that have implemented proactive conservation around the world are far fewer than those that simply acknowledge the need for such action. I provide examples of proactive actions that can ameliorate shortfalls in funding and other assets, thus helping conservation practitioners and managers cope with the constraints that resource limitation imposes. Not all of these options are new; however, the timing of their implementation is critical for effective conservation, and the need for more proactive conservation is increasingly recognized. These actions are (1) strengthening and diversifying stakeholder involvement in conservation projects; (2) complementing time-consuming and labor-intensive demographic studies with alternative approaches of detecting declines and estimating extinction risk; and (3) minimizing future costly conservation and management by proactively keeping common species common. These approaches may not constitute a cure-all for every conservation crisis. However, given escalating rates of species' losses, perhaps a reminder that these proactive actions can reduce conservation costs, save time, and potentially thwart population declines is warranted.
Heeter, Jenny; Bird, Lori
As of October 2012, 29 states, the District of Columbia, and Puerto Rico have instituted a renewable portfolio standard (RPS). Each state policy is unique, varying in percentage targets, timetables, and eligible resources. Increasingly, new RPS polices have included alternative resources. Alternative resources have included energy efficiency, thermal resources, and, to a lesser extent, non-renewables. This paper examines state experience with implementing renewable portfolio standards that include energy efficiency, thermal resources, and non-renewable energy and explores compliance experience, costs, and how states evaluate, measure, and verify energy efficiency and convert thermal energy. It aims to gain insights from the experience of states for possible federal clean energy policy as well as to share experience and lessons for state RPS implementation. - Highlights: • Increasingly, new RPS policies have included alternative resources. • Nearly all states provide a separate tier or cap on the quantity of eligible alternative resources. • Where allowed, non-renewables and energy efficiency are being heavily utilized
Anderson, R Eleanor; Ahn, Roy; Nelson, Brett D; Chavez, Jean; de Redon, Emily; Burke, Thomas
In resource-limited settings, severe shortages of anesthetists and anesthesiologists lead to surgical delays that increase maternal and neonatal mortality and morbidity. To more clearly understand the individual components of the anesthesia gap pertaining to reproductive health surgeries and procedures in resource-limited settings. Medline, the Cochrane Library, CINAHL, Embase, and POPLINE were systematically searched for reports published before December 31, 2013. Search terms were related to obstetric surgery, resource-limited settings, and anesthesia. Studies that addressed the use of anesthesia in reproductive procedures in resource-limited settings were included. Reviewers independently evaluated the full text of identified studies, extracted information related to study objectives and conclusions, and identified the anesthesia gap. Overall, 14 publications met the inclusion criteria. A significant lack of infrastructure, equipment and supplies, and trained personnel were identified as key factors responsible for a lack of anesthesia services. A shortage of trained anesthesia providers, equipment, supplies, medications, and infrastructure, along with limitations in transportation in resource-limited settings have produced a wide gap between available anesthesia services and the demand for them for reproductive health surgeries and procedures. Safe, affordable, and scalable solutions to address the anesthesia gap are urgently needed. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Yilmaz, Pelin; Hakan Hocaoglu, M.; Konukman, Alp Er S.
In recent years, economical and environmental constraints force governments and energy policy decision-makers to change the prominent characteristics of the electricity markets. Accordingly, depending on local conditions on the demand side, usage of integrated resource planning approaches in conjunction with renewable technologies has gained more importance. In this respect, an integrated resource planning option, which includes the design and optimization of grid-connected renewable energy plants, should be evaluated to facilitate a cost-effective and green solution to a sustainable future. In this paper, an integrated resource planning case is studied for an educational campus, located in Gebze, Turkey. It is found that for the considered campus, the integrated resource planning scenario that includes renewables as a supply-side option with existing time-of-use tariff may provide a cost-effective energy production, particularly for the high penetration level of the renewables. (author)
Children represent the most vulnerable members of our global society, a truth that is magnified when they are physically wounded. In much of the developed world, society has responded by offering protection in the form of law, injury prevention guidelines, and effective trauma systems to provide care for the injured child. Much of our world, though, remains afflicted by poverty and a lack of protective measures. As the globe becomes smaller by way of ease of travel and technology, surgeons are increasingly able to meet these children where they live and in doing so offer their hands and voices to care and protect these young ones. This article is intended as an overview of current issues in pediatric trauma care in the developing world as well as to offer some tips for the volunteer surgeon who may be involved in the care of the injured child in a setting of limited resource availability. Published by Elsevier Inc.
Seden, Kay; Khoo, Saye H; Back, David; Byakika-Kibwika, Pauline; Lamorde, Mohammed; Ryan, Mairin; Merry, Concepta
Scale-up of HIV treatment services may have contributed to an increase in functional health facilities available in resource-limited settings and an increase in patient use of facilities and retention in care. As more patients are reached with medicines, monitoring patient safety is increasingly important. Limited data from resource-limited settings suggest that medication error and antiretroviral drug-drug interactions may pose a significant risk to patient safety. Commonly cited causes of medication error in the developed world include the speed and complexity of the medication use cycle combined with inadequate systems and processes. In resource-limited settings, specific factors may contribute, such as inadequate human resources and high disease burden. Management of drug-drug interactions may be complicated by limited access to alternative medicines or laboratory monitoring. Improving patient safety by addressing the issue of antiretroviral drug-drug interactions has the potential not just to improve healthcare for individuals, but also to strengthen health systems and improve vital communication among healthcare providers and with regulatory agencies.
Ford, Nathan; Calmy, Alexandra
Access to first-line antiretroviral therapy in resource-limited settings has increased rapidly in the last 5 years. Newer medicines with greater potency and better safety profiles open the possibility for improving first-line antiretroviral therapy for developing countries. Several medicines offer the potential to improve the simplicity, safety and efficacy of first-line antiretroviral therapy in resource-limited settings. These include tenofovir, raltegravir, elvitegravir, rilpivirine and protease inhibitors. A number of clinical questions are outstanding, particularly regarding safety in pregnancy and compatibility with drugs to treat common coinfections including tuberculosis. Simple, affordable regimens were key to the initial emergency response, but the long-term response to HIV calls for a reconsideration of current treatment options. Preconditions for widespread use in developing countries include affordability, simplicity and answers to relevant research questions. In the absence of strong pharmacovigilance systems, cohort monitoring will be critical to assessing the safety profile of new drugs in such settings.
Barry, Karen M; Quentin, Audrey; Eyles, Alieta; Pinkard, Elizabeth A
Recovery following defoliation can be modified by co-occurring site resource limitations. The growth response of young Eucalyptus globulus saplings to two defoliation events was examined in an experimental plantation with combinations of low (-) or high (+) water (W) and nitrogen (N) resources. Artificial defoliation was applied at 3 and 9 months of age to remove ~40 and 55% of leaf area in the upper crown, respectively. At 18 months of age, height, stem diameter and leaf area were not significantly different between control and defoliated saplings, across all resource treatments. However, stem volume, bark volume and branch number were significantly increased in defoliated saplings, including a significant interaction with resource treatment. Total above-ground biomass of saplings in response to defoliation was significantly higher (almost double) than controls for the low water (N + W-) treatment only. Significantly increased foliar starch content (and a trend for increased soluble sugars) in the upper crown zone was found in the defoliated saplings of the N + W- treatment compared with the upper zone of control saplings. Foliar total non-structural carbohydrates were significantly correlated to stem biomass regardless of resource treatment or defoliation, and we suggest that foliar resources are most important for stem growth in E. globulus rather than stored carbon (C) from other tissues. After repeated defoliation and several months recovery, E. globulus saplings were generally not C limited in this study.
The incidence of breast cancer in sub-Saharan nations is increasing. There is a worsening scarcity of Human Resource for Health in Uganda in particular and Sub Saharan Africa in general. Resources available for health care are predominantly spent on infectious disease care such as (HIV/AIDS, Tuberculosis and ...
Yeh, Kenneth B; Adams, Martin; Stamper, Paul D; Dasgupta, Debanjana; Hewson, Roger; Buck, Charles D; Richards, Allen L; Hay, John
Strategic laboratory planning in limited resource areas is essential for addressing global health security issues. Establishing a national reference laboratory, especially one with BSL-3 or -4 biocontainment facilities, requires a heavy investment of resources, a multisectoral approach, and commitments from multiple stakeholders. We make the case for donor organizations and recipient partners to develop a comprehensive laboratory operations roadmap that addresses factors such as mission and roles, engaging national and political support, securing financial support, defining stakeholder involvement, fostering partnerships, and building trust. Successful development occurred with projects in African countries and in Azerbaijan, where strong leadership and a clear management framework have been key to success. A clearly identified and agreed management framework facilitate identifying the responsibility for developing laboratory capabilities and support services, including biosafety and biosecurity, quality assurance, equipment maintenance, supply chain establishment, staff certification and training, retention of human resources, and sustainable operating revenue. These capabilities and support services pose rate-limiting yet necessary challenges. Laboratory capabilities depend on mission and role, as determined by all stakeholders, and demonstrate the need for relevant metrics to monitor the success of the laboratory, including support for internal and external audits. Our analysis concludes that alternative frameworks for success exist for developing and implementing capabilities at regional and national levels in limited resource areas. Thus, achieving a balance for standardizing practices between local procedures and accepted international standards is a prerequisite for integrating new facilities into a country's existing public health infrastructure and into the overall international scientific community.
Fitzgibbon, Joseph E; Wallis, Carole L
There are many challenges to performing clinical research in resource-limited settings. Here, we discuss several of the most common laboratory issues that must be addressed. These include issues relating to organization and personnel, laboratory facilities and equipment, standard operating procedures, external quality assurance, shipping, laboratory capacity, and data management. Although much progress has been made, innovative ways of addressing some of these issues are still very much needed.
Xu, Melody J; Su, David; Deboer, Rebecca; Garcia, Michael; Tahir, Peggy; Anderson, Wendy; Kinderman, Anne; Braunstein, Steve; Sherertz, Tracy
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.
Heeter, J.; Bird, L.
Currently, 29 states, the District of Columbia, and Puerto Rico have instituted a renewable portfolio standard (RPS). An RPS sets a minimum threshold for how much renewable energy must be generated in a given year. Each state policy is unique, varying in percentage targets, timetables, and eligible resources. This paper examines state experience with implementing renewable portfolio standards that include energy efficiency, thermal resources, and non-renewable energy and explores compliance experience, costs, and how states evaluate, measure, and verify energy efficiency and convert thermal energy. It aims to gain insights from the experience of states for possible federal clean energy policy as well as to share experience and lessons for state RPS implementation.
Full Text Available Michael L Scanlon,1,2 Rachel C Vreeman1,21Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA; 2USAID, Academic Model Providing Access to Healthcare (AMPATH Partnership, Eldoret, KenyaAbstract: The rollout of antiretroviral therapy (ART significantly reduced human immunodeficiency virus (HIV-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world’s HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a
The present CD-ROM summarizes some activities carried out by the Departments of Nuclear Energy and Nuclear Safety and Security in the area of nuclear knowledge management in the period 2003-2005. It comprises, as open resource, most of the relevant documents in full text, including policy level documents, reports, presentation material by Member States and meeting summaries. The collection starts with a reprint of the report to the IAEA General Conference 2004 on Nuclear Knowledge [GOV/2004/56-GC(48)/12] summarizing the developments in nuclear knowledge management since the 47th session of the General Conference in 2003 and covers Managing Nuclear Knowledge including safety issues and Information and Strengthening Education and Training for Capacity Building. It contains an excerpt on Nuclear Knowledge from the General Conference Resolution [GC(48)/RES/13] on Strengthening the Agency's Activities Related to Nuclear Science, Technology and Applications. On the CD-ROM itself, all documents can easily be accessed by clicking on their titles on the subject pages (also printed at the end of this Working Material). Part 1 of the CD-ROM covers the activities in the period 2003-2005 and part 2 presents a resource material full text CD-ROM on Managing Nuclear Knowledge issued in October 2003
CENUSER-PANCZEL ANDREEA; MUSCALU EMANOIL
Due to its size, and to the number of activities it encompasses, the public sector has an essential place in the continued working of the state system. This article treats the aspects and particularities of human in Romanian public administration, as well as the obstacles that come from the internal or external medium the management of that level faces. The duties that the public administration must deal with are diverse and need to have the management of human resources oriented ...
McHenry, Megan S; Fischer, Lydia J; Chun, Yeona; Vreeman, Rachel C
The objective of this study is to conduct a systematic review of the literature of how portable electronic technologies with offline functionality are perceived and used to provide health education in resource-limited settings. Three reviewers evaluated articles and performed a bibliography search to identify studies describing health education delivered by portable electronic device with offline functionality in low- or middle-income countries. Data extracted included: study population; study design and type of analysis; type of technology used; method of use; setting of technology use; impact on caregivers, patients, or overall health outcomes; and reported limitations. Searches yielded 5514 unique titles. Out of 75 critically reviewed full-text articles, 10 met inclusion criteria. Study locations included Botswana, Peru, Kenya, Thailand, Nigeria, India, Ghana, and Tanzania. Topics addressed included: development of healthcare worker training modules, clinical decision support tools, patient education tools, perceptions and usability of portable electronic technology, and comparisons of technologies and/or mobile applications. Studies primarily looked at the assessment of developed educational modules on trainee health knowledge, perceptions and usability of technology, and comparisons of technologies. Overall, studies reported positive results for portable electronic device-based health education, frequently reporting increased provider/patient knowledge, improved patient outcomes in both quality of care and management, increased provider comfort level with technology, and an environment characterized by increased levels of technology-based, informal learning situations. Negative assessments included high investment costs, lack of technical support, and fear of device theft. While the research is limited, portable electronic educational resources present promising avenues to increase access to effective health education in resource-limited settings, contingent
Teck Resources is Canada’s largest diversified mining company with operations in North and South America and exploration projects worldwide. Teck’s overall leadership is currently comprised of 19.2% women; broken down into management (21.8%), senior management (10%) and executive roles (4.5%). Females make up 14.3% of Teck’s Board of Directors. This project evaluates the challenges and opportunities Teck will face in order to increase female leadership. The assessment identified that with a c...
Full Text Available Abstract Background Efforts to increase access to life-saving treatment, including antiretroviral therapy (ART, for people living with HIV/AIDS in resource-limited settings has been the growing focus of international efforts. One of the greatest challenges to scaling up will be the limited supply of adequately trained human resources for health, including doctors, nurses, pharmacists and other skilled providers. As national treatment programmes are planned, better estimates of human resource needs and improved approaches to assessing the impact of different staffing models are critically needed. However there have been few systematic assessments of staffing patterns in existing programmes or of the estimates being used in planning larger programmes. Methods We reviewed the published literature and selected plans and scaling-up proposals, interviewed experts and collected data on staffing patterns at existing treatment sites through a structured survey and site visits. Results We found a wide range of staffing patterns and patient-provider ratios in existing and planned treatment programmes. Many factors influenced health workforce needs, including task assignments, delivery models, other staff responsibilities and programme size. Overall, the number of health care workers required to provide ART to 1000 patients included 1–2 physicians, 2–7 nurses, Discussion These data are consistent with other estimates of human resource requirements for antiretroviral therapy, but highlight the considerable variability of current staffing models and the importance of a broad range of factors in determining personnel needs. Few outcome or cost data are currently available to assess the effectiveness and efficiency of different staffing models, and it will be important to develop improved methods for gathering this information as treatment programmes are scaled up.
Background: Current lifetime antiretroviral regimes are associated with clinically important toxicities, and have several limitations (eg. cost, development of resistance, complications). There is need for an alternative regime that must be acceptable, easy to administer and permanent for the eradication of HIV/AIDS.
Case, Patty; Cluskey, Mary; Hino, Jeff
Delivering nutrition education using the Internet could allow educators to reach larger audiences at lower cost. Low-income adults living in a rural community participated in focus groups to examine their interest in, experience with, and motivators to accessing nutrition education online. This audience described limited motivation in seeking…
Full Text Available Animals are primarily limited by their capacity to acquire food, yet digestive performance also conditions energy acquisition, and ultimately fitness. Optimal foraging theory predicts that organisms feeding on patchy resources should maximize their food loads within each patch, and should digest these loads quickly to minimize travelling costs between food patches. We tested the prediction of high digestive performance in wandering albatrosses, which can ingest prey of up to 3 kg, and feed on highly dispersed food resources across the southern ocean. GPS-tracking of 40 wandering albatrosses from the Crozet archipelago during the incubation phase confirmed foraging movements of between 475-4705 km, which give birds access to a variety of prey, including fishery wastes. Moreover, using miniaturized, autonomous data recorders placed in the stomach of three birds, we performed the first-ever measurements of gastric pH and temperature in procellariformes. These revealed surprisingly low pH levels (average 1.50±0.13, markedly lower than in other seabirds, and comparable to those of vultures feeding on carrion. Such low stomach pH gives wandering albatrosses a strategic advantage since it allows them a rapid chemical breakdown of ingested food and therefore a rapid digestion. This is useful for feeding on patchy, natural prey, but also on fishery wastes, which might be an important additional food resource for wandering albatrosses.
Kreps, Gary L; Sivaram, Rama
Strategic health communication is a critical component of healthcare that should be implemented across the continuum of care. Recognizing the importance of communication strategies and incorporating such strategies into healthcare policies, programs, and interventions is essential to the effective delivery of breast cancer care. The authors reviewed relevant literature and suggested practical evidence-based strategies for effective communication interventions across the continuum of care for breast cancer patients, including early detection, diagnosis, treatment, survivorship, palliative care, and end-of-life care. Examples were provided from limited-resource nations to support health communication recommendations. (c) 2008 American Cancer Society.
José Eduardo Venson
Full Text Available Abstract Introduction A medical application running outside the workstation environment has to deal with several constraints, such as reduced available memory and low network bandwidth. The aim of this paper is to present an approach to optimize the data flow for fast image transfer and visualization on mobile devices and remote stationary devices. Methods We use a combination of client- and server-side procedures to reduce the amount of information transferred by the application. Our approach was implemented on top of a commercial PACS and evaluated through user experiments with specialists in typical diagnosis tasks. The quality of the system outcome was measured in relation to the accumulated amount of network data transference and the amount of memory used in the host device. Besides, the system's quality of use (usability was measured through participants’ feedback. Results Contrarily to previous approaches, ours keeps the application within the memory constraints, minimizing data transferring whenever possible, allowing the application to run on a variety of devices. Moreover, it does that without sacrificing the user experience. Experimental data point that over 90% of the users did not notice any delays or degraded image quality, and when they did, they did not impact on the clinical decisions. Conclusion The combined activities and orchestration of our methods allow the image viewer to run on resource-constrained environments, such as those with low network bandwidth or little available memory. These results demonstrate the ability to explore the use of mobile devices as a support tool in the medical workflow.
Environmental control methods include natural ventilation, mechanical ventilation as well as upper-room ultraviolet light. The aim of environmental control method is to reduce the concentration of infectious respiratory aerosols (droplet nuclei) in the air, and to control the direction of infectious air. The purpose of this study ...
Basnet, Sangita; Adhikari, Neelam; Koirala, Janak
In collaboration with a host country and international medical volunteers, a PICU and an NICU were conceptualized and realized in the developing country of Nepal. We present here the challenges that were encountered during and after the establishment of these units. The decision to develop an ICU with reasonable goals in a developing country has to be made with careful assessments of need of that patient population and ethical principles guiding appropriate use of limited resources. Considerations during unit design include space allocation, limited supply of electricity, oxygen source, and clean-water availability. Budgetary challenges might place overall sustainability at stake, which can also lead to attrition of trained manpower and affect the quality of care. Those working in the PICU in resource-poor nations perpetually face the challenges of lack of expert support (subspecialists), diagnostic facilities (laboratory and radiology), and appropriate medications and equipment. Increasing transfer of severely ill patients from other health facilities can lead to space constraints, and lack of appropriate transportation for these critically ill patients increases the severity of illness, which leads to increased mortality rates. The staff in these units must make difficult decisions on effective triage of admissions to the units on the basis of individual cases, futility of care, availability of resources, and financial ability of the family.
Cowan, Nelson; Rouder, Jeffrey N
Bays and Husain (Reports, 8 August 2008, p. 851) reported that human working memory, the limited information currently in mind, reflects resources distributed across all items in an array. In an alternative interpretation, memory is limited to several well-represented items. We argue that this item-limit model fits the extant data better than the distributed-resources model and is more interpretable theoretically.
Cowan, Nelson; Rouder, Jeffrey N.
Bays and Husain (Reports, 8 August 2008, p. 851) reported that human working memory, the limited information currently in mind, reflects resources distributed across all items in an array. In an alternative interpretation, memory is limited to several well-represented items. We argue that this item-limit model fits the extant data better than the distributed-resources model and is more interpretable theoretically. PMID:19213899
Schijven, Jack; Derx, Julia; de Roda Husman, Ana Maria; Blaschke, Alfred Paul; Farnleitner, Andreas H
Given the complex hydrologic dynamics of water catchments and conflicts between nature protection and public water supply, models may help to understand catchment dynamics and evaluate contamination scenarios and may support best environmental practices and water safety management. A catchment model can be an educative tool for investigating water quality and for communication between parties with different interests in the catchment. This article introduces an interactive computational tool, QMRAcatch, that was developed to simulate concentrations in water resources of , a human-associated microbial source tracking (MST) marker, enterovirus, norovirus, , and as target microorganisms and viruses (TMVs). The model domain encompasses a main river with wastewater discharges and a floodplain with a floodplain river. Diffuse agricultural sources of TMVs that discharge into the main river are not included in this stage of development. The floodplain river is fed by the main river and may flood the plain. Discharged TMVs in the river are subject to dilution and temperature-dependent degradation. River travel times are calculated using the Manning-Gauckler-Strickler formula. Fecal deposits from wildlife, birds, and visitors in the floodplain are resuspended in flood water, runoff to the floodplain river, or infiltrate groundwater. Fecal indicator and MST marker data facilitate calibration. Infection risks from exposure to the pathogenic TMVs by swimming or drinking water consumption are calculated, and the required pathogen removal by treatment to meet a health-based quality target can be determined. Applicability of QMRAcatch is demonstrated by calibrating the tool for a study site at the River Danube near Vienna, Austria, using field TMV data, including a sensitivity analysis and evaluation of the model outcomes. Copyright © by the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America, Inc.
... accounts, CDs, stocks, bonds, or other similar assets. Equity in real estate holdings and other fixed... personal resources of any owner of 20 percent or more of the equity of the applicant. SBA will require the...
In the present paper a fourth/fifth order upwind biased limiting strategy is presented for the simulation of turbulent flows and combustion. Because high order numerical schemes usually suffer from stability problems and TVD approaches often prevent convergence to machine accuracy the multi-dimensional limiting process (MLP)  is employed. MLP uses information from diagonal volumes of a discretization stencil. It interacts with the TVD limiter in such a way, that local extrema at the corner points of the volume are avoided. This stabilizes the numerical scheme and enables convergence in cases, where standard limiters fail to converge. Up to now MLP has been used for inviscid and laminar flows only. In the present paper this technique is applied to fully turbulent sub- and supersonic flows simulated with a low Reynolds-number turbulence closure. Additionally, combustion based on finite-rate chemistry is investigated. An improved MLP version (MLP ld, low diffusion) as well as an analysis of its capabilities and limitations are given. It is demonstrated, that the scheme offers high accuracy and robustness while keeping the computational cost low. Both steady and unsteady test cases are investigated.
... DEPARTMENT OF ENERGY Federal Energy Regulatory Commission [Docket No. ER13-1896-000] AEP Generation Resources Inc.; Supplemental Notice That Initial Market-Based Rate Filing Includes Request for... Generation Resources Inc.'s application for market-based rate authority, with an accompanying rate schedule...
... DEPARTMENT OF ENERGY Federal Energy Regulatory Commission [Docket No. ER10-726-000] DPL Energy Resources, Inc.; Supplemental Notice That Initial Market-Based Rate Filing Includes Request For Blanket... proceeding of DPL Energy Resources, Inc.'s application for market-based rate authority, with an accompanying...
Full Text Available Abstract Background There is agreement that the infectivity assay with the duck hepatitis B virus (DHBV is a suitable surrogate test to validate disinfectants for hepatitis B virucidal activity. However, since this test is not widely used, information is necessary whether disinfectants with limited virucidal activity also inactivate DHBV. In general, disinfectants with limited virucidal activity are used for skin and sensitive surfaces while agents with full activity are more aggressive. The present study compares the activity of five different biocides against DHBV and the classical test virus for limited virucidal activity, the vaccinia virus strain Lister Elstree (VACV or the modified vaccinia Ankara strain (MVA. Methods Virucidal assay was performed as suspension test according to the German DVV/RKI guideline. Duck hepatitis B virus obtained from congenitally infected Peking ducks was propagated in primary duck embryonic hepatocytes and was detected by indirect immunofluorescent antigen staining. Results The DHBV was inactivated by the use of 40% ethanol within 1-min and 30% isopropanol within 2-min exposure. In comparison, 40% ethanol within 2-min and 40% isopropanol within 1-min exposure were effective against VACV/MVA. These alcohols only have limited virucidal activity, while the following agents have full activity. 0.01% peracetic acid inactivated DHBV within 2 min and a concentration of 0.005% had virucidal efficacy against VACV/MVA within 1 min. After 2-min exposure, 0.05% glutardialdehyde showed a comparable activity against DHBV and VACV/MVA. This is also the case for 0.7% formaldehyde after a contact time of 30 min. Conclusions Duck hepatitis B virus is at least as sensitive to limited virucidal activity as VACV/MVA. Peracetic acid is less effective against DHBV, while the alcohols are less effective against VACV/MVA. It can be expected that in absence of more direct tests the results may be extrapolated to HBV.
Shelomentsev, A. G.; Medvedev, M. A.; Berg, D. B.; Lapshina, S. N.; Taubayev, A. A.; Davletbaev, R. H.; Savina, D. V.
Present study is devoted to the development of competition life cycle mathematical model in the closed business community with limited resources. Growth of each agent is determined by the balance of input and output resource flows: input (cash) flow W is covering the variable V and constant C costs and growth dA/dt of the agent's assets A. Value of V is proportional to assets A that allows us to write down a first order non-stationary differential equation of the agent growth. Model includes the number of such equations due to the number of agents. The amount of resources that is available for agents vary in time. The balances of their input and output flows are changing correspondingly to the different stages of the competition life cycle. According to the theory of systems, the most complete description of any object or process is the model of its life cycle. Such a model describes all stages of its development: from the appearance ("birth") through development ("growth") to extinction ("death"). The model of the evolution of an individual firm, not contradicting the economic meaning of events actually observed in the market, is the desired result from modern AVMs for applied use. With a correct description of the market, rules for participants' actions, restrictions, forecasts can be obtained, which modern mathematics and the economy can not give.
Kim, Jung Hwan; Yim, Man-Sung [KAIST, Daejeon (Korea, Republic of)
To meet the required standards the site owner has to show that the soil at the facility has been sufficiently cleaned up. To do this one must know the contamination of the soil at the site prior to clean up. This involves sampling that soil to identify the degree of contamination. However there is a technical difficulty in determining how much decontamination should be done. The problem arises when measured samples are below the detection limit. Regulatory guidelines for site reuse after decommissioning are commonly challenged because the majority of the activity in the soil at or below the limit of detection. Using additional statistical analyses of contaminated soil after decommissioning is expected to have the following advantages: a better and more reliable probabilistic exposure assessment, better economics (lower project costs) and improved communication with the public. This research will develop an approach that defines an acceptable method for demonstrating compliance of decommissioned NPP sites and validates that compliance. Soil samples from NPP often contain censored data. Conventional methods for dealing with censored data sets are statistically biased and limited in their usefulness. In this research, additional methods are performed using real data from a monazite manufacturing factory.
Soares, Joao; Morais, Hugo; Sousa, Tiago
the intensive use of distributed generation and V2G. The main focus is the comparison of different EV management approaches in the day-ahead energy resources management, namely uncontrolled charging, smart charging, V2G and Demand Response (DR) programs in the V2G approach. Three different DR programs...
Goga, Ameena Ebrahim; Singh, Yagespari; Singh, Michelle; Noveve, Nobuntu; Magasana, Vuyolwethu; Ramraj, Trisha; Abdullah, Fareed; Coovadia, Ashraf H.; Bhardwaj, Sanjana; Sherman, Gayle G.
Introduction Increasing access to HIV-related care and treatment for children aged 0?18?years in resource-limited settings is an urgent global priority. In 2011?2012 the percentage increase in children accessing antiretroviral therapy was approximately half that of adults (11 vs. 21?%). We propose a model for increasing access to, and retention in, paediatric HIV care and treatment in resource-limited settings. Methods Following a rapid appraisal of recent literature seven main challenges in ...
Scalf, Paige E.; Torralbo, Ana; Tapia, Evelina; Beck, Diane M.
Both perceptual load theory and dilution theory purport to explain when and why task-irrelevant information, or so-called distractors are processed. Central to both explanations is the notion of limited resources, although the theories differ in the precise way in which those limitations affect distractor processing. We have recently proposed a neurally plausible explanation of limited resources in which neural competition among stimuli hinders their representation in the brain. This view of limited capacity can also explain distractor processing, whereby the competitive interactions and bias imposed to resolve the competition determine the extent to which a distractor is processed. This idea is compatible with aspects of both perceptual load and dilution models of distractor processing, but also serves to highlight their differences. Here we review the evidence in favor of a biased competition view of limited resources and relate these ideas to both classic perceptual load theory and dilution theory. PMID:23717289
... Colon cancer - resources Cystic fibrosis - resources Depression - resources Diabetes - resources Digestive disease - resources Drug abuse - resources Eating disorders - resources Elder care - resources Epilepsy - resources Family ...
Adly, Amira A M; Ebeid, Fatma Soliman El Sayed
Cultural beliefs of Egyptians with respect to the origin of thalassemia and its prevention, as well as national resources available for care, often differ from those of Western countries. To assess the impact of cultural attitudes and the effect of limited medical and financial resources that could affect the management of Egyptian thalassemic patients. A cross sectional study included 205 Egyptians β-thalassemia major (β-TM) patients, with a mean age of 149±87.90 months and a male to female ratio of 94:111. Demographic data stressing on order of birth, consanguineous marriage, and family history of β-TM, transfusion, and chelation therapy, were reported. HCV-Ab, HBV-Ag, and complete blood count were recorded with calculation of mean pretransfusional hemoglobin. The age distribution was relatively nonhomogenous, with 39% of patients between 10 and 20 years of age and 16% were younger than 5. There were high family birth rates and 35% of patients were third or more in order of birth and a marked cultural preference for consanguineous marriage, representing 61% of all the parents' marriages, as well as a high rate (59.5%) of a positive family history of β-TM. Patients transfused on low pretransfusion hemoglobin levels around 8 g/dL, and those receiving blood transfusion before the establishment of National Blood Transfusion Services showed a statistically significant higher rate of positive hepatitis B and C viral infections. Chelation therapy tended to start at late age, mean age was around 4 years. Before 2000, subcutaneous deferoxamine was the most widely used chelation, and since then a considerable number of patients (50%) had started to use oral iron chelators. The strong cultural preferences for consanguineous marriage and limited preventive programmes and resources have had a negative impact on the management of Egyptians thalassemic patients.
Henry, Jaymie A; Groen, Reinou S; Price, Raymond R; Nwomeh, Benedict C; Kingham, T Peter; Hardy, Mark A; Kushner, Adam L
U.S. surgery residents increasingly are interested in international experiences. Recently, the Residency Review Committee approved international surgery rotations for credit toward graduation. Despite this growing interest, few U.S. surgery residency programs offer formal international rotations. We aimed to present the benefits of international surgery rotations and how these rotations contribute to the attainment of the 6 Accreditation Council for Graduate Medical Education (ACGME) competencies. An e-mail-based survey was sent in November 2011 to the 188 members of Surgeons OverSeas, a group of surgeons, residents, fellows, and medical students with experience working in resource-limited settings. They were asked to list 5 benefits of international rotations for surgery residents. The frequency of benefits was qualitatively grouped into 4 major categories: educational, personal, benefits to the foreign institution/Global Surgery, and benefits to the home institution. The themes were correlated with the 6 ACGME competencies. The 58 respondents (31% response rate) provided a total of 295 responses. Fifty themes were identified. Top benefits included learning to optimally function with limited resources, exposure to a wide variety of operative pathology, exposure to a foreign culture, and forming relationships with local counterparts. All ACGME competencies were covered by the themes. International surgery rotations to locations in which resources are constrained, operative diseases vary, and patient diversity abound provide unique opportunities for surgery residents to attain the 6 ACGME competencies. General surgery residency programs should be encouraged to establish formal international rotations as part of surgery training to promote resident education and assist with necessary oversight. Copyright © 2013 Mosby, Inc. All rights reserved.
Okpechi, Ikechi G; Bello, Aminu K; Ameh, Oluwatoyin I; Swanepoel, Charles R
The prevalence of noncommunicable diseases, including chronic kidney disease (CKD), continues to increase worldwide, and mortality from noncommunicable diseases is projected to surpass communicable disease-related mortality in developing countries. Although the treatment of CKD is expensive, unaffordable, and unavailable in many developing countries, the current structure of the health care system in such countries is not set up to deliver comprehensive care for patients with chronic conditions, including CKD. The World Health Organization Innovative Care for Chronic Conditions framework could be leveraged to improve the care of CKD patients worldwide, especially in resource-limited countries where high cost, low infrastructure, limited workforce, and a dearth of effective health policies exist. Some developing countries already are using established health systems for communicable disease control to tackle noncommunicable diseases such as hypertension and diabetes, therefore existing systems could be leveraged to integrate CKD care. Decision makers in developing countries must realize that to improve outcomes for patients with CKD, important factors should be considered, including enhancing CKD prevention programs in their communities, managing the political environment through involvement of the political class, involving patients and their families in CKD care delivery, and effective use of health care personnel. Copyright © 2017 Elsevier Inc. All rights reserved.
Asea M. Timuş
Full Text Available This paper presents the analysis of insect species in Moldova with a rarity status: vulnerable, critically endangered and endangered, officially included in the "Red Book of the Republic of Moldova", in two editions: 37 species in the 2nd edition (2001 and 80 species in the 3rd edition (2015. The 80 insects of the 3rd edition of the "Red Book of the Republic of Moldova" belong to 8 orders (Odonatoptera, Mantodea, Orthoptera, Coleoptera, Neuroptera, Lepidoptera, Hymenoptera, Diptera. These species are classified according to the rarity status: vulnerable (VU – 33 species, critically endangered (CR – 39 species and endangered (EN – 8 species. The third edition also contains 35 species not included in the previous editions, which for the first time obtained a rarity status: VU – 16 species, CR – 17 and EN – 2 (2 species of the order Odonatoptera, 1 of Mantodea, 1 of Orthoptera, 10 of Coleoptera, 18 of Lepidoptera, and 3 of Hymenoptera.
Background: Bacterial meningitis is a significant cause of morbidity and mortality in the developing world. However, limited research has focused on the diagnosis and management of meningitis in resource-limited settings. Methods: We designed a prospective case series of children admitted to a large, academic referral ...
Ali, Mohd Anuar Md; Yeop Majlis, Burhanuddin; Kayani, Aminuddin Ahmad
Various dielectrophoretic responses of bioparticles, including cell-chain, spinning, rotation and clustering, are of high interest in the field due to their benefit into application for biomedical and clinical implementation potential. Numerous attempts using sophisticated equipment setup have been studied to perform those dielectrophoretic responses, however, for development into resource limited environment application, such as portable, sustainable and environmental friendly diagnostic tools, establishment of pragmatic setup using standard, non-sophisticated and low-cost equipment is of important task. Here we show the advantages in the judicious design optimization of tip microelectrode, also with selection of suspending medium and optimization of electric signal configuration in establishing setup that can promote the aforementioned dielectrophoretic responses within standard equipments, i.e. pragmatic setup.
Mitchell Katrina B
Full Text Available Abstract Introduction Though animal-related injuries and fatalities have been documented throughout the world, the variety of attacks by wild animals native to rural East Africa are less commonly described. Given the proximity of our northwestern Tanzania hospital to Lake Victoria, Lake Tanganyika, and the Serengeti National Park, and presentation of several patients attacked by bush animals and suffering a variety of complex injuries, we sought to report the pattern of attacks and surgical management in a resource-limited setting. Materials and methods Four patients who were admitted to the northwestern Tanzania tertiary referral hospital, Bugando Medical Centre (BMC, in 2010-2011 suffered attacks by different bush animals: hyena, elephant, crocodile, and vervet monkey. These patients were triaged as trauma patients in the Casualty Ward, then admitted for inpatient monitoring and treatment. Their outcomes were followed to discharge. Results The age and gender of the patients attacked was variable, though all but the pediatric patient were participating in food gathering or guarding activities in rural locations at the time of the attacks. All patients required surgical management of their injuries, which included debridement and closure of wounds, chest tube insertion, amputation, and external fixation of an extremity fracture. All patients survived and were discharged home. Discussion Though human injuries secondary to encounters with undomesticated animals such as cows, moose, and camel are reported, they often are indirect traumas resulting from road traffic collisions. Snake attacks are well documented and common. However, this series of unique bush animal attacks describes the initial and surgical management of human injuries in the resource-limited setting of the developing world. Conclusion Animal attacks are common throughout the world, but their pattern may vary in Africa throughout jungle and bush environmental settings. It is
Full Text Available INTRODUCTION: Consequences of lack of viral monitoring in predicting the effects of development of HIV drug resistance mutations during HAART in resource-limited settings (RLS is still a matter of debate. DESIGN: To assess, among HIV+ patients receiving their first-line HAART, prevalence of virological failure and genotypic resistance mutations pattern in a Médécins Sans Frontières/Ministry of Health programme in Busia District (Kenya. METHODS: Patients with HAART treatment for ≥12 months were eligible for the study and those with HIV-RNA ≥5000 copies/ml underwent genotypic study. Total HIV-1 RNA from Dried Blood Spots was extracted using Nuclisens method. RESULTS: 926 patients were included. Among 274 (29.6% patients with detectable viral load, 55 (5.9% experienced treatment failure (viral load >5.000 copies/ml; 61.8% were female and 10 (18.2% had clinical failure. Median CD4 cell count was 116 cell/mm3 (IQR: 54-189. Median HIV-RNA was 32,000 copies/ml (IQR: 11000-68000. Eighteen out of 55 (33% samples could be sequenced on PR and RT genes, with resistance associated mutations (RAMs in 15 out of 18 samples (83%. Among patients carrying RAMs, 12/15 (81% harboured RAMs associated to thymidine analogues (TAMs. All of them (100% showed M184V resistance associated mutation to lamivudine as well as NNRTI's RAMS. CONCLUSIONS: Virological failure rate in resource-limited settings are similar to those observed in developed countries. Resistance mutation patterns were concordant with HAART received by failing patients. Long term detectable viral load confers greater probability of developing resistance and as a consequence, making difficult to find out a cost-effective subsequent treatment regimen.
The uranium reserves exploitable at a cost below 15 dollars/lb U 3 O 8 , are 210,000 tonnes. While present uranium production capacities amount to 26,000 tonnes uranium per year, plans have been announced which would increase this capacity to 44,000 tonnes by 1978. Given an appropriate economic climate, annual capacities of 60,000 tonnes and 87,000 tonnes could be attained by 1980 and 1985, respectively, based on presently known reserves. However, in order to maintain or increase such a capacity beyond 1985, substantial additional resources would have to be identified. Present annual demand for natural uranium amounts to 18,000 tonnes and is expected to establish itself at 50,000 tonnes by 1980 and double this figure by 1985. Influences to increase this demand in the medium term could come from shortages in other fuel cycle capacities, i.e. enrichment (higher tails assays) and reprocessing (no uranium and plutonium recycle). However, the analysis of the near term uranium supply and demand situation does not necessarily indicate a prolongation of the current tight uranium market. Concerning the longer term, the experts believe that the steep increase in uranium demand foreseen in the eighties, according to present reactor programmes, with doubling times of the order of 6 to 7 years, will pose formidable problems for the uranium industry. For example, in order to provide reserves sufficient to support the required production rates, annual additions to reserves must almost triple within the next 15 years. Efforts to expand world-wide exploration levels to meet this challenge would be facilitated if a co-ordinated approach were adopted by the nuclear industry as a whole
The proposed action is the issuance of a Source Material License to Plateau Resources, Ltd., for the construction and operation of the proposed Shootering Canyon Uranium Project with a product (U 3 O 8 ) production limited to 2.2 x 10 5 kg (4.9 x 10 5 lb) per year. Impacts to the area from the operation of the Shootering Canyon Uranium Project will include the following: alterations of up to 140 ha (350 acres) that will be occupied by the mill, mill facilities, borrow areas, tailings areas, and roads; an increase in the existing background radiation levels of the mill area as a result of continuous but small releases of uranium, radium, radon, and other, radioactive materials during construction and operation; socioeconomic effects on the local area, particularly the proposed community of Ticaboo, where the majority of workers will be housed during project construction and operation; and production of solid waste material (tailings) from the mill at a rate of about 680 MT (750 tons) per day and deposition as a slurry in an onsite impoundment area; construction and operation of the Shootering Canyon mill will provide employment and induced economic benefits for the region but may also result in some socioeconomic stress. On the basis of the analysis and evaluation set forth in this Environmental Statement, it is proposed that any license issued for the Shootering Canyon mill should be subject to certain conditions for the protection of the environment. A list is included. Nine appendices are also included
Full Text Available Abstract Background Recent evidence from developed and developing countries shows clear clinical and public health benefit to starting antiretroviral therapy (ART earlier. While discussions about when to start ART have often focused on the clinical risks and benefits, the main issue is one of fair limit-setting. We applied a human rights framework to assess a policy of early treatment initiation according to the following criteria: public-health purpose; likely effectiveness; specificity; human rights burdens and benefits; potential for less restrictive approaches; and fair administration. Discussion According to our analysis, a policy of earlier ART initiation would better serve both public health and human rights objectives. We highlight a number of policy approaches that could be taken to help meet this aim, including increased international financial support, alternative models of care, and policies to secure the most affordable sources of appropriate antiretroviral drugs. Summary Widespread implementation of earlier ART initiation is challenging in resource-limited settings. Nevertheless, rationing of essential medicines is a restriction of human rights, and the principle of least restriction serves to focus attention on alternative measures such as adapting health service models to increase capacity, decreasing costs, and seeking additional international funding. Progressive realisation using well-defined steps will be necessary to allow for a phased implementation as part of a framework of short-term targets towards nationwide policy adoption, and will require international technical and financial support.
Bezuidenhout, A Fourie; Hurter, Delme; Maydell, Arthur T; van Niekerk, Francois; de Figueiredo, Sonia A B; Harvey, Justin; Vlok, Adriaan J; Pitcher, Richard D
The indications for urgent computed tomography of the brain (CTB) in the acute setting are controversial. While guidelines have been proposed for CTB in well-resourced countries, these are not always appropriate for resource-limited environments. Furthermore, no unifying guideline exists for trauma-related and non-trauma-related acute intracranial pathology. Adoption by resource-limited countries of more conservative scanning protocols, with outcomes comparable to well-resourced countries, would have significant benefit. A multidisciplinary team from Kimberley Hospital in the Northern Cape Province of South Africa adopted the principles defined in the National Institute for Health and Care Excellence (NICE) guideline for the early management of head injury and drafted the Kimberley Hospital Rule (KHR), a proposed unifying guideline for the imaging of acute intracranial pathology in a resource-limited environment. To evaluate the sensitivity and specificity of the KHR. A prospective cohort study was conducted in the Northern Cape Province between 1 May 2010 and 30 April 2011. All patients older than 16 years presenting to emergency departments with acute intracranial symptoms were triaged according to the KHR into three groups, as follows: group 1 - immediate scan (within 1 hour); group 2 - urgent scan (within 8 hours); and group 3 - no scan required. Patients in groups 1 and 2 were studied. The primary outcome was CTB findings of clinically significant intracranial pathology requiring acute change in management. Seven hundred and three patients were included. The KHR achieved 90.3% sensitivity and 45.5% specificity, while reducing the number of immediate CTBs by 36.0%. The KHR is an accurate, unifying clinical guideline that appears to optimise the utilisation of CTB in a resource-limited environment.
Full Text Available Allowing resource users to communicate in behavioural experiments on commons dilemmas increases the level of cooperation. In actual common pool resource dilemmas in the real world, communication is costly, which is an important detail missing from most typical experiments. We conducted experiments where participants must give up harvesting opportunities to communicate. The constrained communication treatment is compared with the effect of limited information about the state of the resource and the actions of the other participants. We find that despite making communication costly, performance of groups improves in all treatments with communication. We also find that constraining communication has a more significant effect than limiting information on the performance of groups.
Meintjes, Graeme; Lawn, Stephen D.; Scano, Fabio; Maartens, Gary; French, Martyn A.; Worodria, William; Elliott, Julian H.; Murdoch, David; Wilkinson, Robert J.; Seyler, Catherine; John, Laurence; van der Loeff, Maarten Schim; Reiss, Peter; Lynen, Lut; Janoff, Edward N.; Gilks, Charles; Colebunders, Robert
The immune reconstitution inflammatory syndrome (IRIS) has emerged as an important early complication of antiretroviral therapy (ART) in resource-limited settings, especially in patients with tuberculosis. However, there are no consensus case definitions for IRIS or tuberculosis-associated IRIS.
Vacuum-assisted closure of the open abdomen in a resource-limited setting. ... Massive delays in presentation of patients with acute abdomen are common. Closure at initial laparotomy is not possible in many cases ... with an open abdomen. The management of these patients is particularly labour intensive for nursing staff.
Susan L. Eggert; J. Bruce Wallace
Leaf inputs in temperate forest streams may limit caddisfly production because leaf detritus serves both as a food and case-material resource. We estimated Pycnopsyche gentilis produdion in a stream experimentally decoupled fmm its riparian habitat and a reference stream for 8 y in the southern Appalachians. We also examined laboratory survivorship,...
Devetter, Miloslav; Seďa, Jaromír
Roč. 546, č. 1 (2005), s. 509-518 ISSN 0018-8158 Institutional research plan: CEZ:AV0Z60660521 Keywords : resource limitation * rotifers * birth rate Subject RIV: EH - Ecology, Behaviour Impact factor: 0.978, year: 2005
Sarkar, Nurul I.
Motivating students to learn Wi-Fi (wireless fidelity) wireless networking to undergraduate students is often difficult because many students find the subject rather technical and abstract when presented in traditional lecture format. This paper focuses on the teaching and learning aspects of Wi-Fi networking using limited hardware resources. It…
Davis Kendrick, Kaetrena
Through the use of case studies, research, and practical interviews, The Small or Rural Academic Library: Leveraging Resources and Overcoming Limitations explores how academic librarians in such environments can keep pace with, create, and improve modern library practices and services, network with colleagues, and access continuing education and professional development opportunities.
Francis, Sarah L.; Martin, Peggy; Taylor, Kristin
Spend Smart Eat Smart (SSES), a unique website combining nutrition and food buying education for limited resource audiences (LRAs), was revised using social marketing theory to make it more appealing and relevant to LRAs (25-40 years). Focus groups and surveys identified the needs and preferences of LRAs. Needs were cooking, basic health, and…
The Limits of Multiple Resource Theory in Display Fonnattlng: Effects of task integration Christopher 0. Wickens, University of Illinois; David ...In R. Sugarman (Ed.) Proceedings 25th Annual Meeting Human Factors Society. Santa Monica: Human Factors, 1981. 444 :^% 2&£&i . vv^vk-.viv.^v •:.:>::>>\\^L^>^>: S:->::VV>X-^:
Dulchavsky, Scott A.; Sargsyan, Ashot E.; Garcia, Kathleen M.; Melton, Shannon L.; Ebert, Douglas; Hamilton, Douglas R.
Management of health problems in limited resource environments, including spaceflight, faces challenges in both available equipment and personnel. The medical support for spaceflight outside Low Earth Orbit is still being defined; ultrasound (US) imaging is a candidate since trials on the International Space Station (ISS) prove that this highly informative modality performs very well in spaceflight. Considering existing estimates, authors find that US could be useful in most potential medical problems, as a powerful factor to mitigate risks and protect mission. Using outcome-oriented approach, an intuitive and adaptive US image catalog is being developed that can couple with just-in-time training methods already in use, to allow non-expert crew to autonomously acquire and interpret US data for research or diagnosis. The first objective of this work is to summarize the experience in providing imaging expertise from a central location in real time, enabling data collection by a minimally trained operator onsite. In previous investigations, just-in-time training was combined with real-time expert guidance to allow non-physician astronauts to perform over 80 h of complex US examinations on ISS, including abdominal, cardiovascular, ocular, musculoskeletal, dental/sinus, and thoracic exams. The analysis of these events shows that non-physician crew-members, after minimal training, can perform complex, quality US examinations. These training and guidance methods were also adapted for terrestrial use in professional sporting venues, the Olympic Games, and for austere locations including Mt. Everest. The second objective is to introduce a new imaging support system under development that is based on a digital catalog of existing sample images, complete with image recognition and acquisition logic and technique, and interactive multimedia reference tools, to guide and support autonomous acquisition, and possibly interpretation, of images without real-time link with a human
Jacobson, Lianne M; Edmunds, Peter J; Muller, Erik B; Nisbet, Roger M
Many organisms exhibit depressed metabolism when resources are limited, a change that makes it possible to balance an energy budget. For symbiotic reef corals, daily cycles of light and periods of intense cloud cover can be chronic causes of food limitation through reduced photosynthesis. Furthermore, coral bleaching is common in present-day reefs, creating a context in which metabolic depression could have beneficial value to corals. In the present study, corals (massive Porites spp.) were exposed to an extreme case of resource limitation by starving them of food and light for 20 days. When resources were limited, the corals depressed area-normalized respiration to 37% of initial rates, and coral biomass declined to 64% of initial amounts, yet the corals continued to produce skeletal mass. However, the declines in biomass cannot account for the declines in area-normalized respiration, as mass-specific respiration declined to 30% of the first recorded time point. Thus, these corals appear to be capable of metabolic depression. It is possible that some coral species are better able to depress metabolic rates than others; such variation could explain differential survival during conditions that limit resources (e.g. shading). Furthermore, we found that maintenance of existing biomass, in part, supports the production of skeletal mass. This association could be explained if maintenance supplies needed energy (e.g. ATP) or inorganic carbon (i.e. CO2) that otherwise limits the production of skeletal mass. Finally, the observed metabolic depression can be explained as a change in pool sizes, and does not require a change in metabolic rules. © 2016. Published by The Company of Biologists Ltd.
Zin, Thant; Mudin, Kamarudin D; Myint, Than; Naing, Daw K S; Sein, Tracy; Shamsul, B S
Water and sanitation are major public health issues exacerbated by rapid population growth, limited resources, disasters and environmental depletion. This study was undertaken to study the influencing factors for household water quality improvement for reducing diarrhoea in resource-limited areas. Data were collected from articles and reviews from relevant randomized controlled trials, new articles, systematic reviews and meta-analyses from PubMed, World Health Organization (WHO), United Nations Children's Fund (UNICEF) and WELL Resource Centre For Water, Sanitation And Environmental Health. Water quality on diarrhoea prevention could be affected by contamination during storage, collection and even at point-of-use. Point-of-use water treatment (household-based) is the most cost-effective method for prevention of diarrhoea. Chemical disinfection, filtration, thermal disinfection, solar disinfection and flocculation and disinfection are five most promising household water treatment methodologies for resource-limited areas. Promoting household water treatment is most essential for preventing diarrhoeal disease. In addition, the water should be of acceptable taste, appropriate for emergency and non-emergency use.
Charles M. Kwobah
Full Text Available Mycobacteria leprae(leprosy and HIV coinfection are rare in Kenya. This is likely related to the low prevalence (1 per 10,000 of population of leprosy. Because leprosy is no longer a public health challenge there is generally a low index of suspicion amongst clinicians for its diagnosis. Management of a HIV-1-leprosy-coinfected individual in a resource-constrained setting is challenging. Some of these challenges include difficulties in establishing a diagnosis of leprosy; the high pill burden of cotreatment with both antileprosy and antiretroviral drugs (ARVs; medications’ side effects; drug interactions; scarcity of drug choices for both diseases. This challenge is more profound when managing a patient who requires second-line antiretroviral therapy (ART. We present an adult male patient coinfected with HIV and leprosy, who failed first-line antiretroviral therapy (ART and required second-line treatment. Due to limited choices in antileprosy drugs available, the patient received monthly rifampicin and daily lopinavir-/ritonavir-based antileprosy and ART regimens, respectively. Six months into his cotreatment, he seemed to have adequate virological control. This case report highlights the challenges of managing such a patient.
Wong, Vincent; Johnson, Cheryl; Cowan, Elliot; Rosenthal, Matthew; Peeling, Rosanna; Miralles, Maria; Sands, Anita; Brown, Charlene
HIV self-testing (HIVST) is an emerging HIV testing strategy intended to address challenges of increasing access to preliminary knowledge of serostatus. It offers the potential for tests and testing to reach more people than previously possible, including those who do not seek testing in facilities. With approval of an HIV self-test kit in the USA, increasing evidence from public pilot programs in sub-Saharan Africa showing high acceptability and feasibility, and evidence of the informal sale of rapid HIV test kits in the private sector, options for individuals to access HIV self-testing, as well as consumer-demand, appear to be increasing. More recently WHO and UNAIDS have explored self-testing as an option to achieving greater HIV testing coverage to support global treatment targets. However, for resource-limited settings, technological development, diagnostic device regulation and quality assurance policies are lagging behind. This commentary will examine regulatory and policy issues with HIVST, given its increased prominence as a potential part of the global HIV/AIDS response.
Harris, Kari M; Marsico, Travis D
Small herbaria represent a significant portion of herbaria in the United States, but many are not digitizing their collections. At the Arkansas State University Herbarium (STAR), we have created a viable workflow to help small herbaria begin the digitization process, including suggestions for publishing data on the Internet. We calculated hourly rates of each phase of the digitization process. We also mapped accessions at the county level to determine geographic strengths in the collection. All 17,678 accessioned flowering plant specimens at STAR are imaged, databased in Specify, and available electronically on the herbarium's website. Students imaged the specimens at a mean rate of 145/h. We found differences in databasing rates between the graduate student leading the project (47/h) and undergraduate assistants (25/h). The majority of specimens at STAR were collected within the counties neighboring the institution. With this workflow, we estimate that one person can digitize a 20,000-specimen collection in less than 2.5 yr by working only 10 h/wk. Because STAR is a small herbarium with limited resources, the application of the workflow described should assist curators of similar-sized collections as they contemplate and undertake the digitization process.
Harris, Kari M.; Marsico, Travis D.
Premise of the study: Small herbaria represent a significant portion of herbaria in the United States, but many are not digitizing their collections. Methods: At the Arkansas State University Herbarium (STAR), we have created a viable workflow to help small herbaria begin the digitization process, including suggestions for publishing data on the Internet. We calculated hourly rates of each phase of the digitization process. We also mapped accessions at the county level to determine geographic strengths in the collection. Results: All 17,678 accessioned flowering plant specimens at STAR are imaged, databased in Specify, and available electronically on the herbarium’s website. Students imaged the specimens at a mean rate of 145/h. We found differences in databasing rates between the graduate student leading the project (47/h) and undergraduate assistants (25/h). The majority of specimens at STAR were collected within the counties neighboring the institution. Discussion: With this workflow, we estimate that one person can digitize a 20,000-specimen collection in less than 2.5 yr by working only 10 h/wk. Because STAR is a small herbarium with limited resources, the application of the workflow described should assist curators of similar-sized collections as they contemplate and undertake the digitization process. PMID:28439474
Strzałka, Dominik; Dymora, Paweł; Mazurek, Mirosław
In this paper we present some preliminary results in the field of computer systems management with relation to Tsallis thermostatistics and the ubiquitous problem of hardware limited resources. In the case of systems with non-deterministic behaviour, management of their resources is a key point that guarantees theirs acceptable performance and proper working. This is very wide problem that stands for many challenges in financial, transport, water and food, health, etc. areas. We focus on computer systems with attention paid to cache memory and propose to use an analytical model that is able to connect non-extensive entropy formalism, long-range dependencies, management of system resources and queuing theory. Obtained analytical results are related to the practical experiment showing interesting and valuable results.
Olusanya, Bolajoko O
From a developmental perspective, optimal speech and language outcome is indisputably the primary motivation for neonatal hearing screening of infants with congenital or early-onset hearing loss (PCHL). This paper additionally outlines more broadly the potential value of early hearing detection and intervention in resource-poor countries against the backdrop of limitations of primary prevention of PCHL based on a review of literature from low-income and middle-income countries with per capita incomes of approximately US$6000 or less. It establishes the scientific and developmental foundation for priority consideration for neonatal hearing screening and intervention in any global initiatives for effective early childhood development programmes in resource-limited countries. It also highlights approaches to addressing the various challenges to implementing effective early hearing detection and intervention programmes, and concludes with a discussion on the pivotal role of paediatricians in facilitating timely referral for requisite tests and (re)habilitative services especially for infants with established risk factors.
Pezzetti, M; Tovar-Gonzalez, A; Coppier, H; Almeida, M
This project provides a solution for problems in which there is a limited cryogen resource that supplies several clients in parallel, which can cause the resource’s depletion. This study emerged from the need to solve a specific problem of the Cryogenics Group of the European Organization for Nuclear Research (CERN). A generic solution is proposed for the application in a larger number of situations. The solution is based on the Fuzzy algorithm model, which bases itself on the human reasoning as a problem-solving technique. The Fuzzy approach is presented as well as the limited resource distribution problem, via a cryogenic simulation tools. The paper describes also the comparison of the fuzzy solutions with a former one that has been previously adopted by CERN’s Cryogenic Group.
Chen, Zhaobo; Teng, Chunxian; Zhang, Ding; Sun, Jiayi
This paper proposes a comprehensive model for studying supply chain versus supply chain competition with resource limitation and demand disruption. We assume that there are supply chains with heterogeneous supply network structures that compete at multiple demand markets. Each supply chain is comprised of internal and external firms. The internal firms are coordinated in production and distribution and share some common but limited resources within the supply chain, whereas the external firms are independent and do not share the internal resources. The supply chain managers strive to develop optimal strategies in terms of production level and resource allocation in maximising their profit while facing competition at the end market. The Cournot-Nash equilibrium of this inter-supply chain competition is formulated as a variational inequality problem. We further study the case when there is demand disruption in the plan-execution phase. In such a case, the managers need to revise their planned strategy in order to maximise their profit with the new demand under disruption and minimise the cost of change. We present a bi-criteria decision-making model for supply chain managers and develop the optimal conditions in equilibrium, which again can be formulated by another variational inequality problem. Numerical examples are presented for illustrative purpose.
Mtisi, Takudzwa J; Maponga, Charles; Monera-Penduka, Tsitsi G; Mudzviti, Tinashe; Chagwena, Dexter; Makita-Chingombe, Faithful; DiFranchesco, Robin; Morse, Gene D
A growing number of drug development studies that include pharmacokinetic evaluations are conducted in regions lacking a specialised pharmacology laboratory. This necessitated the development of an International Pharmacology Specialty Laboratory (IPSL) in Zimbabwe. The aim of this article is to describe the development of an IPSL in Zimbabwe. The IPSL was developed collaboratively by the University of Zimbabwe and the University at Buffalo Center for Integrated Global Biomedical Sciences. Key stages included infrastructure development, establishment of quality management systems and collaborative mentorship in clinical pharmacology study design and chromatographic assay development and validation. Two high performance liquid chromatography instruments were donated by an instrument manufacturer and a contract research organisation. Laboratory space was acquired through association with the Zimbabwe national drug regulatory authority. Operational policies, standard operating procedures and a document control system were established. Scientists and technicians were trained in aspects relevant to IPSL operations. A high-performance liquid chromatography method for nevirapine was developed with the guidance of the Clinical Pharmacology Quality Assurance programme and approved by the assay method review programme. The University of Zimbabwe IPSL is engaged with the United States National Institute of Allergy and Infectious Diseases Division of AIDS research networks and is poised to begin drug assays and pharmacokinetic analyses. An IPSL has been successfully established in a resource-limited setting through the efforts of an external partnership providing technical guidance and motivated internal faculty and staff. Strategic partnerships were beneficial in navigating challenges leading to laboratory development and training new investigators. The IPSL is now engaged in clinical pharmacology research.
Godpower Chinedu Michael
Full Text Available Venomous snakebite is a medical emergency encountered worldwide, especially in resource-limited communities. It usually leaves victims at the mercy of traditional care, whose effectiveness have come under scrutiny over time. Several of these traditional/ first aid practices have also been reported over time. Controversies over their efficacy often result in confusion among snakebite victims, their caregivers, and sometimes, among health-care providers. This narrative review describes reported prehospital interventions for venomous snakebites highlighting their usefulness, dangers, and/or limitations associated with their use and the currently widely recommended prehospital activities for venomous snakebite.
Katie Clouthier, DO
Full Text Available In developed countries, surgeons and anesthesiologists approach the mediastinal mass causing airway compression with prudence and trepidation. Resource-limited settings provide unique challenges in the diagnosis and management of patients with critical airway compression. We report the successful treatment of a patient in Port-au-Prince, Haiti with a posterior mediastinal mass that filled the left chest cavity and caused critical airway stenosis. The pathology revealed a Gardner Fibroma, which is rarely associated with mediastinal airway obstruction.
Martin, Thomas E.
Resource selection specialization may increase vulnerability of populations to environmental change. One environmental change that may negatively impact some populations is the broad decline of quaking aspen Populus tremuloides, a preferred nest tree of cavity-nesting organisms who are commonly limited by nest-site availability. However, the long-term consequences of this habitat change for cavity-nesting bird populations are poorly studied.
Madden, Erin Fanning
Communities struggling with access to healthcare in the U.S. are often considered to be disadvantaged and lacking in resources. Yet, these communities develop and nurture valuable strategies for healthcare access that are underrecognized by health scholars. Combining medical sociology and critical race theory perspectives on cultural capital, this paper examines the health-relevant cultural resources, or Cultural Health Capital, in South Texas Mexican American border communities. Ethnographic data collected during 2011-2013 in Cameron and Hidalgo counties on the U.S.-Mexico border provide empirical evidence for expanding existing notions of health-relevant cultural capital. These Mexican American communities use a range of cultural resources to manage healthcare exclusion and negotiate care in alternative healthcare spaces like community clinics, flea markets and Mexican pharmacies. Navigational, social, familial, and linguistic skills and knowledge are used to access doctors and prescription drugs in these spaces despite social barriers to mainstream healthcare (e.g. cost, English language skills, etc.). Cultural capital used in marginalized communities to navigate limited healthcare options may not always fully counteract healthcare exclusion. Nevertheless, recognizing the cultural resources used in Mexican American communities to facilitate healthcare challenges deficit views and yields important findings for policymakers, healthcare providers, and advocates seeking to capitalize on community resources to improve healthcare access. Copyright © 2015 Elsevier Ltd. All rights reserved.
Li, Youxu; Swaisgood, Ronald R; Wei, Wei; Nie, Yonggang; Hu, Yibo; Yang, Xuyu; Gu, Xiaodong; Zhang, Zejun
In response to seasonal variation in quality and quantity of available plant biomass, herbivorous foragers may alternate among different plant resources to meet nutritional requirements. Giant pandas (Ailuropoda melanoleuca) are reliant almost exclusively on bamboo which appears omnipresent in most occupied habitat, but subtle temporal variation in bamboo quality may still govern foraging strategies, with population-level effects. In this paper, we investigated the possibility that temporal variation in the quality of this resource is involved in population regulation and examined pandas' adaptive foraging strategies in response to temporal variation in bamboo quality. Giant pandas in late winter and early spring consumed a less optimal diet in Foping Nature Reserve, as the availability of the most nutritious and preferred components and age classes of Bashania fargesii declined, suggesting that bamboo may be a seasonally limiting resource. Most panda mortalities and rescues occurred during the same period of seasonal food limitation. Our findings raised the possibility that while total bamboo biomass may not be a limiting factor, carrying capacity may be influenced by subtle seasonal variation in bamboo quality. We recommend that managers and policy-makers should consider more than just the quantity of bamboo in the understory and that carrying capacity estimates should be revised downward to reflect the fact that all bamboos are not equal.
Cervical cancer remains a significant cause of morbidity and mortality among women globally, even though it is the cancer with the greatest demonstrated potential for secondary prevention. In some regions of the world the incidence is alarmingly high, such as in sub-Saharan Africa, some countries in Latin America, India and South-East Asia. This disease is highly preventable and curable at a relatively low risk and low cost when screening of asymptomatic women is available, together with appropriate diagnosis, treatment and follow-up. In developing clinical guidelines, the International Atomic Energy Agency (IAEA) has selected forms of cancer or clinical situations that are very common in low and middle income Member States and for which radiation oncologists consistently express a need for guidance. Clinical guidelines for the management of cervical cancer do exist in the published literature. However, these guidelines have usually been developed in and for affluent environments where all modern diagnosis and treatment modalities are available for the practitioner. In limited resource environments, the radiation oncologist is faced with the question, what would be the minimally acceptable line of action with the limited resources available? Clinical guidelines focusing on low and middle income countries provide a practical tool to these practitioners. This publication is aimed at the radiation oncologist working in centres with limited resources and treating a large number of patients with cervical cancer on a daily basis. The approach and techniques are intended to be simple, feasible and resource sparing to the extent that this is possible when dealing with a complex treatment modality. The Division of Human Health is placing special emphasis on the subject of cervical cancer, which is addressed not only in this guide but also in regional training courses and coordinated research projects on the subject
Bougma, Moussa; LeGrand, Thomas K; Kobiané, Jean-François
Using original data collected in Ouagadougou, Burkina Faso, this study investigates evidence for the competing theories that fertility reductions increase children's education through either the quantity-quality tradeoff (intentionally choosing smaller families to make greater investments in education and other indicators of child quality) or resource dilution (having more children reduces resources available per child, regardless of intentionality of family size). The results provide evidence for both hypotheses: children having four or fewer siblings were significantly more likely to be enrolled in school if their mothers had intentionally stopped childbearing relative to those whose mothers wanted more children but whose childbearing was limited by subfecundity. The difference between intentional and unintentional family limitation was not significant for parities greater than five. In addition, the relationship between number of siblings and their schooling is negative, regardless of the intentionality of family-size limitation, but the strength of this negative relationship is approximately twice as high among children whose mothers intentionally limited fertility (reflecting both selection and dilution effects) than among children whose mothers were subfecund (reflecting the pure dilution effect). © 2015 The Population Council, Inc.
Asombang, Akwi W; Turner-Moss, Eleanor; Seetharam, Anil; Kelly, Paul
awareness in areas where resources are limited.
The Effects of Limited Resources and Opportunities on Women’s Careers in Physics: Results from the Global Survey of Physicists, by Rachel Ivie (American Institute of Physics). Thursday, May 3, 2012 from 16:30 to 17:30 (Europe/Zurich) at CERN ( 503-1-001 - Council Chamber ) The results of the Global Survey of Physicists draw attention to the need to focus on factors other than representation when discussing the situation of women in physics. Previous studies of women in physics have mostly focused on the lack of women in the field. This study goes beyond the obvious shortage of women and shows that there are much deeper issues. For the first time, a multinational study was conducted with 15000 respondents from 130 countries, showing that problems for women in physics transcend national borders. Across all countries, women have fewer resources and opportunities and are more affected by cultural expectations concerning child care. We show that limited resources and opportunities hurt ca...
Recognition of the pervasiveness of risk in everyday life in modern industrial society has elicited calls for greater efforts to protect individual and public health. Yet, it is increasingly clear that decisions to do so must often be made in the context of significant limits in the amounts of financial resources available for achieving that protection. Achieving risk-free work, residential, and community environments may be so expensive as to render a private business unit uncompetitive or as to divert resources from or prelude commencing with other governmental projects with equal or greater health benefit potential. Ethical low-level risk communication (LLRC) is something risk-generating entities are morally obligated to do. However, such communication also offers important opportunities for such entities to move toward achieving better balances between health and the costs of protecting it. In this paper, the authors elaborate on several features of an ethically ideal LLRC process, focusing on those with aspects they hope are not obvious or common knowledge. In discussing these features, they provide examples of conflicts between health risks and resource limits at the level of the individual private firm, the local community, or the national government, such that LLRC with the feature in question provides an opportunity for mitigating or at least clarifying the conflict in question
Obenson, Ken; Enow Orock, George
A properly operated death investigation system (DIS) serves multiple stakeholders. Law enforcement, public health departments and members of the public, benefit in various ways from the information that it provides. This information must be collected systematically and efficiently. The system must also be flexible enough to respond to pressures on its resources such as occurs during mass disasters. These obligations on a DIS require an investment of public money. However even in affluent Western countries the recent world economic crisis has led to a cut in spending on public services that affect both the healthcare system and services associated with death investigation. Although pathologists and other stake holders (judiciary, police, families) would like to see death investigations conducted to international standards, the fact is that policy makers in resource limited countries face additional population health and sociopolitical pressures which generally result in very little funding for the service. The purpose of this paper is to review some of the challenges that impede the proper functioning of a death investigation system in resource limited countries in Sub-Saharan Africa and the Caribbean. Possible solutions are discussed. Copyright © 2017. Published by Elsevier Ltd.
Full Text Available Cryptococcal meningitis (CM is the most common form of meningitis in Africa. World Health Organization guidelines recommend 14-d amphotericin-based induction therapy; however, this is impractical for many resource-limited settings due to cost and intensive monitoring needs. A cost-effectiveness analysis was performed to guide stakeholders with respect to optimal CM treatment within resource limitations.We conducted a decision analysis to estimate the incremental cost-effectiveness ratio (ICER of six CM induction regimens: fluconazole (800-1,200 mg/d monotherapy, fluconazole + flucytosine (5FC, short-course amphotericin (7-d + fluconazole, 14-d of amphotericin alone, amphotericin + fluconazole, and amphotericin + 5FC. We computed actual 2012 healthcare costs in Uganda for medications, supplies, and personnel, and average laboratory costs for three African countries. A systematic review of cryptococcal treatment trials in resource-limited areas summarized 10-wk survival outcomes. We modeled one-year survival based on South African, Ugandan, and Thai CM outcome data, and survival beyond one-year on Ugandan and Thai data. Quality-adjusted life years (QALYs were determined and used to calculate the cost-effectiveness ratio and ICER. The cost of hospital care ranged from $154 for fluconazole monotherapy to $467 for 14 d of amphotericin + 5FC. Based on 18 studies investigating outcomes for HIV-infected individuals with CM in resource-limited settings, the estimated mean one-year survival was lowest for fluconazole monotherapy, at 40%. The cost-effectiveness ratio ranged from $20 to $44 per QALY. Overall, amphotericin-based regimens had higher costs but better survival. Short-course amphotericin (1 mg/kg/d for 7 d with fluconazole (1,200 mg/d for14 d had the best one-year survival (66% and the most favorable cost-effectiveness ratio, at $20.24/QALY, with an ICER of $15.11 per additional QALY over fluconazole monotherapy. The main limitation of this
Full Text Available The incidence of acute kidney injury (AKI among acutely ill patients is reportedly very high and has vexing consequences on patient outcomes and health care systems. The risks and impact of AKI differ between developed and developing countries. Among developing countries, AKI occurs in young individuals with no or limited comorbidities, and is usually due to environmental causes, including infectious diseases. Although several risk factors have been identified for AKI in different settings, there is limited information on how risk assessment can be used at population and patient levels to improve care in patients with AKI, particularly in developing countries where significant health disparities may exist. The Acute Disease Quality Initiative consensus conference work group addressed the issue of identifying risk factors for AKI and provided recommendations for developing individualized risk stratification strategies to improve care. We proposed a 5-dimension, evidence-based categorization of AKI risk that allows clinicians and investigators to study, define, and implement individualized risk assessment tools for the region or country where they practice. These dimensions include environmental, socioeconomic and cultural factors, processes of care, exposures, and the inherent risks of AKI. We provide examples of these risks and describe approaches for risk assessments in the developing world. We anticipate that these recommendations will be useful for health care providers to plan and execute interventions to limit the impact of AKI on society and each individual patient. Using a modified Delphi process, this group reached consensus regarding several aspects of AKI risk stratification.
The range of tobacco control activities should be viewed as essential parts of a complex multi-component puzzle. Intervention strategies designed to address tobacco control should be comprehensive and include both primary and secondary prevention activities and be multi-faceted and capable of bringing about change at both the individual and broader social and cultural levels. In this paper I argue for a mutually inclusive framework in which the various components contribute in important and different ways. I examine the prevalence of smoking and identify the high risk groups, then I examine the range of available strategies and present the evidence for their success. I discuss the primary prevention approaches such as warning labels, taxes, price increases, workplace bans, education in schools, mass media and self-help materials, as well as brief interventions and treatment strategies which are conducted at the worksite, general practice and specialized cessation clinics. The areas for future research are delineated for increased resource allocation and include: the best ways to disseminate brief interventions to smokers, methods to motivate smokers; training of health professionals to deliver brief interventions; enhancing quitting and access to existing treatment resources among specific disadvantaged minority groups, e.g. migrants, unemployed youth, the effect on smoking prevalence of warning labels on cigarette packets and price rises on cigarettes.
Full Text Available Yard storage space and yard crane equipment are the core resources in the container terminal yard area. This paper studies the integrated yard space allocation (outbound container space and yard crane deployment problem in resource-limited container terminals where yard space and yard cranes are extremely scarce. Two corresponding counterstrategies are introduced, respectively, and the integrated problem is solved as mixed integer programming. The model this paper formulated considers the container volume fluctuation of the service line, and the objective is a trade-off between yard sharing space and terminal operation cost. In numerical experiments, this paper tries to reveal the management meaning in practical operation of container terminal and provides decision support for terminal managers; therefore a series of scenarios are presented to analyze the relations among the yard sharing space, the number of yard cranes, the size of yard subblock, and the cost of terminal operation.
Allen, Heidi; Baicker, Katherine; Taubman, Sarah; Wright, Bill; Finkelstein, Amy
In 2008 Oregon allocated access to its Medicaid expansion program, Oregon Health Plan Standard, by drawing names from a waiting list by lottery. The lottery was chosen by policy makers and stakeholders as the preferred way to allocate limited resources. At the same time, it also gave rise to the Oregon Health Insurance Experiment: an unprecedented opportunity to do a randomized evaluation - the gold standard in medical and scientific research - of the impact of expanding Medicaid. In this article we provide historical context for Oregon's decision to conduct a lottery, discuss the importance of randomized controlled designs for policy evaluation, and describe some of the practical challenges in successfully capitalizing on the research opportunity presented by the Oregon lottery through public-academic partnerships. Since policy makers will always face tough choices about how to distribute scarce resources, we urge thoughtful consideration of the opportunities to incorporate randomization that can substantially improve the evidence available to inform policy decisions without compromising policy goals.
Sun, Lijun; Wang, Fang; Liu, An; Xin, Ruolei; Zhu, Yunxia; Li, Jianwei; Shao, Ying; Ye, Jiangzhu; Chen, Danqing; Li, Zaicun
Many HIV serodiscordant couples have a strong desire to have their own biological children. Natural conception may be the only choice in some resource limited settings but data about natural conception is limited. Here, we reported our findings of natural conception in HIV serodiscordant couples. Between January 2008 and June 2014, we retrospectively collected data on 91 HIV serodiscordant couples presenting to Beijing Youan Hospital with childbearing desires. HIV counseling, effective ART on HIV infected partners, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) in negative female partners and timed intercourse were used to maximally reduce the risk of HIV transmission. Of the 91 HIV serodiscordant couples, 43 were positive in male partners and 48 were positive in female partners. There were 196 unprotected vaginal intercourses, 100 natural conception and 97 newborns. There were no cases of HIV seroconversion in uninfected sexual partners. Natural conception may be an acceptable option in HIV-serodiscordant couples in resource limited settings if HIV-positive individuals have undetectable viremia on HAART, combined with HIV counseling, PrEP, PEP and timed intercourse.
Nkrumah, Bernard; van der Puije, Beatrice; Bekoe, Veronica; Adukpo, Rowland; Kotey, Nii A; Yao, Katy; Fonjungo, Peter N; Luman, Elizabeth T; Duh, Samuel; Njukeng, Patrick A; Addo, Nii A; Khan, Fazle N; Woodfill, Celia J I
In 2009, Ghana adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme in order to improve laboratory quality. The programme was implemented successfully with limited donor funding and local human resources. To demonstrate how Ghana, which received very limited PEPFAR funding, was able to achieve marked quality improvement using local human resources. Local partners led the SLMTA implementation and local mentors were embedded in each laboratory. An in-country training-of-trainers workshop was conducted in order to increase the pool of local SLMTA implementers. Three laboratory cohorts were enrolled in SLMTA in 2011, 2012 and 2013. Participants from each cohort attended in a series of three workshops interspersed with improvement projects and mentorship. Supplemental training on internal audit was provided. Baseline, exit and follow-up audits were conducted using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. In November 2013, four laboratories underwent official SLIPTA audits by the African Society for Laboratory Medicine (ASLM). The local SLMTA team successfully implemented three cohorts of SLMTA in 15 laboratories. Seven out of the nine laboratories that underwent follow-up audits have reached at least one star. Three out of the four laboratories that underwent official ASLM audits were awarded four stars. Patient satisfaction increased from 25% to 70% and sample rejection rates decreased from 32% to 10%. On average, $40 000 was spent per laboratory to cover mentors' salaries, SLMTA training and improvement project support. Building in-country capacity through local partners is a sustainable model for improving service quality in resource-constrained countries such as Ghana. Such models promote country ownership, capacity building and the use of local human resources for the expansion of SLMTA.
Full Text Available Background: In 2009, Ghana adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA programme in order to improve laboratory quality. The programme was implemented successfully with limited donor funding and local human resources. Objectives: To demonstrate how Ghana, which received very limited PEPFAR funding, was able to achieve marked quality improvement using local human resources. Method: Local partners led the SLMTA implementation and local mentors were embedded in each laboratory. An in-country training-of-trainers workshop was conducted in order to increase the pool of local SLMTA implementers. Three laboratory cohorts were enrolled in SLMTA in 2011, 2012 and 2013. Participants from each cohort attended in a series of three workshops interspersed with improvement projects and mentorship. Supplemental trainingon internal audit was provided. Baseline, exit and follow-up audits were conducted using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA checklist. In November 2013, four laboratories underwent official SLIPTA audits by the African Society for Laboratory Medicine (ASLM. Results: The local SLMTA team successfully implemented three cohorts of SLMTA in 15 laboratories. Seven out of the nine laboratories that underwent follow-up audits have reached at least one star. Three out of the four laboratories that underwent official ASLM audits were awarded four stars. Patient satisfaction increased from 25% to 70% and sample rejection rates decreased from 32% to 10%. On average, $40 000 was spent per laboratory to cover mentors’salaries, SLMTA training and improvement project support. Conclusion: Building in-country capacity through local partners is a sustainable model for improving service quality in resource-constrained countries such as Ghana. Such modelspromote country ownership, capacity building and the use of local human resources for the expansion of SLMTA.
Scott, John W; Lin, Yihan; Ntakiyiruta, Georges; Mutabazi, Zeta A; Davis, William Austin; Morris, Megan A; Smink, Douglas S; Riviello, Robert; Yule, Steven
Safe surgery should be available to all patients, no matter the setting. The purpose of this study was to explore the contextual-specific challenges to safe surgical care encountered by surgeons and surgical teams in many in low- and middle-income countries (LMICs), and to understand the ways in which surgical teams overcome them. Optimal surgical performance is highly complex and requires providers to integrate and communicate information regarding the patient, task, team, and environment to coordinate team-based care that is timely, effective, and safe. Resource limitations common to many LMICs present unique challenges to surgeons operating in these environments, but have never been formally described. Using a grounded theory approach, we interviewed 34 experienced providers (surgeons, anesthetists, and nurses) at the 4 tertiary referral centers in Rwanda, to understand the challenges to safe surgical care and strategies to overcome them. Interview transcripts were coded line-by-line and iteratively analyzed for emerging themes until thematic saturation was reached. Rwandan-described challenges related to 4 domains: physical resources, human resources, overall systems support, and communication/language. The majority of these challenges arose from significant variability in either the quantity or quality of these domains. Surgical providers exhibited examples of resilient strategies to anticipate, monitor, respond to, and learn from these challenges. Resource variability rather than lack of resources underlies many contextual challenges to safe surgical care in a LMIC setting. Understanding these challenges and resilient strategies to overcome them is critical for both LMIC surgical providers and surgeons from HICs working in similar settings.
Rattanaumpawan, Pinyo; Boonyasiri, Adhiratha; Vong, Sirenda; Thamlikitkul, Visanu
Electronic surveillance of infectious diseases involves rapidly collecting, collating, and analyzing vast amounts of data from interrelated multiple databases. Although many developed countries have invested in electronic surveillance for infectious diseases, the system still presents a challenge for resource-limited health care settings. We conducted a systematic review by performing a comprehensive literature search on MEDLINE (January 2000-December 2015) to identify studies relevant to electronic surveillance of infectious diseases. Study characteristics and results were extracted and systematically reviewed by 3 infectious disease physicians. A total of 110 studies were included. Most surveillance systems were developed and implemented in high-income countries; less than one-quarter were conducted in low-or middle-income countries. Information technologies can be used to facilitate the process of obtaining laboratory, clinical, and pharmacologic data for the surveillance of infectious diseases, including antimicrobial resistance (AMR) infections. These novel systems require greater resources; however, we found that using electronic surveillance systems could result in shorter times to detect targeted infectious diseases and improvement of data collection. This study highlights a lack of resources in areas where an effective, rapid surveillance system is most needed. The availability of information technology for the electronic surveillance of infectious diseases, including AMR infections, will facilitate the prevention and containment of such emerging infectious diseases. Copyright © 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Lofgren, Sarah; Abassi, Mahsa; Rhein, Joshua; Boulware, David R
Recent advances in the treatment and prevention of cryptococcal meningitis have the potential to decrease AIDS-related deaths. Areas covered: Targeted screening for asymptomatic cryptococcal antigenemia in persons with AIDS is a cost effective method for reducing early mortality in patients on antiretroviral therapy. For persons with symptomatic cryptococcal meningitis, optimal initial management with amphotericin and flucytosine improves survival compared to alternative therapies; however, amphotsericin is difficult to administer and flucytosine has not been available in middle or low income countries, where cryptococcal meningitis is most prevalent. Expert commentary: Improved care for cryptococcal meningitis patients in resource-limited settings is possible, and new treatment possibilities are emerging.
Lofgren, Sarah M; Abassi, Mahsa; Rhein, Joshua; Boulware, David R
Introduction Recent advances in the treatment and prevention of cryptococcal meningitis have the potential to decrease AIDS-related deaths. Areas covered Targeted screening for asymptomatic cryptococcal antigenemia in persons with AIDS is a cost effective method for reducing early mortality in patients on antiretroviral therapy. For persons with symptomatic cryptococcal meningitis, optimal initial management with amphotericin and flucytosine improves survival compared to alternative therapies; however, amphotericin is difficult to administer and flucytosine has not been available in middle or low income countries, where cryptococcal meningitis is most prevalent. Expert Commentary Improved care for cryptococcal meningitis patients in resource-limited settings is possible, and new treatment possibilities are emerging. PMID:28111998
Zimmer, Hubert D.; Münzer, Stefan; Umla-Runge, Katja
Working memory is considered a cognitive component that mainly serves two functions. It temporarily maintains information that was either perceived but is no longer present in the environment, or that was internally generated, and it supplies a work space for transforming and manipulating elements of perception and thinking. Both functions are relevant for a successful interaction with the environment and it is therefore not surprising that WM is a central topic of research in the field of general psychology. This interest is further increased by the fact that WM is seen as a limited resource that constrains cognitive performances.
Porkka, Miina; Guillaume, Joseph H. A.; Schaphoff, Sibyll; Siebert, Stefan; Gerten, Dieter; Kummu, Matti
There is a fundamental tension between population growth and carrying capacity, i.e. the population that could potentially be supported using the resources and technologies available at a given time. This makes the assessments of resource use and agricultural productivity central to the debate on future food security. Local carrying capacity can be increased by expanding (e.g. through land conversion and irrigation infrastructure) or intensifying (e.g. through technologies and practices that increase efficiency) the resource use in agriculture. Food imports can be considered another way of overcoming current local limits and continuing growth beyond the local human-carrying capacity. Focusing on water as the key limiting resource, we performed a global assessment of the capacity for food self-sufficiency at sub-national and national scale for 1961-2009, taking into account the availability of both green and blue water as well as technology and management practices affecting water productivity at a given time, and using the hydrology and agriculture model LPJmL as our primary tool. Furthermore, we examined the use of food imports as a strategy to increase carrying capacity in regions where the potential for food self-sufficiency was limited by water availability and productivity. We found that the capacity for food self-sufficiency reduced notably during the study period due to the rapid population growth that outpaced the substantial improvements in water productivity. In 2009 more than a third (2.2 billion people) of the world's population lived in areas where sufficient food production to meet the needs of the population was not possible, and some 800 million people more were approaching this threshold. Food imports have nearly universally been used to overcome these local limits to growth, though the success of this strategy has been highly dependent on economic purchasing power. In the unsuccessful cases, increases in imports and local productivity have not
Full Text Available We consider SIR epidemic model in which population growth is subject to logistic growth in absence of disease. We get the condition for Hopf bifurcation of a delayed epidemic model with information variable and limited medical resources. By analyzing the corresponding characteristic equations, the local stability of an endemic equilibrium and a disease-free equilibrium is discussed. If the basic reproduction ratio ℛ01, we obtain sufficient conditions under which the endemic equilibrium E* of system is locally asymptotically stable. And we also have discussed the stability and direction of Hopf bifurcations. Numerical simulations are carried out to explain the mathematical conclusions.
Full Text Available A WHO and UNICEF joint report states that in 2008, 884 million people lacked access to potable drinking water. A life-cycle approach to develop potable water systems may improve the sustainability for such systems, however, a review of the literature shows that such an approach has primarily been used for urban systems located in resourced countries. Although urbanization is increasing globally, over 40 percent of the world’s population is currently rural with many considered poor. In this paper, we present a first step towards using life-cycle assessment to develop sustainable rural water systems in resource-limited countries while pointing out the needs. For example, while there are few differences in costs and environmental impacts for many improved rural water system options, a system that uses groundwater with community standpipes is substantially lower in cost that other alternatives with a somewhat lower environmental inventory. However, a LCA approach shows that from institutional as well as community and managerial perspectives, sustainability includes many other factors besides cost and environment that are a function of the interdependent decision process used across the life cycle of a water system by aid organizations, water user committees, and household users. These factors often present the biggest challenge to designing sustainable rural water systems for resource-limited countries.
Evison, Sophie E F; Gallagher, Joe D; Thompson, John J W; Siva-Jothy, Michael T; Armitage, Sophie A O
Central to the basis of ecological immunology are the ideas of costs and trade-offs between immunity and life history traits. As a physical barrier, the insect cuticle provides a key resistance trait, and Tenebrio molitor shows phenotypic variation in cuticular colour that correlates with resistance to the entomopathogenic fungus Metarhizium anisopliae. Here we first examined whether there is a relationship between cuticular colour variation and two aspects of cuticular architecture that we hypothesised may influence resistance to fungal invasion through the cuticle: its thickness and its porosity. Second, we tested the hypothesis that tyrosine, a semi-essential amino acid required for immune defence and cuticular melanisation and sclerotisation, can act as a limiting resource by supplementing the larval diet and subsequently examining adult cuticular colouration and thickness. We found that stock beetles and beetles artificially selected for extremes of cuticular colour had thicker less porous cuticles when they were darker, and thinner more porous cuticles when they were lighter, showing that colour co-varies with two architectural cuticular features. Experimental supplementation of the larval diet with tyrosine led to the development of darker adult cuticle and affected thickness in a sex-specific manner. However, it did not affect two immune traits. The results of this study provide a mechanism for maintenance of cuticular colour variation in this species of beetle; darker cuticles are thicker, but their production is potentially limited by resource constraints and differential investments in resistance mechanisms between the sexes. Copyright © 2016 Elsevier Ltd. All rights reserved.
Background The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries. Methods A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature. Results Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC), placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52% - 65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71% - 75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors. Conclusions This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries. It indicates that no single
Urassa David P
Full Text Available Abstract Background The burden of maternal mortality in resource limited countries is still huge despite being at the top of the global public health agenda for over the last 20 years. We systematically reviewed the impacts of interventions on maternal health and factors for change in these countries. Methods A systematic review was carried out using the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA. Articles published in the English language reporting on implementation of interventions, their impacts and underlying factors for maternal health in resource limited countries in the past 23 years were searched from PubMed, Popline, African Index Medicus, internet sources including reproductive health gateway and Google, hand-searching, reference lists and grey literature. Results Out of a total of 5084 articles resulting from the search only 58 qualified for systematic review. Programs integrating multiple interventions were more likely to have significant positive impacts on maternal outcomes. Training in emergency obstetric care (EmOC, placement of care providers, refurbishment of existing health facility infrastructure and improved supply of drugs, consumables and equipment for obstetric care were the most frequent interventions integrated in 52% - 65% of all 54 reviewed programs. Statistically significant reduction of maternal mortality ratio and case fatality rate were reported in 55% and 40% of the programs respectively. Births in EmOC facilities and caesarean section rates increased significantly in 71% - 75% of programs using these indicators. Insufficient implementation of evidence-based interventions in resources limited countries was closely linked to a lack of national resources, leadership skills and end-users factors. Conclusions This article presents a list of evidenced-based packages of interventions for maternal health, their impacts and factors for change in resource limited countries
Jensen, Jakob D; Carcioppolo, Nick; King, Andy J; Bernat, Jennifer K; Davis, LaShara; Yale, Robert; Smith, Jessica
Past research has demonstrated that news coverage of cancer research, and scientific research generally, rarely contains discourse-based hedging, including caveats, limitations, and uncertainties. In a multiple message experiment (k = 4 news stories, N = 1082), the authors examined whether hedging shaped the perceptions of news consumers. The results revealed that participants were significantly less fatalistic about cancer (p = .039) and marginally less prone to nutritional backlash (p = .056) after exposure to hedged articles. Participants exposed to articles mentioning a second researcher (unaffiliated with the present study) exhibited greater trust in medical professions (p = .001). The findings provide additional support for the inclusion of discourse-based hedging in cancer news coverage and suggest that news consumers will use scientific uncertainty in illness representations.
Full Text Available The differences between countries in national income, growth, human development and many other factors are used to classify countries into developed and developing countries. There are several classification systems that use different sets of measures and criteria. The most common classifications are the United Nations (UN and the World Bank (WB systems. The UN classification system uses the UN Human Development Index (HDI, an indicator that uses statistic of life expectancy, education, and income per capita for countries' classification. While the WB system uses gross national income (GNI per capita that is calculated using the World Bank Atlas method. According to the UN and WB classification systems, there are 151 and 134 developing countries, respectively, with 89% overlap between the two systems. Developing countries have limited human development, and limited expenditure in education and research, among several other limitations. The biggest challenge facing genomic researchers and clinicians is limited resources. As a result, genomic tools, specifically genome sequencing technologies, which are rapidly becoming indispensable, are not widely available. In this report, we explore the current status of sequencing technologies in developing countries, describe the associated challenges and emphasize potential solutions.
Campbell, Jeffrey I; Aturinda, Isaac; Mwesigwa, Evans; Burns, Bridget; Santorino, Data; Haberer, Jessica E; Bangsberg, David R; Holden, Richard J; Ware, Norma C; Siedner, Mark J
Although mobile health (mHealth) technologies have shown promise in improving clinical care in resource-limited settings (RLS), they are infrequently brought to scale. One limitation to the success of many mHealth interventions is inattention to end-user acceptability, which is an important predictor of technology adoption. We conducted in-depth interviews with 43 people living with HIV in rural Uganda who had participated in a clinical trial of a short messaging system (SMS)-based intervention designed to prompt return to clinic after an abnormal laboratory test. Interviews focused on established features of technology acceptance models, including perceived ease of use and perceived usefulness, and included open-ended questions to gain insight into unexplored issues related to the intervention's acceptability. We used conventional (inductive) and direct content analysis to derive categories describing use behaviors and acceptability. Interviews guided development of a proposed conceptual framework, the technology acceptance model for resource-limited settings (TAM-RLS). This framework incorporates both classic technology acceptance model categories as well as novel factors affecting use in this setting. Participants described how SMS message language, phone characteristics, and experience with similar technologies contributed to the system's ease of use. Perceived usefulness was shaped by the perception that the system led to augmented HIV care services and improved access to social support from family and colleagues. Emergent themes specifically related to mHealth acceptance among PLWH in Uganda included (1) the importance of confidentiality, disclosure, and stigma, and (2) the barriers and facilitators downstream from the intervention that impacted achievement of the system's target outcome. The TAM-RLS is a proposed model of mHealth technology acceptance based upon end-user experiences in rural Uganda. Although the proposed model requires validation, the TAM
Sarah A. Budischak
Full Text Available Resources are a core currency of species interactions and ecology in general (e.g., think of food webs or competition. Within parasite-infected hosts, resources are divided among the competing demands of host immunity and growth as well as parasite reproduction and growth. Effects of resources on immune responses are increasingly understood at the cellular level (e.g., metabolic predictors of effector function, but there has been limited consideration of how these effects scale up to affect individual energetic regimes (e.g., allocation trade-offs, susceptibility to infection, and feeding behavior (e.g., responses to local resource quality and quantity. We experimentally rewilded laboratory mice (strain C57BL/6 in semi-natural enclosures to investigate the effects of dietary protein and gastrointestinal nematode (Trichuris muris infection on individual-level immunity, activity, and behavior. The scale and realism of this field experiment, as well as the multiple physiological assays developed for laboratory mice, enabled us to detect costs, trade-offs, and potential compensatory mechanisms that mice employ to battle infection under different resource conditions. We found that mice on a low-protein diet spent more time feeding, which led to higher body fat stores (i.e., concentration of a satiety hormone, leptin and altered metabolite profiles, but which did not fully compensate for the effects of poor nutrition on albumin or immune defenses. Specifically, immune defenses measured as interleukin 13 (IL13 (a primary cytokine coordinating defense against T. muris and as T. muris-specific IgG1 titers were lower in mice on the low-protein diet. However, these reduced defenses did not result in higher worm counts in mice with poorer diets. The lab mice, living outside for the first time in thousands of generations, also consumed at least 26 wild plant species occurring in the enclosures, and DNA metabarcoding revealed that the consumption of different
Catlin, Ann Christine; Fernando, Sumudinie; Gamage, Ruwan; Renner, Lorna; Antwi, Sampson; Tettey, Jonas Kusah; Amisah, Kofi Aikins; Kyriakides, Tassos; Cong, Xiangyu; Reynolds, Nancy R; Paintsil, Elijah
Prevalence of pediatric HIV disclosure is low in resource-limited settings. Innovative, culturally sensitive, and patient-centered disclosure approaches are needed. Conducting such studies in resource-limited settings is not trivial considering the challenges of capturing, cleaning, and storing clinical research data. To overcome some of these challenges, the Sankofa pediatric disclosure intervention adopted an interactive cyber infrastructure for data capture and analysis. The Sankofa Project database system is built on the HUBzero cyber infrastructure ( https://hubzero.org ), an open source software platform. The hub database components support: (1) data management - the "databases" component creates, configures, and manages database access, backup, repositories, applications, and access control; (2) data collection - the "forms" component is used to build customized web case report forms that incorporate common data elements and include tailored form submit processing to handle error checking, data validation, and data linkage as the data are stored to the database; and (3) data exploration - the "dataviewer" component provides powerful methods for users to view, search, sort, navigate, explore, map, graph, visualize, aggregate, drill-down, compute, and export data from the database. The Sankofa cyber data management tool supports a user-friendly, secure, and systematic collection of all data. We have screened more than 400 child-caregiver dyads and enrolled nearly 300 dyads, with tens of thousands of data elements. The dataviews have successfully supported all data exploration and analysis needs of the Sankofa Project. Moreover, the ability of the sites to query and view data summaries has proven to be an incentive for collecting complete and accurate data. The data system has all the desirable attributes of an electronic data capture tool. It also provides an added advantage of building data management capacity in resource-limited settings due to its
Nana Ama Amissah
Full Text Available Objectives:Staphylococcus aureus infections in burn patients can lead to serious complications and death. The frequency of S. aureus infection is high in low- and middle-income countries presumably due to limited resources, misuse of antibiotics and poor infection control. The objective of the present study was to apply population genomics to precisely define, for the first time, the transmission of antibiotic resistant S. aureus in a resource-limited setting in sub-Saharan Africa.Methods:Staphylococcus aureus surveillance was performed amongst burn patients and healthcare workers during a 7-months survey within the burn unit of the Korle Bu Teaching Hospital in Ghana.Results: Sixty-six S. aureus isolates (59 colonizing and 7 clinical were obtained from 31 patients and 10 healthcare workers. Twenty-one of these isolates were ST250-IV methicillin-resistant S. aureus (MRSA. Notably, 25 (81% of the 31 patients carried or were infected with S. aureus within 24 h of admission. Genome comparisons revealed six distinct S. aureus clones circulating in the burn unit, and demonstrated multiple transmission events between patients and healthcare workers. Further, the collected S. aureus isolates exhibited a wide range of genotypic resistances to antibiotics, including trimethoprim (21%, aminoglycosides (33%, oxacillin (33%, chloramphenicol (50%, tetracycline (59% and fluoroquinolones (100%.Conclusion: Population genomics uncovered multiple transmission events of S. aureus, especially MRSA, within the investigated burn unit. Our findings highlight lapses in infection control and prevention, and underscore the great importance of active surveillance to protect burn victims against multi-drug resistant pathogens in resource-limited settings.
Catlin, Ann Christine; Fernando, Sumudinie; Gamage, Ruwan; Renner, Lorna; Antwi, Sampson; Tettey, Jonas Kusah; Amisah, Kofi Aikins; Kyriakides, Tassos; Cong, Xiangyu; Reynolds, Nancy R.; Paintsil, Elijah
Prevalence of pediatric HIV disclosure is low in resource-limited settings. Innovative, culturally sensitive, and patient-centered disclosure approaches are needed. Conducting such studies in resource-limited settings is not trivial considering the challenges of capturing, cleaning, and storing clinical research data. To overcome some of these challenges, the Sankofa pediatric disclosure intervention adopted an interactive cyber infrastructure for data capture and analysis. The Sankofa Project database system is built on the HUBzero cyber infrastructure (https://hubzero.org), an open source software platform. The hub database components support: (1) data management – the “databases” component creates, configures, and manages database access, backup, repositories, applications, and access control; (2) data collection – the “forms” component is used to build customized web case report forms that incorporate common data elements and include tailored form submit processing to handle error checking, data validation, and data linkage as the data are stored to the database; and (3) data exploration – the “dataviewer” component provides powerful methods for users to view, search, sort, navigate, explore, map, graph, visualize, aggregate, drill-down, compute, and export data from the database. The Sankofa cyber data management tool supports a user-friendly, secure, and systematic collection of all data. We have screened more than 400 child–caregiver dyads and enrolled nearly 300 dyads, with tens of thousands of data elements. The dataviews have successfully supported all data exploration and analysis needs of the Sankofa Project. Moreover, the ability of the sites to query and view data summaries has proven to be an incentive for collecting complete and accurate data. The data system has all the desirable attributes of an electronic data capture tool. It also provides an added advantage of building data management capacity in resource-limited settings
Soheyli, Saman; Shafiei Mayam, Mohamad Hossein; Mehrjoo, Mehri
Highlights: • Considering renewable energy resources as the main prime movers in CCHP systems. • Simultaneous application of FEL and FTL by optimizing two probability functions. • Simultaneous optimization the equipment and penalty factors by CC-MOPSO algorithm. • Reducing fuel consumption and pollution up to 263 and 353 times, respectively. - Abstract: Due to problems, such as, heat losses of equipment, low energy efficiency, increasing pollution and the fossil fuels consumption, combined cooling, heating, and power (CCHP) systems have attracted lots of attention during the last decade. In this paper, for minimizing fossil fuel consumption and pollution, a novel CCHP system including photovoltaic (PV) modules, wind turbines, and solid oxide fuel cells (SOFC) as the prime movers is considered. Moreover, in order to minimize the excess electrical and heat energy production of the CCHP system and so reducing the need for the local power grid and any auxiliary heat production system, following electrical load (FEL) and following thermal load (FTL) operation strategies are considered, simultaneously. In order to determine the optimal number of each system component and also set the penalty factors in the used penalty function, a co-constrained multi objective particle swarm optimization (CC-MOPSO) algorithm is applied. Utilization of the renewable energy resources, the annual total cost (ATC) and the CCHP system area are considered as the objective functions. It also includes constraints such as, loss of power supply probability (LPSP), loss of heat supply probability (LHSP), state of battery charge (SOC), and the number of each CCHP component. A hypothetical hotel in Kermanshah, Iran is conducted to verify the feasibility of the proposed system. 10 wind turbines, 430 PV modules, 11 SOFCs, 106 batteries and 2 heat storage tanks (HST) are numerical results for the spring as the best season in terms of decreasing cost and fuel consumption. Comparing the results
Mosepele, Mosepele; Botsile, Elizabeth
As access to effective antiretroviral therapy (ART) expands globally, a decline in AIDS-related morbidity and mortality has been complicated by rising rates of noncommunicable diseases (NCDs). This review provides a brief description of NCDs and existing gaps on knowledge about NCDs among HIV-infected adults mostly in Africa. Recent reports show that one in every five persons living with HIV has a chronic illness, predominantly diabetes and/or hypertension, depression, and most of these conditions are either not diagnosed or not being managed. Human papilloma virus-associated anal dysplasia occurs among 70% of HIV-infected women in RLS. Recognizing risk factors for NCDs and providing effective screening and optimal care remains challenging. Research is urgently needed to carefully characterize HIV-associated NCDs in RLS. Such studies should provide a framework for high-priority NCDs that the limited resources can be focused on in these settings.
Coutsoudis, Anna; Kwaan, Leith; Thomson, Mairi
One of the most exciting areas of HIV research is that of prevention of vertical transmission from mother to child, since it accounts for 90% of childhood HIV infections, and therefore prevention in this context has an enormous potential impact on the spread of HIV among children. Focused research has yielded highly successful strategies for reducing infant infection rates, particularly in the developed world, and much work is underway to implement appropriate strategies in resource-limited settings, although this is not without challenges. Although transmission rates in some settings have been reduced to approximately 1%, scale-up and widespread implementation and application of strategic interventions for prevention of mother-to-child transmission of HIV during pregnancy, delivery and breastfeeding are needed in the developing world.
Peeling, Rosanna W; McNerney, Ruth
Emerging molecular technologies to diagnose infectious diseases at the point at which care is delivered have the potential to save many lives in developing countries where access to laboratories is poor. Molecular tests are needed to improve the specificity of syndromic management, monitor progress towards disease elimination and screen for asymptomatic infections with the goal of interrupting disease transmission and preventing long-term sequelae. In simplifying laboratory-based molecular assays for use at point-of-care, there are inevitable compromises between cost, ease of use and test performance. Despite significant technological advances, many challenges remain for the development of molecular diagnostics for resource-limited settings. There needs to be more advocacy for these technologies to be applied to infectious diseases, increased efforts to lower the barriers to market entry through streamlined and harmonized regulatory approaches, faster policy development for adoption of new technologies and novel financing mechanisms to enable countries to scale up implementation.
Implementation of the Siteview(TM) computer software package designed to capture and manage reclamation data, by Canadian Natural Resources Limited is reported. Use of this software, developed by Pelodon Computer Enterprises in Calgary, enables Canadian Natural Resources to track from a single file data from each of over 3000 sites from the pre-construction stage right through to the final reclamation. Having all data in a single file permits the company to track the number of Reclamation Certificate applications submitted and received for a specific time period, helping them to capture the liability reduction and rental reduction associated with those sites and in general, manage their reclamation program more efficiently. Tracking the reclamation sites is by specific Site Status Codes, which allow the company to quickly determine current status of each site. Budgeting for reclamation can also be planned more accurately based on the current status of sites. Siteview(TM) also manages waste disposal information in the Guide 50 Drilling Waste Disposal Notification forms by digitally inputting all required data such as waste disposal location, mud system, and the volume of mud, and generating reports based on various waste disposal parameters. The software is also used by environmental consultants to track client's well site operations, and display them graphically in their reports, thus providing value-added services to their clients
Nemiroski, Alex; Christodouleas, Dionysios C; Hennek, Jonathan W; Kumar, Ashok A; Maxwell, E Jane; Fernández-Abedul, Maria Teresa; Whitesides, George M
This paper describes an inexpensive, handheld device that couples the most common forms of electrochemical analysis directly to "the cloud" using any mobile phone, for use in resource-limited settings. The device is designed to operate with a wide range of electrode formats, performs on-board mixing of samples by vibration, and transmits data over voice using audio--an approach that guarantees broad compatibility with any available mobile phone (from low-end phones to smartphones) or cellular network (second, third, and fourth generation). The electrochemical methods that we demonstrate enable quantitative, broadly applicable, and inexpensive sensing with flexibility based on a wide variety of important electroanalytical techniques (chronoamperometry, cyclic voltammetry, differential pulse voltammetry, square wave voltammetry, and potentiometry), each with different uses. Four applications demonstrate the analytical performance of the device: these involve the detection of (i) glucose in the blood for personal health, (ii) trace heavy metals (lead, cadmium, and zinc) in water for in-field environmental monitoring, (iii) sodium in urine for clinical analysis, and (iv) a malarial antigen (Plasmodium falciparum histidine-rich protein 2) for clinical research. The combination of these electrochemical capabilities in an affordable, handheld format that is compatible with any mobile phone or network worldwide guarantees that sophisticated diagnostic testing can be performed by users with a broad spectrum of needs, resources, and levels of technical expertise.
Benjamin C. McLellan
Full Text Available The nexus of minerals and energy becomes ever more important as the economic growth and development of countries in the global South accelerates and the needs of new energy technologies expand, while at the same time various important minerals are declining in grade and available reserves from conventional mining. Unconventional resources in the form of deep ocean deposits and urban ores are being widely examined, although exploitation is still limited. This paper examines some of the implications of the transition towards cleaner energy futures in parallel with the shifts through conventional ore decline and the uptake of unconventional mineral resources. Three energy scenarios, each with three levels of uptake of renewable energy, are assessed for the potential of critical minerals to restrict growth under 12 alternative mineral supply patterns. Under steady material intensities per unit of capacity, the study indicates that selenium, indium and tellurium could be barriers in the expansion of thin-film photovoltaics, while neodymium and dysprosium may delay the propagation of wind power. For fuel cells, no restrictions are observed.
Rumman, Nisreen; Jackson, Claire; Collins, Samuel; Goggin, Patricia; Coles, Janice; Lucas, Jane S
Primary ciliary dyskinesia is a genetic disease of ciliary function leading to chronic upper and lower respiratory tract symptoms. The diagnosis is frequently overlooked because the symptoms are nonspecific and the knowledge about the disease in the primary care setting is poor. Additionally, none of the available tests is accurate enough to be used in isolation. These tests are expensive, and need sophisticated equipment and expertise to analyse and interpret results; diagnosis is therefore only available at highly specialised centres. The diagnosis is particularly challenging in countries with limited resources due to the lack of such costly equipment and expertise.In this review, we discuss the importance of early and accurate diagnosis especially for countries where the disease is clinically prevalent but diagnostic tests are lacking. We review the diagnostic tests available in specialised centres (nasal nitric oxide, high-speed video microscopy, transmission electron microscopy, immunofluorescence and genetics). We then consider modifications that might be considered in less well-resourced countries whilst maintaining acceptable accuracy. Copyright ©ERS 2017.
Full Text Available Primary ciliary dyskinesia is a genetic disease of ciliary function leading to chronic upper and lower respiratory tract symptoms. The diagnosis is frequently overlooked because the symptoms are nonspecific and the knowledge about the disease in the primary care setting is poor. Additionally, none of the available tests is accurate enough to be used in isolation. These tests are expensive, and need sophisticated equipment and expertise to analyse and interpret results; diagnosis is therefore only available at highly specialised centres. The diagnosis is particularly challenging in countries with limited resources due to the lack of such costly equipment and expertise. In this review, we discuss the importance of early and accurate diagnosis especially for countries where the disease is clinically prevalent but diagnostic tests are lacking. We review the diagnostic tests available in specialised centres (nasal nitric oxide, high-speed video microscopy, transmission electron microscopy, immunofluorescence and genetics. We then consider modifications that might be considered in less well-resourced countries whilst maintaining acceptable accuracy.
Andrew W. Nelson
Full Text Available In resource-limited developing nations, such as Cameroon, the expense of modern water-quality monitoring techniques is prohibitive to frequent water testing, as is done in the developed world. Inexpensive, shelf-stable 3M™ Petrifilm™ Escherichia coli/Coliform Count Plates potentially can provide significant opportunity for routine water-quality monitoring in the absence of infrastructure for state-of-the-art testing. We used shelf-stable E. coli/coliform culture plates to assess the water quality at twenty sampling sites in Kumbo, Cameroon. Culture results from treated and untreated sources were compared to modern bacterial DNA pyrosequencing methods using established bioinformatics and statistical tools. Petrifilms were reproducible between replicates and sampling dates. Additionally, cultivation on Petrifilms suggests that treatment by the Kumbo Water Authority (KWA greatly improves water quality as compared with untreated river and rainwater. The majority of sequences detected were representative of common water and soil microbes, with a minority of sequences (<40% identified as belonging to genera common in fecal matter and/or causes of human disease. Water sources had variable DNA sequence counts that correlated significantly with the culture count data and may therefore be a proxy for bacterial load. Although the KWA does not meet Western standards for water quality (less than one coliform per 100 mL, KWA piped water is safer than locally available alternative water sources such as river and rainwater. The culture-based technology described is easily transferrable to resource-limited areas and provides local water authorities with valuable microbiological safety information with potential to protect public health in developing nations.
Dobbins, James T., III; Wells, Jered R.; Segars, W. Paul; Li, Christina M.; Kigongo, Christopher J. N.
This paper describes an initial investigation into means for producing lower-cost CT scanners for resource limited regions of the world. In regions such as sub-Saharan Africa, intermediate level medical facilities serving millions have no CT machines, and lack the imaging resources necessary to determine whether certain patients would benefit from being transferred to a hospital in a larger city for further diagnostic workup or treatment. Low-cost CT scanners would potentially be of immense help to the healthcare system in such regions. Such scanners would not produce state-of-theart image quality, but rather would be intended primarily for triaging purposes to determine the patients who would benefit from transfer to larger hospitals. The lower-cost scanner investigated here consists of a fixed digital radiography system and a rotating patient stage. This paper describes initial experiments to determine if such a configuration is feasible. Experiments were conducted using (1) x-ray image acquisition, a physical anthropomorphic chest phantom, and a flat-panel detector system, and (2) a computer-simulated XCAT chest phantom. Both the physical phantom and simulated phantom produced excellent image quality reconstructions when the phantom was perfectly aligned during acquisition, but artifacts were noted when the phantom was displaced to simulate patient motion. An algorithm was developed to correct for motion of the phantom and demonstrated success in correcting for 5-mm motion during 360-degree acquisition of images. These experiments demonstrated feasibility for this approach, but additional work is required to determine the exact limitations produced by patient motion.
Leski Tomasz A
Full Text Available Abstract Background Resource-limited tropical countries are home to numerous infectious pathogens of both human and zoonotic origin. A capability for early detection to allow rapid outbreak containment and prevent spread to non-endemic regions is severely impaired by inadequate diagnostic laboratory capacity, the absence of a “cold chain” and the lack of highly trained personnel. Building up detection capacity in these countries by direct replication of the systems existing in developed countries is not a feasible approach and instead requires “leapfrogging” to the deployment of the newest diagnostic systems that do not have the infrastructure requirements of systems used in developed countries. Methods A laboratory for molecular diagnostics of infectious agents was established in Bo, Sierra Leone with a hybrid solar/diesel/battery system to ensure stable power supply and a satellite modem to enable efficient communication. An array of room temperature stabilization and refrigeration technologies for reliable transport and storage of reagents and biological samples were also tested to ensure sustainable laboratory supplies for diagnostic assays. Results The laboratory demonstrated its operational proficiency by conducting an investigation of a suspected avian influenza outbreak at a commercial poultry farm at Bo using broad range resequencing microarrays and real time RT-PCR. The results of the investigation excluded influenza viruses as a possible cause of the outbreak and indicated a link between the outbreak and the presence of Klebsiella pneumoniae. Conclusions This study demonstrated that by application of a carefully selected set of technologies and sufficient personnel training, it is feasible to deploy and effectively use a broad-range infectious pathogen detection technology in a severely resource-limited setting.
Full Text Available Samuel N Uwaezuoke Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku–Ozalla, Enugu, Nigeria Abstract: Kangaroo mother care (KMC represents an intervention in low birth weight infants for resource-limited settings which aims to reduce mortality rates by thermoregulation, supporting breastfeeding, and promoting early hospital discharge. In terms of cost and impact on neonatal survival, it has comparative advantages over the conventional method of care (CMC. This paper aimed to review the evidence concerning the progress of KMC implementation, its health benefits, and its cost-effectiveness, especially in developing countries. From the synthesized evidence, KMC was shown to be a useful adjunct to CMC particularly with respect to improving neonatal survival, supporting breastfeeding, and promoting early discharge from the hospital. Substantial progress has been made in its implementation in many developing countries where facility-based KMC has been institutionalized. Despite the cost-effectiveness of KMC in neonatal care, its global implementation is bedeviled with country-specific, multifaceted challenges. In developed countries, there is an implementation gap due to easy accessibility to technology-based CMC. Nevertheless, many developing countries have initiated national policies to scale up KMC services in their domain. Given the major constraints to program implementation peculiar to these resource-limited countries, it has become imperative to boost caregiver confidence and experience using dedicated spaces in the hospital, as well as dedicated staff meant for adequate ambulatory follow-up and continuous health education. Capacity training for health professionals and provision of space infrastructure thus constitute the basic needs which could be funded by International Aid Agencies in order to scale up the program in these settings. Keywords: neonatal care, low birth weight infants, thermoregulation, breastfeeding
Sazykina, Tatiana G; Kryshev, Alexander I
A dynamic mathematical model is formulated, predicting the development of radiation effects in a generic animal population, inhabiting an elemental ecosystem 'population-limiting resource'. Differential equations of the model describe the dynamic responses to radiation damage of the following population characteristics: gross biomass; intrinsic fractions of healthy and reversibly damaged tissues in biomass; intrinsic concentrations of the self-repairing pool and the growth factor; and amount of the limiting resource available in the environment. Analytical formulae are found for the steady states of model variables as non-linear functions of the dose rate of chronic radiation exposure. Analytical solutions make it possible to predict the expected severity of radiation effects in a model ecosystem, including such endpoints as morbidity, mortality, life shortening, biosynthesis, and population biomass. Model parameters are selected from species data on lifespan, physiological growth and mortality rates, and individual radiosensitivity. Thresholds for population extinction can be analytically calculated for different animal species, examples are provided for generic mice and wolf populations. The ecosystem model demonstrates a compensatory effect of the environment on the development of radiation effects in wildlife. The model can be employed to construct a preliminary scale 'radiation exposure-population effects' for different animal species; species can be identified, which are vulnerable at a population level to chronic radiation exposure. Copyright © 2015. Published by Elsevier Ltd.
Sparrow, Asley; Gregorich, Ed; Hopkins, David
Although Antarctic dry valley soils function under some of the harshest environmental conditions on the planet, there is significant biological activity concentrated in small areas in the landscape. These productive areas serve as a source of C and N in organic matter redistributed to the surroun......Although Antarctic dry valley soils function under some of the harshest environmental conditions on the planet, there is significant biological activity concentrated in small areas in the landscape. These productive areas serve as a source of C and N in organic matter redistributed...... to the surrounding biologically impoverished soils. We conducted a 3-yr replicated field experiment involving soil amendment with C and N in simple (glucose and NH4Cl) and complex (glycine and lacustrine detritus) forms to evaluate the resource limitations on soil microbial activity in an Antarctic dry valley....... The respiratory response for all substrates was slow, with a significant but weak response to NH4Cl, followed by a more widespread response to all substrates after 2 yr and in laboratory incubations conducted 3 yr after substrate addition. This response suggests that the soil microbial community is N limited and...
Mulchandani, Rubina; Lyngdoh, Tanica; Chakraborty, Praloy; Kakkar, Ashish Kumar
Statins are the most widely prescribed class of drugs for coronary artery disease (CAD) patients and yet literature on the prevalence of statin related adverse effects (AEs) and gaps in patient education is quite limited especially in resource-limited settings of developing world. The present study was conducted to determine the prevalence of myopathy (muscle ailments) and other statin associated adverse effects among CAD patients on statin therapy. The study also aimed to assess patient perceptions, attitudes and awareness concerning the use of statins. It was a cross-sectional study conducted among 300 adult CAD patients visiting the out-patient department of a tertiary care hospital in North India, who were receiving statins for their diagnosis. An interviewer administered questionnaire was used to collect data on statin use among patients and adverse effects experienced. Myopathy or muscle related ailments like muscle pain, cramps and muscle weakness were the most prevalent (32, 34 and 47%, respectively), followed by numbness, tingling and burning in the extremities (31%). Joint pain and cognitive impairments were seen in nearly 20% of the patients. The level of awareness among participants regarding the use of statins was sub-optimal. Lack of knowledge and under-reporting of adverse effects were major concerns. The study shows that a considerable proportion of statin users experience adverse effects and knowledge and awareness amongst patients is inadequate. Awareness programmes and counselling for patients, sensitisation of healthcare professionals and better screening systems for monitoring AEs can help improve the scenario.
Leligdowicz, Aleksandra; Bhagwanjee, Satish; Diaz, Janet V; Xiong, Wei; Marshall, John C; Fowler, Robert A; Adhikari, Neill Kj
Capacity to provide critical care in resource-limited settings is poorly understood because of lack of data about resources available to manage critically ill patients. Our objective was to develop a survey to address this issue. We developed and piloted a cross-sectional self-administered survey in 9 resource-limited countries. The survey consisted of 8 domains; specific items within domains were modified from previously developed survey tools. We distributed the survey by e-mail to a convenience sample of health care providers responsible for providing care to critically ill patients. We assessed clinical sensibility and test-retest reliability. Nine of 15 health care providers responded to the survey on 2 separate occasions, separated by 2 to 4 weeks. Clinical sensibility was high (3.9-4.9/5 on assessment tool). Test-retest reliability for questions related to resource availability was acceptable (intraclass correlation coefficient, 0.94; 95% confidence interval, 0.75-0.99; mean (SD) of weighted κ values = 0.67 [0.19]). The mean (SD) time for survey completion survey was 21 (16) minutes. A reliable cross-sectional survey of available resources to manage critically ill patients can be feasibly administered to health care providers in resource-limited settings. The survey will inform future research focusing on access to critical care where it is poorly described but urgently needed. Copyright © 2016 Elsevier Inc. All rights reserved.
Full Text Available Jessica S Grignon,1,2 Jenny H Ledikwe,1,2 Ditsapelo Makati,2 Robert Nyangah,2 Baraedi W Sento,2 Bazghina-werq Semo1,2 1Department of Global Health, University of Washington, Seattle, WA, USA; 2International Training and Education Center for Health, Gaborone, Botswana Abstract: To address health systems challenges in limited-resource settings, global health initiatives, particularly the President's Emergency Plan for AIDS Relief, have seconded health workers to the public sector. Implementation considerations for secondment as a health workforce development strategy are not well documented. The purpose of this article is to present outcomes, best practices, and lessons learned from a President's Emergency Plan for AIDS Relief-funded secondment program in Botswana. Outcomes are documented across four World Health Organization health systems' building blocks. Best practices include documentation of joint stakeholder expectations, collaborative recruitment, and early identification of counterparts. Lessons learned include inadequate ownership, a two-tier employment system, and ill-defined position duration. These findings can inform program and policy development to maximize the benefit of health workforce secondment. Secondment requires substantial investment, and emphasis should be placed on high-level technical positions responsible for building systems, developing health workers, and strengthening government to translate policy into programs. Keywords: human resources, health policy, health worker, HIV/AIDS, PEPFAR
Sheri L Lewis
Full Text Available Public health surveillance is undergoing a revolution driven by advances in the field of information technology. Many countries have experienced vast improvements in the collection, ingestion, analysis, visualization, and dissemination of public health data. Resource-limited countries have lagged behind due to challenges in information technology infrastructure, public health resources, and the costs of proprietary software. The Suite for Automated Global Electronic bioSurveillance (SAGES is a collection of modular, flexible, freely-available software tools for electronic disease surveillance in resource-limited settings. One or more SAGES tools may be used in concert with existing surveillance applications or the SAGES tools may be used en masse for an end-to-end biosurveillance capability. This flexibility allows for the development of an inexpensive, customized, and sustainable disease surveillance system. The ability to rapidly assess anomalous disease activity may lead to more efficient use of limited resources and better compliance with World Health Organization International Health Regulations.
Ralston, Mark E; Myatt, Mark A
A simple, reliable anthropometric tool for rapid estimation of weight in children would be useful in limited-resource settings where current weight estimation tools are not uniformly reliable, nearly all global under-five mortality occurs, severe acute malnutrition is a significant contributor in approximately one-third of under-five mortality, and a weight scale may not be immediately available in emergencies to first-response providers. To determine the accuracy and precision of mid-upper arm circumference (MUAC) and height as weight estimation tools in children under five years of age in low-to-middle income countries. This was a retrospective observational study. Data were collected in 560 nutritional surveys during 1992-2006 using a modified Expanded Program of Immunization two-stage cluster sample design. Locations with high prevalence of acute and chronic malnutrition. A total of 453,990 children met inclusion criteria (age 6-59 months; weight ≤ 25 kg; MUAC 80-200 mm) and exclusion criteria (bilateral pitting edema; biologically implausible weight-for-height z-score (WHZ), weight-for-age z-score (WAZ), and height-for-age z-score (HAZ) values). Weight was estimated using Broselow Tape, Hong Kong formula, and database MUAC alone, height alone, and height and MUAC combined. Mean percentage difference between true and estimated weight, proportion of estimates accurate to within ± 25% and ± 10% of true weight, weighted Kappa statistic, and Bland-Altman bias were reported as measures of tool accuracy. Standard deviation of mean percentage difference and Bland-Altman 95% limits of agreement were reported as measures of tool precision. Database height was a more accurate and precise predictor of weight compared to Broselow Tape 2007 [B], Broselow Tape 2011 [A], and MUAC. Mean percentage difference between true and estimated weight was +0.49% (SD = 10.33%); proportion of estimates accurate to within ± 25% of true weight was 97.36% (95% CI 97.40%, 97.46%); and
Mark E Ralston
Full Text Available A simple, reliable anthropometric tool for rapid estimation of weight in children would be useful in limited-resource settings where current weight estimation tools are not uniformly reliable, nearly all global under-five mortality occurs, severe acute malnutrition is a significant contributor in approximately one-third of under-five mortality, and a weight scale may not be immediately available in emergencies to first-response providers.To determine the accuracy and precision of mid-upper arm circumference (MUAC and height as weight estimation tools in children under five years of age in low-to-middle income countries.This was a retrospective observational study. Data were collected in 560 nutritional surveys during 1992-2006 using a modified Expanded Program of Immunization two-stage cluster sample design.Locations with high prevalence of acute and chronic malnutrition.A total of 453,990 children met inclusion criteria (age 6-59 months; weight ≤ 25 kg; MUAC 80-200 mm and exclusion criteria (bilateral pitting edema; biologically implausible weight-for-height z-score (WHZ, weight-for-age z-score (WAZ, and height-for-age z-score (HAZ values.Weight was estimated using Broselow Tape, Hong Kong formula, and database MUAC alone, height alone, and height and MUAC combined.Mean percentage difference between true and estimated weight, proportion of estimates accurate to within ± 25% and ± 10% of true weight, weighted Kappa statistic, and Bland-Altman bias were reported as measures of tool accuracy. Standard deviation of mean percentage difference and Bland-Altman 95% limits of agreement were reported as measures of tool precision.Database height was a more accurate and precise predictor of weight compared to Broselow Tape 2007 [B], Broselow Tape 2011 [A], and MUAC. Mean percentage difference between true and estimated weight was +0.49% (SD = 10.33%; proportion of estimates accurate to within ± 25% of true weight was 97.36% (95% CI 97.40%, 97
Autry, Amy M; Knight, Sharon; Lester, Felicia; Dubowitz, Gerald; Byamugisha, Josaphat; Nsubuga, Yosam; Muyingo, Mark; Korn, Abner
To study the feasibility and acceptability of using video Internet communication to teach and evaluate surgical skills in a low-resource setting. This case-controlled study used video Internet communication for surgical skills teaching and evaluation. We randomized intern physicians rotating in the Obstetrics and Gynecology Department at Mulago Hospital at Makerere University in Kampala, Uganda, to the control arm (usual practice) or intervention arm (three video teaching sessions with University of California, San Francisco faculty). We made preintervention and postintervention videos of all interns tying knots using a small video camera and uploaded the files to a file hosting service that offers cloud storage. A blinded faculty member graded all of the videos. Both groups completed a survey at the end of the study. We randomized 18 interns with complete data for eight in the intervention group and seven in the control group. We found score improvement of 50% or more in six of eight (75%) interns in the intervention group compared with one of seven (14%) in the control group (P=.04). Scores declined in five of the seven (71%) controls but in none in the intervention group. Both intervention and control groups used attendings, colleagues, and the Internet as sources for learning about knot-tying. The control group was less likely to practice knot-tying than the intervention group. The trainees and the instructors felt this method of training was enjoyable and helpful. Remote teaching in low-resource settings, where faculty time is limited and access to visiting faculty is sporadic, is feasible, effective, and well-accepted by both learner and teacher. II.
Bahr, Nathan C; Rolfes, Melissa A; Musubire, Abdu; Nabeta, Henry; Williams, Darlisha A; Rhein, Joshua; Kambugu, Andrew; Meya, David B; Boulware, David R
Amphotericin B is the preferred treatment for cryptococcal meningitis, but it has cumulative severe side effects, including nephrotoxicity, hypokalemia, and hypomagnesemia. Amphotericin-induced severe hypokalemia may predispose the patient to cardiac arrhythmias and death, and there is very little data available regarding these toxicities in resource-limited settings. We hypothesized that standardized electrolyte management during amphotericin therapy is essential to minimize toxicity and optimize survival in sub-Saharan Africa. Human immunodeficiency virus-infected, antiretroviral therapy naive adults with cryptococcal meningitis were prospectively enrolled at Mulago Hospital in Kampala, Uganda in 3 sequential cohorts with amphotericin B deoxycholate induction treatment. Intravenous fluid use was intermittent in 2001-2002, and universal in 2006-2012. In 2001-2009, serum potassium (K(+)) was monitored on days 1, 7, and 14 of treatment with replacement (K(+), Mg(2+)) per clinician discretion. In 2011-2012, K(+) was measured on days 1, 5, and approximately every 48 hours thereafter with universal electrolyte (K(+), Mg(2+)) supplementation and standardized replacement. Clinical outcomes were retrospectively compared between fluid and electrolyte management strategies. With limited intravenous fluids, the 14-day survival was 49% in 2001-2002. With universal intravenous fluids, the 30-day survival improved to 62% in 2006-2010 (P = .003). In 2011-2012, with universal supplementation of fluids and electrolytes, 30-day cumulative survival improved to 78% (P = .021 vs 2006-2010 cohort). The cumulative incidence of severe hypokalemia (<2.5 mEq/L) decreased from 38% in 2010 to 8.5% in 2011-2012 with universal supplementation (P < .001). Improved survival was seen in a resource-limited setting with proactive fluid and electrolyte management (K(+), Mg(2+)), as part of comprehensive amphotericin-based cryptococcal therapy.
Goga, Ameena Ebrahim; Singh, Yagespari; Singh, Michelle; Noveve, Nobuntu; Magasana, Vuyolwethu; Ramraj, Trisha; Abdullah, Fareed; Coovadia, Ashraf H; Bhardwaj, Sanjana; Sherman, Gayle G
Introduction Increasing access to HIV-related care and treatment for children aged 0-18 years in resource-limited settings is an urgent global priority. In 2011-2012 the percentage increase in children accessing antiretroviral therapy was approximately half that of adults (11 vs. 21 %). We propose a model for increasing access to, and retention in, paediatric HIV care and treatment in resource-limited settings. Methods Following a rapid appraisal of recent literature seven main challenges in paediatric HIV-related care and treatment were identified: (1) lack of regular, integrated, ongoing HIV-related diagnosis; (2) weak facility-based systems for tracking and retention in care; (3) interrupted availability of dried blood spot cards (expiration/stock outs); (4) poor quality control of rapid HIV testing; (5) supply-related gaps at health facility-laboratory interface; (6) poor uptake of HIV testing, possibly relating to a fatalistic belief about HIV infection; (7) community-associated reasons e.g. non-disclosure and weak systems for social support, resulting in poor retention in care. Results To increase sustained access to paediatric HIV-related care and treatment, regular updating of Policies, review of inter-sectoral Plans (at facility and community levels) and evaluation of Programme implementation and impact (at national, subnational, facility and community levels) are non-negotiable critical elements. Additionally we recommend the intensified implementation of seven main interventions: (1) update or refresher messaging for health care staff and simple messaging for key staff at early childhood development centres and schools; (2) contact tracing, disclosure and retention monitoring; (3) paying particular attention to infant dried blood spot (DBS) stock control; (4) regular quality assurance of rapid HIV testing procedures; (5) workshops/meetings/dialogues between health facilities and laboratories to resolve transport-related gaps and to facilitate return of
Cohen, S.A.; Hosea, J.C.; Timberlake, J.R.
A limiter with a specially contoured front face is provided. The front face of the limiter (the plasma-side face) is flat with a central indentation. In addition, the limiter shape is cylindrically symmetric so that the limiter can be rotated for greater heat distribution. This limiter shape accommodates the various power scrape-off distances lambda p, which depend on the parallel velocity, V/sub parallel/, of the impacting particles.
Wexler, Bryan; Smith, Mary-Elise
In this article the authors provide an overview of some issues that inhibit disaster planning and response for people experiencing homelessness and discuss the planning process conducted for this population in Worcester, MA. People experiencing homelessness face numerous challenges in preparing for disasters both natural and human caused. Similarly, providers attempting to aid these individuals must recognize and overcome various factors that hamper efforts to provide assistance. People experiencing homelessness lack the general resources many in the United States take for granted, including food, shelter, communication methods, and transportation. The population also has an increased prevalence of medical and psychiatric conditions. These factors amplify the typical difficulties in preparedness, communication, sheltering, and training for disasters. With these principles in mind, the authors reviewed the literature for best practices, identified potential stakeholders, and developed an annex to help address organization and delivery of care to those experiencing homelessness during a disaster.
Jane J Kim
Full Text Available Increasing evidence supporting the value of screening women for cervical cancer once in their lifetime, coupled with mounting interest in scaling up successful screening demonstration projects, present challenges to public health decision makers seeking to take full advantage of the single-visit opportunity to provide additional services. We present an analytic framework for packaging multiple interventions during a single point of contact, explicitly taking into account a budget and scarce human resources, constraints acknowledged as significant obstacles for provision of health services in poor countries.We developed a binary integer programming (IP model capable of identifying an optimal package of health services to be provided during a single visit for a particular target population. Inputs to the IP model are derived using state-transition models, which compute lifetime costs and health benefits associated with each intervention. In a simplified example of a single lifetime cervical cancer screening visit, we identified packages of interventions among six diseases that maximized disability-adjusted life years (DALYs averted subject to budget and human resource constraints in four resource-poor regions. Data were obtained from regional reports and surveys from the World Health Organization, international databases, the published literature, and expert opinion. With only a budget constraint, interventions for depression and iron deficiency anemia were packaged with cervical cancer screening, while the more costly breast cancer and cardiovascular disease interventions were not. Including personnel constraints resulted in shifting of interventions included in the package, not only across diseases but also between low- and high-intensity intervention options within diseases.The results of our example suggest several key themes: Packaging other interventions during a one-time visit has the potential to increase health gains; the shortage of
Full Text Available Abstract Background We present an innovative approach to healthcare worker (HCW training using mobile phones as a personal learning environment. Twenty physicians used individual Smartphones (Nokia N95 and iPhone, each equipped with a portable solar charger. Doctors worked in urban and peri-urban HIV/AIDS clinics in Peru, where almost 70% of the nation's HIV patients in need are on treatment. A set of 3D learning scenarios simulating interactive clinical cases was developed and adapted to the Smartphones for a continuing medical education program lasting 3 months. A mobile educational platform supporting learning events tracked participant learning progress. A discussion forum accessible via mobile connected participants to a group of HIV specialists available for back-up of the medical information. Learning outcomes were verified through mobile quizzes using multiple choice questions at the end of each module. Methods In December 2009, a mid-term evaluation was conducted, targeting both technical feasibility and user satisfaction. It also highlighted user perception of the program and the technical challenges encountered using mobile devices for lifelong learning. Results With a response rate of 90% (18/20 questionnaires returned, the overall satisfaction of using mobile tools was generally greater for the iPhone. Access to Skype and Facebook, screen/keyboard size, and image quality were cited as more troublesome for the Nokia N95 compared to the iPhone. Conclusions Training, supervision and clinical mentoring of health workers are the cornerstone of the scaling up process of HIV/AIDS care in resource-limited settings (RLSs. Educational modules on mobile phones can give flexibility to HCWs for accessing learning content anywhere. However lack of softwares interoperability and the high investment cost for the Smartphones' purchase could represent a limitation to the wide spread use of such kind mLearning programs in RLSs.
Marks, Michael; Mabey, David Cw
Syphilis remains an important and preventable cause of stillbirth and neonatal mortality. About 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby and 33% a low birth weight baby with an increased chance of dying in the first month of life. Adverse pregnancy outcomes due to syphilis can be prevented by screening pregnant women, and treating those who test positive with a single dose of penicillin before 28 weeks' gestation. Areas covered: This manuscript covers the impact of syphilis on pregnancy outcome, the diagnosis of syphilis, with a special focus on point of care (POC) tests, and challenges to the introduction of POC tests, and their potential impact on the control and prevention of syphilis in resource limited settings. Expert commentary: POC tests for syphilis are available which meet the ASSURED criteria, and could make syphilis screening accessible to all women anywhere in the world who attend an antenatal clinic. High quality dual POC tests for HIV and syphilis could ensure that well-funded programmes for the prevention of mother to child transmission of HIV can contribute towards increased coverage of antenatal syphilis screening, and prevent more than 300,000 adverse pregnancy outcomes due to syphilis annually. Alongside investment to increase availability of syphilis POC tests, operational research is needed to understand how best to improve screening of pregnant women and to translate test availability into improved pregnancy outcomes.
Full Text Available The aim of this work is to analyse the role that typical products can play in the local development process. Territorial resources involved, limits and strategies for their enhancement are analysed; this analysis will permit both to define the results that have been achieved since nowadays in the local development process and to point out future themes for the research in the field of agricultural economics. The typicality of an agri-food product regards qualitative characteristics that derive from its tie with the territory, this tie becomes a relevant element for the differentiation of the typical product from the others. In this context, the typical product maintains all the specificities associated to its origin, involving also aspects related to the traditions and the culture of the territories, to the collective dimension and to the local knowledge. Consumers tent to look for good which are differentiated and to connect authenticity and local specificity of food with healthiness. Due to the strong socio-economic ties that typical products have with the territory, they play a crucial role in the economy of the local systems and can promote development in lagging areas.
Karki, Bindu; Kittel, Guenter; Bolokon, Ignatius; Duke, Trevor
Papua New Guinea is one of the 14 highest-burden countries for tuberculosis (TB) infection, but few community-based studies exist. We evaluated a low-cost method of active community case finding in Kabwum and Wasu in Morobe Province, Papua New Guinea. Over 3 months we visited 26 villages and screened adults and children for symptoms and signs of TB. Sputum samples were examined using smear microscopy. A total of 1700 people had chronic symptoms, of which 267 were suspicious for TB on further examination. Sputum from 230 symptomatic adults yielded 97 samples that were positive for acid-fast bacilli. In addition, 15 cases of extrapulmonary TB in adults and 17 cases of TB in children were identified. One hundred and thirty people were identified with active TB disease among the source population of approximately 17 000, giving an estimated prevalence of 765 per 100 000. One hundred and six (82%) cases were not previously diagnosed. The cost per case identified was US$146. It is feasible to conduct active community-based case finding and treatment initiation for TB with limited resources and in remote areas, and in Papua New Guinea the yield was high. Active case finding and follow-up of treatment in villages is needed to address the hidden burden of TB in Papua New Guinea and other high-burden Asia Pacific countries. PMID:28033717
Full Text Available This research analyzes the role of prosocialness and trust in the use of water as a limited resource under situations of competition or cooperation. For this purpose, 107 participants played the role of farmers and made decisions about irrigating their fields in the web-based multiplayer game Irrigania. Before the simulation exercise, participants’ prosocialness and trust levels were evaluated and they were randomly assigned to an experimental condition (competition or cooperation. Repeated measures analysis, using the 10 fields and the experimental conditions as factors, showed that, in the cooperation condition, farmers and their villages used a less selfish strategy to cultivate their fields, which produced greater benefits. Under competition, benefits to farmers and their villages were reduced over time. Mediational analysis shows that the selfish irrigation strategy fully mediated the relationship between prosocialness and accumulated profits; prosocial individuals choose less selfish irrigation strategies and, in turn, accumulated more benefit. Moreover, moderation analysis shows that trust moderated the link between prosocialness and water use strategy by strengthening the negative effect of prosocialness on selection of selfish strategies. The implications of these results highlight the importance of promoting the necessary trust to develop prosocial strategies in collectives; therefore, the efficacy of interventions, such as the creation of cooperative educational contexts or organization of collective actions with groups affected by water scarcity, are discussed.
Background Kaposi’s sarcoma (KS) is the most frequently occurring cancer in Mozambique among men and the second most frequently occurring cancer among women. Effective therapeutic treatments for KS are poorly understood in this area. There is an unmet need to develop a simple but accurate tool for improved monitoring and diagnosis in a resource-limited setting. Standardized clinical photographs have been considered to be an essential part of the evaluation. Methods When a therapeutic response is achieved, nodular KS often exhibits a reduction of the thickness without a change in the base area of the lesion. To evaluate the vertical space along with other characters of a KS lesion, we have created an innovative imaging system with a consumer light-field camera attached to a miniature “photography studio” adaptor. The image file can be further processed by computational methods for quantification. Results With this novel imaging system, each high-quality 3D image was consistently obtained with a single camera shot at bedside by minimally trained personnel. After computational processing, all-focused photos and measurable 3D parameters were obtained. More than 80 KS image sets were processed in a semi-automated fashion. Conclusions In this proof-of-concept study, the feasibility to use a simple, low-cost and user-friendly system has been established for future clinical study to monitor KS therapeutic response. This 3D imaging system can be also applied to obtain standardized clinical photographs for other diseases. PMID:24929434
Charles Edward Tunuka
Full Text Available Introduction. Clinical evaluation of patients with torso trauma is often a diagnostic challenge. Extended focused assessment with sonography for trauma (EFAST is an emergency ultrasound scan that adds to the evaluation of intrathoracic abdominal and pericardial cavities done in FAST (focused assessment with sonography for trauma. Objective. This study compares EFAST (the index test with the routine standard of care (SoC investigations (the standard reference test for torso trauma injuries. Methods. A cross-sectional descriptive study was conducted over a 3-month period. Eligible patients underwent EFAST scanning and the SoC assessment. The diagnostic accuracy of EFAST was calculated using sensitivity and specificity scores. Results. We recruited 197 patients; the M : F ratio was 5 : 1, with mean age of 27 years (SD 11. The sensitivity of EFAST was 100%, the specificity was 97%, the PPV was 87%, and the NPV was 100%. It took 5 minutes on average to complete an EFAST scan. 168 (85% patients were EFAST-scanned. Most patients (82 (48% were discharged on the same day of hospitalization, while 7 (4% were still at the hospital after two weeks. The mortality rate was 18 (9%. Conclusion. EFAST is a reliable method of diagnosing torso injuries in a resource limited context.
Cuadrado, Esther; Tabernero, Carmen; García, Rocío; Luque, Bárbara; Seibert, Jan
This research analyzes the role of prosocialness and trust in the use of water as a limited resource under situations of competition or cooperation. For this purpose, 107 participants played the role of farmers and made decisions about irrigating their fields in the web-based multiplayer game Irrigania. Before the simulation exercise, participants’ prosocialness and trust levels were evaluated and they were randomly assigned to an experimental condition (competition or cooperation). Repeated measures analysis, using the 10 fields and the experimental conditions as factors, showed that, in the cooperation condition, farmers and their villages used a less selfish strategy to cultivate their fields, which produced greater benefits. Under competition, benefits to farmers and their villages were reduced over time. Mediational analysis shows that the selfish irrigation strategy fully mediated the relationship between prosocialness and accumulated profits; prosocial individuals choose less selfish irrigation strategies and, in turn, accumulated more benefit. Moreover, moderation analysis shows that trust moderated the link between prosocialness and water use strategy by strengthening the negative effect of prosocialness on selection of selfish strategies. The implications of these results highlight the importance of promoting the necessary trust to develop prosocial strategies in collectives; therefore, the efficacy of interventions, such as the creation of cooperative educational contexts or organization of collective actions with groups affected by water scarcity, are discussed. PMID:28533760
Minugh, P. Allison; Janke, Susan L.; Lomuto, Nicoletta A.; Galloway, Diane K.
Context: Rural and frontier states are significantly affected by substance abuse and poverty. The high rate of substance abuse coupled with high levels of dependence on state-funded treatment systems places a burden on rural treatment systems and makes resource allocation a central planning issue. Purpose: The goal of this study was to combine…
Sloan, Derek; Dlamini, Sipho; Paul, Navin; Dedicoat, Martin
Despite the advent and increasingly wide availability of antiretroviral therapy, cryptococcal meningitis (CM) remains a significant cause of mortality and morbidity amongst individuals with HIV infection in resource-limited settings. The ideal management of CM remains unclear. The aim of this review is to assess the evidence for deciding on which antifungal regimen to use as well as other modalities of management to utilise especially resource poor settings in order to achieve the best possible outcome and enable an individual with CM to survive their acute illness and benefit from antiretroviral therapy. To determine the most effective initial and consolidation treatment strategy for CM in HIV infected adults. The Cochrane HIV/AIDS group search strategy was used. Key words in the search included, meningitis, cryptococcus neoformans, treatment, trial, human immunodeficiency virus, acquired immunodeficiency syndrome, antifungal agents, amphotericin, flucytosine, fluconazole, azole, lumbar puncture, cerebrospinal fluid (CSF) pressure and acetazolamide. Randomised of HIV-infected adults with a first episode of CM diagnosed on CSF examination, by India ink staining, CSF culture or cryptococcal antigen testing. Data were extracted using standardised forms and analysed using Rev Man 4.2.7 software. Six studies are included in the review. Five of the studies compared antifungal treatments and one study addressed lowering intracranial pressure. This study was stopped early due to excess adverse effects. The results of the other five studies as summarised as follows.Mayanja-Kizza 1998 compared fluconazole to fluconazole with 5 flucytosine. The dose of fluconazole used 200mg initially is lower than the recommended initial dose of 400mg. No survival advantage was found with the use of 5 flucytosine in addition to fluconazole.Two studies Brouwer 2004 and van der Horst 1997 compared Amphotericin (AmB) to AmB with 5 flucytosine. Both drugs were given at currently recommended
Drummond, Jennifer L; Were, Martin C; Arrossi, Silvina; Wools-Kaloustian, Kara
Appropriate collection and use of health information is critical to the planning, scaling up, and improvement of cervical cancer programs. The health information systems implementation landscape is unique to each country; however, systems serving cervical cancer programs in low-resource settings share characteristics that present common challenges. In response, many programs have taken innovative approaches to generating the quality information needed for decision making. Recent advances in health information technology also provide feasible solutions to challenges. This article draws from the experiences of the authors and from current literature to describe outstanding challenges and promising practices in the implementation of cervical cancer data systems, and to make recommendations for next steps. Recommendations include engaging all stakeholders-including providers, program managers, implementing partners, and donors-in promoting national, district, and community information systems; building on existing systems and processes, as well as introducing new technologies; and evolving data collection and data systems as programs advance. © 2017 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.
Chidambaram, Swathi; Nair, M Nathan; Krishnan, Shyam Sundar; Cai, Ling; Gu, Weiling; Vasudevan, Madabushi Chakravarthy
Postoperative central nervous system infections (PCNSIs) are rare but serious complications after neurosurgery. The purpose of this study was to examine the prevalence and causative pathogens of PCNSIs at a modernized, resource-limited neurosurgical center in South Asia. A retrospective analysis was conducted of the medical records of all 363 neurosurgical cases performed between June 1, 2012, and June 30, 2013, at a neurosurgical center in South Asia. Data from all operative neurosurgical cases during the 13-month period were included. Cerebrospinal fluid (CSF) analysis indicated that 71 of the 363 surgical cases had low CSF glucose or CSF leukocytosis. These 71 cases were categorized as PCNSIs. The PCNSIs with positive CSF cultures (9.86%) all had gram-negative bacteria with Pseudomonas aeruginosa (n = 5), Escherichia coli (n = 1), or Klebsiella pneumoniae (n = 1). The data suggest a higher rate of death (P = 0.031), a higher rate of CSF leak (P < 0.001), and a higher rate of cranial procedures (P < 0.001) among the infected patients and a higher rate of CSF leak among the patients with culture-positive infections (P = 0.038). This study summarizes the prevalence, causative organism of PCNSI, and antibiotic usage for all of the neurosurgical cases over a 13-month period in a modernized yet resource-limited neurosurgical center located in South Asia. The results from this study highlight the PCNSI landscape in an area of the world that is often underreported in the neurosurgical literature because of the paucity of clinical neurosurgical research undertaken there. This study shows an increasing prevalence of gram-negative organisms in CSF cultures from PCNSIs, which supports a trend in the recent literature of increasing gram-negative bacillary meningitis. Copyright © 2015 Elsevier Inc. All rights reserved.
El Tantawi, Maha M A; Abdelsalam, Maha M; Mourady, Ahmed M; Elrifae, Ismail M B
e-Assessment provides solutions to some problems encountered in dental students' evaluation. The aim of this study was to evaluate the experience of a limited-resources dental school with e-assessment provided through an open-source learning management system (LMS). Data about users' access and types of e-assessment activities at the Faculty of Dentistry, Alexandria University, Egypt, were obtained from the web-based LMS Moodle. A questionnaire developed to assess students' perceptions of the e-assessment was also sent to students registered in two courses (undergraduate and postgraduate) with the same instructor. The results showed that most e-courses at the school had one form of e-assessment (82%) and, of these, 16.7% had summative assessment activities. There were significant differences among departments in the number of e-courses with e-assessment. One-quarter of e-courses with e-assessment used Moodle quizzes. Of 285 students registered in the two courses that included the questionnaire, 170 responded (response rate=59.6%). The responding students positively perceived the impact of e-assessment on learning and its reliability and security, whereas technical issues and related stresses were negatively perceived. This study suggests that e-assessment can be used at minimal cost in dental schools with limited resources and large class sizes with the least demands on faculty members and teaching staff time. For these schools, an open-source LMS such as Moodle provides formative e-assessment not available otherwise and accommodates various question formats and varying levels of instructors' technical skills. These students seemed to have a positive impression of the e-assessment although technical problems and related stresses are issues that need to be addressed.
Bensman, Rachel S; Slusher, Tina M; Butteris, Sabrina M; Pitt, Michael B; On Behalf Of The Sugar Pearls Investigators; Becker, Amanda; Desai, Brinda; George, Alisha; Hagen, Scott; Kiragu, Andrew; Johannsen, Ron; Miller, Kathleen; Rule, Amy; Webber, Sarah
The authors describe a multiinstitutional collaborative project to address a gap in global health training by creating a free online platform to share a curriculum for performing procedures in resource-limited settings. This curriculum called PEARLS (Procedural Education for Adaptation to Resource-Limited Settings) consists of peer-reviewed instructional and demonstration videos describing modifications for performing common pediatric procedures in resource-limited settings. Adaptations range from the creation of a low-cost spacer for inhaled medications to a suction chamber for continued evacuation of a chest tube. By describing the collaborative process, we provide a model for educators in other fields to collate and disseminate procedural modifications adapted for their own specialty and location, ideally expanding this crowd-sourced curriculum to reach a wide audience of trainees and providers in global health.
Moore, B.; Savage, N.; Gladwell, J.S.; Warnick, C.C.
A brief overview is given of the physical, socioeconomic, and heritage resources of each KGRA summarized from the draft reports submitted to EG and G by subcontractors for this project. Included under the subheading of Physical Environment are geology, topography, and ecology with brief mention of climate, hydrology, and soils. Under Socioeconomic and Heritage Resources are demographic and economic data, land use and ownership, and known prehistoric and historic features. The information gaps are listed.
Lavarenne, C.; Rouyer, V. [IRSN, Fontenay aux Roses (France); Mennerdahl, D. [EMS, TABY (Sweden); Dean, C. [SERCO, Winfrith Technology Center, Dorchester, Dorset (United Kingdom); Barton, N. [Dept. for Transport, London (United Kingdom); Jean, F. [APTUS, Versailles (France)
Since 1998, there have been some speculations about future transport of significant quantities and concentrations of other actinide nuclides than the four currently listed in the regulation for the safe transport of the radioactive material. Therefore, it raised a need to specify exception limits for such actinides. In order to define credible exception limits, it was necessary to have reasonably accurate data for all actinide nuclides. Then the DGTREN/participants decided to perform calculations with different codes (MONK, MCNP, CRISTAL and SCALE) and different cross-section libraries (JEF2.2, ENDFB, etc.). The parameters of interest (such as k-infinite, critical masses) were determined. This article presents the work achieved and the questions raised, e.g. related to the effect of the radioactive decay of the isotopes on the criticality risks. It also points out the need for an evolution of the regulation of the safe transport of radioactive materials and gives a proposition of modification for the IAEA requirements related to, firstly, the list of the fissile materials, secondly, the rule to determine the quantities of actinide nuclides that can be excepted from the requirements for the packages containing fissile materials.
Lavarenne, C.; Rouyer, V.; Mennerdahl, D.; Dean, C.; Barton, N.; Jean, F.
Since 1998, there have been some speculations about future transport of significant quantities and concentrations of other actinide nuclides than the four currently listed in the regulation for the safe transport of the radioactive material. Therefore, it raised a need to specify exception limits for such actinides. In order to define credible exception limits, it was necessary to have reasonably accurate data for all actinide nuclides. Then the DGTREN/participants decided to perform calculations with different codes (MONK, MCNP, CRISTAL and SCALE) and different cross-section libraries (JEF2.2, ENDFB, etc.). The parameters of interest (such as k-infinite, critical masses) were determined. This article presents the work achieved and the questions raised, e.g. related to the effect of the radioactive decay of the isotopes on the criticality risks. It also points out the need for an evolution of the regulation of the safe transport of radioactive materials and gives a proposition of modification for the IAEA requirements related to, firstly, the list of the fissile materials, secondly, the rule to determine the quantities of actinide nuclides that can be excepted from the requirements for the packages containing fissile materials
Croft, Gregory Donald
below 36 of the 40 carbon emission scenarios from the IPCC, and the global peak of coal production from existing coalfields is predicted to occur about the year 2011. The peak coal production rate calculated here is 160 EJ/y, and the associated peak carbon emissions from coal burning are 4.5 Gt C per year. After 2011, the production rates of coal and CO2 decline, reaching 1990 levels by the year 2037, and reaching 50% of the peak value in the year 2047. It is unlikely that future mines will reverse the trend predicted in the base case scenario here, and current efforts to sequester carbon or to convert coal into liquid fuels should be reexamined in light of resource limits. (Abstract shortened by UMI.)
Rouhani, Shada A; Israel, Kerling; Leandre, Fernet; Pierre, Sosthène; Bollman, Brennan; Marsh, Regan H
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. 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. 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. 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.
Krelja Kurelovic, Elena
Educational resources in the competitive world of higher education were often considered as key intellectual property, so access to those resources was restricted to privileged groups of students and professors, which is unacceptable in today's networked society. Today, an increasing number of institutions and individuals share such digital…
Basu, Partha; Meheus, Filip; Chami, Youssef; Hariprasad, Roopa; Zhao, Fanghui; Sankaranarayanan, Rengaswamy
Management algorithms for screen-positive women in cervical cancer prevention programs have undergone substantial changes in recent years. The WHO strongly recommends human papillomavirus (HPV) testing for primary screening, if affordable, or if not, then visual inspection with acetic acid (VIA), and promotes treatment directly following screening through the screen-and-treat approach (one or two clinic visits). While VIA-positive women can be offered immediate ablative treatment based on certain eligibility criteria, HPV-positive women need to undergo subsequent VIA to determine their eligibility. Simpler ablative methods of treatment such as cryotherapy and thermal coagulation have been demonstrated to be effective and to have excellent safety profiles, and these have become integral parts of new management algorithms. The challenges faced by low-resource countries are many and include, from the management perspective, identifying an affordable point-of-care HPV detection test, minimizing over-treatment, and installing an effective information system to ensure high compliance to treatment and follow-up. © 2017 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.
German, Matthew; Creatore, Maria I.; Brent, Shannon; Watts, Alexander G.; Hay, Simon I.; Kulkarni, Manisha A.; Brownstein, John S.; Khan, Kamran
Summary Background As the epidemic of Zika virus expands in the Americas, countries across Africa and the Asia-Pacific region are becoming increasingly susceptible to the importation and possible local spread of the virus. To support public health readiness, we aim to identify regions and times where the potential health, economic, and social effects from Zika virus are greatest, focusing on resource-limited countries in Africa and the Asia-Pacific region. Methods Our model combined transportation network analysis, ecological modelling of mosquito occurrences, and vector competence for flavivirus transmission, using data from the International Air Transport Association, entomological observations from Zika’s primary vector species, and climate conditions using WorldClim. We overlaid monthly flows of airline travellers arriving to Africa and the Asia-Pacific region from areas of the Americas suitable for year-round transmission of Zika virus with monthly maps of climatic suitability for mosquito-borne transmission of Zika virus within Africa and the Asia-Pacific region. Findings An estimated 2·6 billion people live in areas of Africa and the Asia-Pacific region where the presence of competent mosquito vectors and suitable climatic conditions could support local transmission of Zika virus. Countries with large volumes of travellers arriving from Zika affected areas of the Americas and large populations at risk of mosquito-borne Zika virus infection include, India (67 422 travellers arriving per year; 1·2 billion residents in potential Zika transmission areas), China (238 415 travellers; 242 million residents), Indonesia (13 865 travellers; 197 million residents), Philippines (35 635 travellers; 70 million residents), and Thailand (29 241 travellers; 59 million residents). Interpretation Many countries across Africa and the Asia-Pacific region are vulnerable to Zika virus. Strategic use of available health and human resources is essential to prevent or mitigate
Kiguchi, M.; Shen, Y.; Kanae, S.; Oki, T.
In an argument of the reduction and the adaptation for the climate change, the evaluation of the influence by the climate change is important. When we argue in adaptation plan from a damage scale and balance with the cost, it is particularly important. Parry et al (2001) evaluated the risks in shortage of water, malaria, food, the risk of the coast flood by temperature function and clarified the level of critical climate change. According to their evaluation, the population to be affected by the shortage of water suddenly increases in the range where temperature increases from 1.5 to 2.0 degree in 2080s. They showed how much we need to reduce emissions in order to draw-down significantly the number at risk. This evaluation of critical climate change threats and targets of water shortage did not include the water withdrawal divided by water availability. Shen et al (2008a) estimated the water withdrawal of projection of future world water resources according to socio-economic driving factors predicted for scenarios A1b, A2, B1, and B2 of the Special Report on Emission Scenarios (SRES). However, these results were in function of not temperature but time. The assessment of the highly water-stressed population considered the socioeconomic development is necessary for a function of the temperature. Because of it is easy to understand to need to reduce emission. We present a multi-GCM analysis of the global and regional populations lived in highly water-stressed basin for a function of the temperature using the socioeconomic data and the outputs of GCMs. In scenario A2, the population increases gradually with warming. On the other hand, the future projection population in scenario A1b and B1 increase gradually until the temperature anomaly exceeds around from +1 to +1.5 degree. After that the population is almost constant. From Shen et al (2008b), we evaluated the HWSP and its ratio in the world with temperature function for scenarios A1B, A2, and B1 by the index of W
Lawn, Stephen D.; Harries, Anthony D.; Wood, Robin
Purpose of review We review recently published literature concerning early morbidity and mortality during antiretroviral therapy (ART) among patients in resource-limited settings. We focus on articles providing insights into this burden of disease and strategies to address it. Recent findings In sub-Saharan Africa mortality rates during the first year of ART are very high (8%-26%), with most deaths occurring in the first few months. This compares to 3%-13% in programmes in Latin America and the Caribbean and 11%-13% in South-East Asia. Risk factors generally reflect late presentation with advanced symptomatic disease. Key causes of morbidity and mortality include tuberculosis, acute sepsis, cryptococcal meningitis, malignancy, wasting syndrome/chronic diarrhoea. Current literature shows the fundamental need is for much earlier HIV diagnosis and initiation of ART. In addition, further studies provide data on the role of screening and prophylaxis against opportunistic diseases (particularly TB, bacterial sepsis and cryptococcal disease) and the management of specific opportunistic diseases and complications of ART. Effective and sustainable delivery of these interventions requires strengthening of programmes. Summary Strategies to address this disease burden should include earlier HIV diagnosis and ART initiation, screening and prophylaxis for opportunistic infections, optimised management of specific diseases and treatment complications, and programme strengthening. PMID:20046144
Badenhorst, Jacob AC
Full Text Available Training (CAPT) and monitoring students' progress. However, the automatic recognition of low-proficient, non-native speech is a particularly challenging task, especially for under-resourced languages. Data augmentation strategies aim to increase...
Campbell, Casey; Koszewski, Wanda M.; Behrends, Donnia
The study reported here sought to determine if the use of distance education lessons for teaching limited resource participants in a nutrition education program (NEP) is as effective as face-to-face methodology. One hundred and six participants were in the experimental group. Data was gathered at entry and examined behavior change, nutrient intake…
Campbell Timothy C
Full Text Available Abstract Background Emerging public health threats often originate in resource-limited countries. In recognition of this fact, the World Health Organization issued revised International Health Regulations in 2005, which call for significantly increased reporting and response capabilities for all signatory nations. Electronic biosurveillance systems can improve the timeliness of public health data collection, aid in the early detection of and response to disease outbreaks, and enhance situational awareness. Methods As components of its Suite for Automated Global bioSurveillance (SAGES program, The Johns Hopkins University Applied Physics Laboratory developed two open-source, electronic biosurveillance systems for use in resource-limited settings. OpenESSENCE provides web-based data entry, analysis, and reporting. ESSENCE Desktop Edition provides similar capabilities for settings without internet access. Both systems may be configured to collect data using locally available cell phone technologies. Results ESSENCE Desktop Edition has been deployed for two years in the Republic of the Philippines. Local health clinics have rapidly adopted the new technology to provide daily reporting, thus eliminating the two-to-three week data lag of the previous paper-based system. Conclusions OpenESSENCE and ESSENCE Desktop Edition are two open-source software products with the capability of significantly improving disease surveillance in a wide range of resource-limited settings. These products, and other emerging surveillance technologies, can assist resource-limited countries compliance with the revised International Health Regulations.
Amissah, Nana Ama; Buultjens, Andrew H.; Ablordey, Anthony; van Dam, Lieke; Opoku-Ware, Ampomah; Baines, Sarah L.; Bulach, Dieter; Tetteh, Caitlin S.; Prah, Isaac; van der Werf, Tjip S.; Friedrich, Alexander W.; Seemann, Torsten; van Dijl, Jan Maarten; Stienstra, Ymkje; Stinear, Timothy P.; Rossen, John W.
. Objectives: Staphylococcus aureus infections in burn patients can lead to serious complications and death. The frequency of S. aureus infection is high in low-and middle-income countries presumably due to limited resources, misuse of antibiotics and poor infection control. The objective of the
Nosofsky, Robert M.; Donkin, Chris
We report an experiment designed to provide a qualitative contrast between knowledge-limited versions of mixed-state and variable-resources (VR) models of visual change detection. The key data pattern is that observers often respond "same" on big-change trials, while simultaneously being able to discriminate between same and small-change…
The field of oncology with its numerous high-priced innovations contributes considerably to the fact that medical progress is expensive. Additionally, due to the demographic changes and the increasing life expectancy, a growing number of cancer patients want to profit from this progress. Since resources are limited also in the health system, the fair distribution of the available resources urgently needs to be addressed. Dealing with scarcity is a typical problem in the domain of justice theory; therefore, this article first discusses different strategies to manage limited resources: rationalization, rationing, and prioritization. It then presents substantive as well as procedural criteria that assist in the just distribution of effective health benefits. There are various strategies to reduce the utilization of limited resources: Rationalization means that efficiency reserves are being exhausted; by means of rationing, effective health benefits are withheld due to cost considerations. Rationing can occur implicitly and thus covertly, e.g. through budgeting or the implementation of waiting periods, or explicitly, through transparent rules or policies about healthcare coverage. Ranking medical treatments according to their importance (prioritization) is often a prerequisite for rationing decisions. In terms of requirements of justice, both procedural and substantive criteria (e.g. equality, urgency, benefit) are relevant for the acceptance and quality of a decision to limit access to effective health benefits. Copyright © 2011 S. Karger AG, Basel.
Kouotou, Emmanuel Armand; Nansseu, Jobert Richie N; Sieleunou, Isidore; Defo, Defo; Bissek, Anne-Cécile Zoung-Kanyi; Ndam, Elie Claude Ndjitoyap
The persistent high prevalence of human scabies, especially in low- and middle-income countries prompted us to research the sociodemographic profile of patients suffering from it, and its spreading factors in Cameroon, a resource-poor setting. We conducted a cross-sectional survey from October 2011 to September 2012 in three hospitals located in Yaoundé, Cameroon, and enrolled patients diagnosed with human scabies during dermatologists' consultations who volunteered to take part in the study. We included 255 patients of whom 158 (62 %) were male. Age ranged from 0 to 80 years old with a median of 18 (Inter quartile range: 3-29) years. One to eight persons of our patients' entourage exhibited pruritus (mean = 2.1 ± 1.8). The number of persons per bed/room varied from 1 to 5 (mean = 2.1 ± 0.8). The first dermatologist's consultation occurred 4 to 720 days after the onset of symptoms (mean = 77.1 ± 63.7). The post-scabies pruritus (10.2 % of cases) was unrelated to the complications observed before correct treatment (all p values > 0.05), mainly impetiginization (7.1 %) and eczematization (5.9 %). Human scabies remains preponderant in our milieu. Populations should be educated on preventive measures in order to avoid this disease, and clinicians' knowledges must be strengthened for its proper diagnosis and management.
Sazykina, Tatiana G.; Kryshev, Alexander I.
A dynamic mathematical model is formulated, predicting the development of radiation effects in a generic animal population, inhabiting an elemental ecosystem ‘population-limiting resource’. Differential equations of the model describe the dynamic responses to radiation damage of the following population characteristics: gross biomass; intrinsic fractions of healthy and reversibly damaged tissues in biomass; intrinsic concentrations of the self-repairing pool and the growth factor; and amount of the limiting resource available in the environment. Analytical formulae are found for the steady states of model variables as non-linear functions of the dose rate of chronic radiation exposure. Analytical solutions make it possible to predict the expected severity of radiation effects in a model ecosystem, including such endpoints as morbidity, mortality, life shortening, biosynthesis, and population biomass. Model parameters are selected from species data on lifespan, physiological growth and mortality rates, and individual radiosensitivity. Thresholds for population extinction can be analytically calculated for different animal species, examples are provided for generic mice and wolf populations. The ecosystem model demonstrates a compensatory effect of the environment on the development of radiation effects in wildlife. The model can be employed to construct a preliminary scale ‘radiation exposure-population effects’ for different animal species; species can be identified, which are vulnerable at a population level to chronic radiation exposure. - Highlights: • Mathematical model is formulated predicting radiation effects in elemental ecosystem. • Analytical formulae are found for steady states of variables as functions of exposure. • Severity of radiation effects are calculated, including population extinction. • Model parameterization is made for generic mice and wolf populations.
Zakumumpa, Henry; Taiwo, Modupe Oladunni; Muganzi, Alex; Ssengooba, Freddie
Human resources for health (HRH) constraints are a major barrier to the sustainability of antiretroviral therapy (ART) scale-up programs in Sub-Saharan Africa. Many prior approaches to HRH constraints have taken a top-down trend of generalized global strategies and policy guidelines. The objective of the study was to examine the human resources for health strategies adopted by front-line providers in Uganda to sustain ART delivery beyond the initial ART scale-up phase between 2004 and 2009. A two-phase mixed-methods approach was adopted. In the first phase, a survey of a nationally representative sample of health facilities (n = 195) across Uganda was conducted. The second phase involved in-depth interviews (n = 36) with ART clinic managers and staff of 6 of the 195 health facilities purposively selected from the first study phase. Quantitative data was analysed based on descriptive statistics, and qualitative data was analysed by coding and thematic analysis. The identified strategies were categorized into five themes: (1) providing monetary and non-monetary incentives to health workers on busy ART clinic days; (2) workload reduction through spacing ART clinic appointments; (3) adopting training workshops in ART management as a motivation strategy for health workers; (4) adopting non-physician-centred staffing models; and (5) devising ART program leadership styles that enhanced health worker commitment. Facility-level strategies for responding to HRH constraints are feasible and can contribute to efforts to increase country ownership of HIV programs in resource-limited settings. Consideration of the human resources for health strategies identified in the study by ART program planners and managers could enhance the long-term sustainment of ART programs by providers in resource-limited settings.
Ohio State Univ., Columbus, OH. Information Reference Center for Science, Mathematics, and Environmental Education.
Compiled are abstracts and indexes to selected print and non-print materials related to wastewater treatment and water quality education and instruction, as well as materials related to pesticides, hazardous wastes, and public participation. Sources of abstracts/indexed materials include all levels of government, private concerns, and educational…
Orris, Greta J.; Cocker, Mark D.; Dunlap, Pamela; Wynn, Jeff C.; Spanski, Gregory T.; Briggs, Deborah A.; Gass, Leila; Bliss, James D.; Bolm, Karen S.; Yang, Chao; Lipin, Bruce R.; Ludington, Stephen; Miller, Robert J.; Słowakiewicz, Mirosław
Potash is mined worldwide to provide potassium, an essential nutrient for food crops. Evaporite-hosted potash deposits are the largest source of salts that contain potassium in water-soluble form, including potassium chloride, potassium-magnesium chloride, potassium sulfate, and potassium nitrate. Thick sections of evaporitic salt that form laterally continuous strata in sedimentary evaporite basins are the most common host for stratabound and halokinetic potash-bearing salt deposits. Potash-bearing basins may host tens of millions to more than 100 billion metric tons of potassium oxide (K2O). Examples of these deposits include those in the Elk Point Basin in Canada, the Pripyat Basin in Belarus, the Solikamsk Basin in Russia, and the Zechstein Basin in Germany.
An, Ruopeng; Khan, Naiman; Loehmer, Emily; McCaffrey, Jennifer
We assessed the network of agencies in local communities that promote healthy eating and lifestyles among populations with limited resources. Network surveys were administered among 159 Illinois agencies identified as serving limited-resource audiences categorized into 8 types: K-12 schools, early childhood centers, emergency food providers, health-related agencies, social resource centers, low-income/subsidized housing complexes, continuing education organizations, and others. Network analysis was conducted to examine 4 network structures - communications, funding, cooperation, and collaboration networks between agencies within each county/county cluster. Agencies in a network were found to be loosely connected, indicated by low network density. Reporting accuracy might be of concern, indicated by low reciprocity. Agencies in a network are decentralized rather than centralized around a few influential agencies, indicated by low betweenness centrality. There is suggestive evidence regarding homophily in a network, indicated by some significant correlations within agencies of the same type. Agencies connected in one network are significantly more likely to be connected in all the other networks as well. Promoting healthy eating and lifestyles among populations with limited resources warrants strong partnership across agencies in communities. Network analysis serves as a useful tool to evaluate community partnerships and facilitate coalition building..
Sayed, Shahin; Moloo, Zahir; Ngugi, Anthony; Allidina, Amyn; Ndumia, Rose; Mutuiri, Anderson; Wasike, Ronald; Wahome, Charles; Abdihakin, Mohamed; Kasmani, Riaz; Spears, Carol D; Oigara, Raymond; Mwachiro, Elizabeth B; Busarla, Satya V P; Kibor, Kibet; Ahmed, Abdulaziz; Wawire, Jonathan; Sherman, Omar; Saleh, Mansoor; Zujewski, Jo Anne; Dawsey, Sanford M
Breast cancer is the most common cancer of women in Kenya. There are no national breast cancer early diagnosis programs in Kenya. The objective was to conduct a pilot breast cancer awareness and diagnosis program at three different types of facilities in Kenya. This program was conducted at a not-for-profit private hospital, a faith-based public hospital, and a government public referral hospital. Women aged 15 years and older were invited. Demographic, risk factor, knowledge, attitudes, and screening practice data were collected. Breast health information was delivered, and clinical breast examinations (CBEs) were performed. When appropriate, ultrasound imaging, fine-needle aspirate (FNA) diagnoses, core biopsies, and onward referrals were provided. A total of 1,094 women were enrolled in the three breast camps. Of those, 56% knew the symptoms and signs of breast cancer, 44% knew how breast cancer was diagnosed, 37% performed regular breast self-exams, and 7% had a mammogram or breast ultrasound in the past year. Of the 1,094 women enrolled, 246 (23%) had previously noticed a lump in their breast. A total of 157 participants (14%) had abnormal CBEs, of whom 111 had ultrasound exams, 65 had FNAs, and 18 had core biopsies. A total of 14 invasive breast cancers and 1 malignant phyllodes tumor were diagnosed Conducting a multidisciplinary breast camp awareness and early diagnosis program is feasible in different types of health facilities within a low- and middle-income country setting. This can be a model for breast cancer awareness and point-of-care diagnosis in countries with limited resources like Kenya. This work describes a novel breast cancer awareness and early diagnosis demonstration program in a low- and middle-income country within a limited resource setting. The program includes breast self-awareness and breast cancer education, clinical exams, and point-of-care diagnostics for women in three different types of health facilities in Kenya. This pilot
Nadeem, Sayyada Ghufrana; Hakim, Shazia Tabassum; Kazmi, Shahana Urooj
Introduction Identification of yeast isolated from clinical specimens to the species level has become increasingly important. Ever-increasing numbers of immuno-suppressed patients, a widening range of recognized pathogens, and the discovery of resistance to antifungal drugs are contributing factors to this necessity. Material and methods A total of 487 yeast strains were studied for the primary isolation and presumptive identification, directly from clinical specimen. Efficacy of CHROMagar Candida has been evaluated with conventional methods including morphology on Corn meal–tween 80 agar and biochemical methods by using API 20 C AUX. Results The result of this study shows that CHROMagar Candida can easily identify three species of Candida on the basis of colonial color and morphology, and accurately differentiate between them i.e. Candida albicans, Candida tropicalis, and Candida krusei. The specificity and sensitivity of CHROMagar Candida for C. albicans calculated as 99%, for C. tropicalis calculated as 98%, and C. krusei it is 100%. Conclusion The data presented supports the use of CHROMagar Candida for the rapid identification of Candida species directly from clinical specimens in resource-limited settings, which could be very helpful in developing appropriate therapeutic strategy and management of patients. PMID:21483597
Amatya, Yogendra; Rupp, Jordan; Russell, Frances M; Saunders, Jason; Bales, Brian; House, Darlene R
Lung ultrasound is an effective tool for diagnosing pneumonia in developed countries. Diagnostic accuracy in resource-limited countries where pneumonia is the leading cause of death is unknown. The objective of this study was to evaluate the sensitivity of bedside lung ultrasound compared to chest X-ray for pneumonia in adults presenting for emergency care in a low-income country. Patients presenting to the emergency department with suspected pneumonia were evaluated with bedside lung ultrasound, single posterioranterior chest radiograph, and computed tomography (CT). Using CT as the gold standard, the sensitivity of lung ultrasound was compared to chest X-ray for the diagnosis of pneumonia using McNemar's test for paired samples. Diagnostic characteristics for each test were calculated. Of 62 patients included in the study, 44 (71%) were diagnosed with pneumonia by CT. Lung ultrasound demonstrated a sensitivity of 91% compared to chest X-ray which had a sensitivity of 73% (p = 0.01). Specificity of lung ultrasound and chest X-ray were 61 and 50% respectively. Bedside lung ultrasound demonstrated better sensitivity than chest X-ray for the diagnosis of pneumonia in Nepal. ClinicalTrials.gov, registration number NCT02949141 . Registered 31 October 2016.
Campbell, Jeffrey I; Haberer, Jessica E
Numerous cell phone-based and adherence monitoring technologies have been developed to address barriers to effective HIV prevention, testing, and treatment. Because most people living with HIV and AIDS reside in resource-limited settings (RLS), it is important to understand the development and use of these technologies in RLS. Recent research on cell phone-based technologies has focused on HIV education, linkage to and retention in care, disease tracking, and antiretroviral therapy adherence reminders. Advances in adherence devices have focused on real-time adherence monitors, which have been used for both antiretroviral therapy and pre-exposure prophylaxis. Real-time monitoring has recently been combined with cell phone-based technologies to create real-time adherence interventions using short message service (SMS). New developments in adherence technologies are exploring ingestion monitoring and metabolite detection to confirm adherence. This article provides an overview of recent advances in these two families of technologies and includes research on their acceptability and cost-effectiveness when available. It additionally outlines key challenges and needed research as use of these technologies continues to expand and evolve.
Græsbøll, Kaare; Christiansen, Lasse Engbo
Looking for periodicity in sampled data requires that periods (lags) of different length are represented in the sampling plan. We here present a method to assist in planning of temporal studies with sparse resources, which optimizes the number of observed time lags for a fixed amount of samples w...
Bays, Paul M; Husain, Masud
Cowan & Rouder suggest that a modification to the four-slot model of visual working memory fits the available data better than our distributed resource model. However their comparisons of statistical fit are biased in favour of the slot model. Here we compare the predictions of the two models and present further evidence against the division of visual memory into slots. PMID:22822271
Bays, Paul M; Husain, Masud
Cowan & Rouder suggest that a modification to the four-slot model of visual working memory fits the available data better than our distributed resource model. However their comparisons of statistical fit are biased in favour of the slot model. Here we compare the predictions of the two models and present further evidence against the division of visual memory into slots.
Bioregional assessments to deal with critical, even crisis, natural resource issues have emerged as important meeting grounds of science, management, and policy across the United States. They are placing heavy demands on science, scientists, and science organizations to compile, synthesize, and produce data, for policy decisions. There is no blueprint for their conduct...
Escalante Henriquez, Luis Carlos; Charpentier, Claudia; Diez Hernandez, Juan Manuel
Panama competitiveness depends largely on quality and abundance of natural resources, which are being progressively degraded by a disordered urban and economic development. The availability of water in adequate quantity and quality poses serious problems in some areas of the country. This affects both the quality of life of the population and key sectors such as agriculture, industry, hydro and tourism; and stimulates social conflicts related to access, use and disposal of used water. To prevent the degradation of water resources has been promoted a holistic, known as integrated in water resources management (IWRM) strategy. From the Summit of Mar del Plata, Argentina (1977) until the 5th Forum world of the water in Istanbul in Turkey (2009), international meetings that have contributed to defining the principles and recommendations for the IWRM have been held. This work presents a methodological model of IWRM designed for Panama. Essentially consists of a perfected in how to manage water, requiring changes in the political, social, economic and administrative systems of water resource management approach
Rahimi Ghahroodi, Sajjad; Al Hanbali, Ahmad; Zijm, Willem H.M.; Timmer, Judith
In this paper, we study a problem faced by a service provider, who is responsible to repair a group of systems subject to random failures. The service provider needs spare parts and service engineers available to repair the failures. He can fully rely on himself in providing the resources and follow
Howe, Edmund G.
Discusses two of the most formidable bioethical challenges over the next decades which relate to disabilities and aging: elders' exercise of autonomy and the just allocation of resources to older patients. Offers suggestions for developing principles for the treatment of elders. (Author/ABL)
Modi, Payal; Glavis-Bloom, Justin; Nasrin, Sabiha; Guy, Allysia; Chowa, Erika P; Dvor, Nathan; Dworkis, Daniel A; Oh, Michael; Silvestri, David M; Strasberg, Stephen; Rege, Soham; Noble, Vicki E; Alam, Nur H; Levine, Adam C
Although dehydration from diarrhea is a leading cause of morbidity and mortality in children under five, existing methods of assessing dehydration status in children have limited accuracy. To assess the accuracy of point-of-care ultrasound measurement of the aorta-to-IVC ratio as a predictor of dehydration in children. A prospective cohort study of children under five years with acute diarrhea was conducted in the rehydration unit of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Ultrasound measurements of aorta-to-IVC ratio and dehydrated weight were obtained on patient arrival. Percent weight change was monitored during rehydration to classify children as having "some dehydration" with weight change 3-9% or "severe dehydration" with weight change > 9%. Logistic regression analysis and Receiver-Operator Characteristic (ROC) curves were used to evaluate the accuracy of aorta-to-IVC ratio as a predictor of dehydration severity. 850 children were enrolled, of which 771 were included in the final analysis. Aorta to IVC ratio was a significant predictor of the percent dehydration in children with acute diarrhea, with each 1-point increase in the aorta to IVC ratio predicting a 1.1% increase in the percent dehydration of the child. However, the area under the ROC curve (0.60), sensitivity (67%), and specificity (49%), for predicting severe dehydration were all poor. Point-of-care ultrasound of the aorta-to-IVC ratio was statistically associated with volume status, but was not accurate enough to be used as an independent screening tool for dehydration in children under five years presenting with acute diarrhea in a resource-limited setting.
Full Text Available Although dehydration from diarrhea is a leading cause of morbidity and mortality in children under five, existing methods of assessing dehydration status in children have limited accuracy.To assess the accuracy of point-of-care ultrasound measurement of the aorta-to-IVC ratio as a predictor of dehydration in children.A prospective cohort study of children under five years with acute diarrhea was conducted in the rehydration unit of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b. Ultrasound measurements of aorta-to-IVC ratio and dehydrated weight were obtained on patient arrival. Percent weight change was monitored during rehydration to classify children as having "some dehydration" with weight change 3-9% or "severe dehydration" with weight change > 9%. Logistic regression analysis and Receiver-Operator Characteristic (ROC curves were used to evaluate the accuracy of aorta-to-IVC ratio as a predictor of dehydration severity.850 children were enrolled, of which 771 were included in the final analysis. Aorta to IVC ratio was a significant predictor of the percent dehydration in children with acute diarrhea, with each 1-point increase in the aorta to IVC ratio predicting a 1.1% increase in the percent dehydration of the child. However, the area under the ROC curve (0.60, sensitivity (67%, and specificity (49%, for predicting severe dehydration were all poor.Point-of-care ultrasound of the aorta-to-IVC ratio was statistically associated with volume status, but was not accurate enough to be used as an independent screening tool for dehydration in children under five years presenting with acute diarrhea in a resource-limited setting.
Meyer, Ana-Claire L.; Dua, Tarun; Boscardin, John; Escarce, José J.; Saxena, Shekhar; Birbeck, Gretchen L.
Purpose Epilepsy is one of the most common serious neurological disorders worldwide. Our objective was to determine which economic, healthcare, neurology and epilepsy specific resources were associated with untreated epilepsy in resource-constrained settings. Methods A systematic review of the literature identified community-based studies in resource-constrained settings that calculated the epilepsy treatment gap, the proportion with untreated epilepsy, from prevalent active epilepsy cases. Economic, healthcare, neurology and epilepsy specific resources were taken from existing datasets. Poisson regression models with jackknifed standard errors were used to create bivariate and multivariate models comparing the association between treatment status and economic and health resource indicators. Relative risks were reported. Key Findings Forty-seven studies of 8285 individuals from 24 countries met inclusion criteria. Bivariate analysis demonstrated that individuals residing in rural locations had significantly higher risks of untreated epilepsy [Relative Risk(RR)=1.63; 95% confidence interval(CI):1.26,2.11]. Significantly lower risks of untreated epilepsy were observed for higher physician density [RR=0.65, 95% CI:0.55,0.78], presence of a lay [RR=0.74, 95%CI:0.60,0.91] or professional association for epilepsy [RR=0.73, 95%CI:0.59,0.91], or post-graduate neurology training program [RR=0.67, 95%CI:0.55, 0.82]. In multivariate models, higher physician density maintained significant effects [RR=0.67; 95%CI:0.52,0.88]. Significance Even among resource-limited regions, people with epilepsy in countries with fewer economic, healthcare, neurology and epilepsy specific resources are more likely to have untreated epilepsy. Community-based epilepsy care programs have improved access to treatment but in order to decrease the epilepsy treatment gap, poverty and inequalities of healthcare, neurological and epilepsy resources must be dealt with at the local, national, and global
Full Text Available To conduct a preliminary evaluation of the utility and reliability of a diagnostic tool for HIV-associated dementia (HAD for use by primary health care workers (HCW which would be feasible to implement in resource-limited settings.In resource-limited settings, HAD is an indication for anti-retroviral therapy regardless of CD4 T-cell count. Anti-retroviral therapy, the treatment for HAD, is now increasingly available in resource-limited settings. Nonetheless, HAD remains under-diagnosed likely because of limited clinical expertise and availability of diagnostic tests. Thus, a simple diagnostic tool which is practical to implement in resource-limited settings is an urgent need.A convenience sample of 30 HIV-infected outpatients was enrolled in Western Kenya. We assessed the sensitivity and specificity of a diagnostic tool for HAD as administered by a primary HCW. This was compared to an expert clinical assessment which included examination by a physician, neuropsychological testing, and in selected cases, brain imaging. Agreement between HCW and an expert examiner on certain tool components was measured using Kappa statistic.The sample was 57% male, mean age was 38.6 years, mean CD4 T-cell count was 323 cells/µL, and 54% had less than a secondary school education. Six (20% of the subjects were diagnosed with HAD by expert clinical assessment. The diagnostic tool was 63% sensitive and 67% specific for HAD. Agreement between HCW and expert examiners was poor for many individual items of the diagnostic tool (K = .03-.65. This diagnostic tool had moderate sensitivity and specificity for HAD. However, reliability was poor, suggesting that substantial training and formal evaluations of training adequacy will be critical to enable HCW to reliably administer a brief diagnostic tool for HAD.
Carlos José Saldanha Machado
Full Text Available O artigo discute a relação entre a gestão de recursos hídricos e o exercício da cidadania no Brasil. Inicialmente, apresenta um quadro descritivo da distribuição da água e dos problemas associados com o crescimento populacional; em seguida, faz uma descrição das características da gestão da água e das inovações introduzidas com a Lei das Águas nº 9.433/97; na terceira parte, formula e defende argumentos em prol de uma gestão pública integrada e colegiada com negociação sociotécnica das águas ; finalmente, apresenta e discute algumas dificuldades e limites para a implantação e consolidação de uma política de recursos hídricos descentralizada, participativa e sustentável, bem como alguns mecanismos para que aquelas dificuldades e limites venham a ser superados, ou ao menos minimizados.The article discusses the relationship between water resources management and the exercise of citizenship in Brazil. At first, it presents a descriptive framework on water distribution and problems concerned to population growth. On the second part, it describes water management features and innovations introduced by the Water Law (nº 94.333/97. On the third part, it argues in favor of an integrated and collective public management of waterand a sociotechnical negotiation. Finally, it discusses some difficulties and limitations to implement and consolidate a decentralized, participative and sustainable water resources policy, as well as mechanisms to overcome or minimize such difficulties and limitations.
Faeth, Stanley H.; Oberhofer, Martina; Saari, Susanna Talvikki
Hybridization is common among plants, animals and microbes. However, the ecological consequences of hybridization for microbes are far less understood than for plants and animals. For symbiotic Epichloë fungi, hybridization is widespread and may augment the well-known benefits of the endophytes...... to their grass hosts, especially in stressful environments. We tested the hybrid fitness hypothesis (HFH) that hybrid endophytes enhance fitness in stressful environments relative to non-hybrid endophytes. In a long-term field experiment, we monitored growth and reproduction of hybrid-infected (H+), non......-hybrid infected (NH+), naturally endophyte free (E-) plants and those plants from which the endophyte had been experimentally removed (H- and NH-) in resource-rich and resource-poor environments. Infection by both endophyte species enhanced growth and reproduction. H+ plants outperformed NH+ plants in terms...
Coal burns occur in nature primarily due to spontaneous combustion and the result is baked overburden known as clinker. Understanding occurrences of natural coal burns and formation of clinker is important for coal resource exploration and development. Clinker is an indication of potential commercial coal reserves, and can be located easily due to its difference from the unaltered coal section, especially color, geochemical properties, and aquifer properties. The high porosity and variable material strength of clinker create impacts for aspects of mine development such as foundation planning, slope stability, and water handling. This paper describes the formation of clinker, the use of clinker for coal deposit location, its effect on coal quality, its effect on coal resource development, and the use of clinker in surface mine reclamation
Full Text Available Surveying invasive species can be highly resource intensive, yet near-real-time evaluations of invasion progress are important resources for management planning. In the case of the soybean rust invasion of the United States, a linked monitoring, prediction, and communication network saved U.S. soybean growers approximately $200 M/yr. Modeling of future movement of the pathogen (Phakopsora pachyrhizi was based on data about current disease locations from an extensive network of sentinel plots. We developed a dynamic network model for U.S. soybean rust epidemics, with counties as nodes and link weights a function of host hectarage and wind speed and direction. We used the network model to compare four strategies for selecting an optimal subset of sentinel plots, listed here in order of increasing performance: random selection, zonal selection (based on more heavily weighting regions nearer the south, where the pathogen overwinters, frequency-based selection (based on how frequently the county had been infected in the past, and frequency-based selection weighted by the node strength of the sentinel plot in the network model. When dynamic network properties such as node strength are characterized for invasive species, this information can be used to reduce the resources necessary to survey and predict invasion progress.
Full Text Available Many farming-system studies have investigated the design and evaluation of crop-management practices with respect to economic performance and reduction in environmental impacts. In contrast, little research has been devoted to analysing these practices in terms of matching the recurrent context-dependent demand for resources (labour in particular with those available on the farm. This paper presents Dhivine, a simulation model of operational management of grape production at the vineyard scale. Particular attention focuses on representing a flexible plan, which organises activities temporally, the resources available to the vineyard manager and the process of scheduling and executing the activities. The model relies on a generic production-system ontology used in several agricultural production domains. The types of investigations that the model supports are briefly illustrated. The enhanced realism of the production-management situations simulated makes it possible to examine and understand properties of resource-constrained work-organisation strategies and possibilities for improving them.
Sutrave, Sweta; Scoglio, Caterina; Isard, Scott A; Hutchinson, J M Shawn; Garrett, Karen A
Surveying invasive species can be highly resource intensive, yet near-real-time evaluations of invasion progress are important resources for management planning. In the case of the soybean rust invasion of the United States, a linked monitoring, prediction, and communication network saved U.S. soybean growers approximately $200 M/yr. Modeling of future movement of the pathogen (Phakopsora pachyrhizi) was based on data about current disease locations from an extensive network of sentinel plots. We developed a dynamic network model for U.S. soybean rust epidemics, with counties as nodes and link weights a function of host hectarage and wind speed and direction. We used the network model to compare four strategies for selecting an optimal subset of sentinel plots, listed here in order of increasing performance: random selection, zonal selection (based on more heavily weighting regions nearer the south, where the pathogen overwinters), frequency-based selection (based on how frequently the county had been infected in the past), and frequency-based selection weighted by the node strength of the sentinel plot in the network model. When dynamic network properties such as node strength are characterized for invasive species, this information can be used to reduce the resources necessary to survey and predict invasion progress.
English in Australia, 1973
Contains seven short resources''--units, lessons, and activities on the power of observation, man and his earth, snakes, group discussion, colloquial and slang, the continuous story, and retelling a story. (DD)
Rouet, J; Bwelle, G; Cauchy, F; Masso-Misse, P; Gaujoux, S; Dousset, B
In developing countries, most inguinal hernia repairs are performed using Bassini or Shouldice techniques resulting in higher recurrence rates than with mesh placement. Our study aimed to evaluate the postoperative course and quality of life of patients undergoing inguinal hernia repair with a polyester mosquito net meshes during non-governmental organization health campaigns in Cameroon. Patients were prospectively included from January to November 2013. Meshes were made from a polyester non-impregnated mosquito net purchased at a local market in Yaounde and sterilized on site. The total cost of a mesh was 0.21 USD. Among the 41 patients included in the study, 33 (80.5%) were men, 30 (72%) were farmers and the median age was 52 (21-80) years. The time between the onset of symptoms and surgery was 24 (3-240) months. Eleven (26.8%) patients had a previous history of hernia repair: 4 (9.7%) had been operated on the contralateral side and 7 (17.1%) had a recurrence. No intraoperative event related to the meshes was recorded. Three patients (7.2%) had a postoperative uninfected scrotal seroma, and 1 patient (2.4%) experienced a superficial skin infection that was treated using local care and oral antibiotics. No allergic rejection or deep infection was observed. Meshes made from sterilized mosquito nets are safe and effective and provide a cost-effective alternative to commercially available meshes in countries with limited resources especially during non-governmental organization health campaigns. Copyright © 2017 Elsevier Masson SAS. All rights reserved.
Ngo Nonga Bernadette
Full Text Available Late presentation of foreign body impaction in the esophagus, complicated by perforation in children, has rarely been reported in the literature. Esophageal surgery is very difficult and challenging in Cameroon (a resource limited setting. We are reporting herein 2 cases of esophageal perforation in children seen very late (12 days and 40 days after foreign body impaction, complicated with severe sepsis, who were successfully operated upon with very good results.
Ndayizigiye, M.; Fawzi, M. C. Smith; Lively, C. Thompson; Ware, N.C.
Background: Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere. Methods: We investigated uptake of contraceptives among women of reproductive age in ...
Full Text Available Abstract Background The importance of breast milk for infants' growth, development and overall health is widely recognized. In situations where women are not able to provide their infants with sufficient amounts of their own breast milk, donor breast milk is the next preferred option. Although there is considerable research on the safety and scientific aspects of donor milk, and the motivations and experiences of donors, there is limited research addressing the attitudes and experiences of the women and families whose infants receive this milk. This study therefore examined attitudes towards donated breast milk among mothers, families and healthcare providers of potential recipient infants. Methods The study was conducted at a public hospital and nearby clinic in Durban, South Africa. The qualitative data was derived from eight focus group discussions which included four groups with mothers; one with male partners; and one with grandmothers, investigating attitudes towards receiving donated breast milk for infants. There was also one group each with nurses and doctors about their attitudes towards donated breast milk and its use in the hospital. The focus groups were conducted in September and October 2009 and each group had between four and eleven participants, leading to a total of 48 participants. Results Although breast milk was seen as important to child health there were concerns about undermining of breast milk because of concerns about HIV and marketing and promotion of formula milks. In addition there were concerns about the safety of donor breast milk and discomfort about using another mother's milk. Participants believed that education on the importance of breast milk and transparency on the processes involved in sourcing and preparing donor milk would improve the acceptability. Conclusions This study has shown that there are obstacles to the acceptability of donor milk, mainly stemming from lack of awareness/familiarity with the
Full Text Available This article considers the utility of resources designed to assist people undertaking their own legal work. Four in-depth case studies are used to explore the tensions inherent in providing coherent and user-oriented resources to legal self-helpers in environments where service providers attempt to convey complex legal information, knowledge and skills to people at the point of legal exigency. The needs of the consumer for basic process oriented and solutions focused resources do not always coincide with the objectives of providers to impart sufficient legal knowledge, information and skills to allow the consumer to work through those processes as an informed citizen. Cet article porte sur l’utilité des ressources conçues pour aider les gens à effectuer eux-mêmes le travail juridique qu’ils requièrent. Quatre études de cas approfondies servent à examiner les tensions inhérentes à la distribution de ressources d’auto-assistance juridique cohérentes axées sur l’utilisateur dans des milieux où les fournisseurs de services cherchent à transmettre des connaissances, de l’information et des compétences juridiques complexes, selon les exigences de la loi. La nécessité pour le client d’obtenir des ressources axées sur les solutions et les procédures de base ne va pas toujours dans le sens de l’objectif des fournisseurs de services, qui consiste à lui transmettre des connaissances, de l’information et des compétences juridiques suffisantes pour qu’il puisse mener à bien ces procédures en tant que citoyen informé.
Full Text Available Water shortage and water pollution are important factors restricting sustainable social and economic development. As a typical coal resource-exhausted city and a node city of the South-to-North Water Transfer East Route Project in China, Zaozhuang City’s water resources management faces multiple constraints such as transformation of economic development, restriction of groundwater exploitation, and improvement of water environment. In this paper, we develop a linear optimization model by input–output analysis to study water resources management with the introduction of three advanced sewage treatment technologies for pollutant treatment and reclaimed water production. The simulation results showed that from 2014 to 2020, Zaozhuang City will realize an annual GDP growth rate of 7.1% with an annual chemical oxygen demand (COD emissions reduction rate of 5.5%. The proportion of primary industry, secondary industry, and tertiary industry would be adjusted to 5.6%, 40.8%, and 53.6%, respectively. The amount of reclaimed water supply could be increased by 91% and groundwater supply could be decreased by 6%. Based on the simulation, this model proposes a scientific reference on water resources management policies, including water environment control, water supply plan, and financial subsidy, to realize the sustainable development of economy and water resources usage.
Full Text Available Globalization processes now affect and are affected by most of organizations, different type resources, and the natural environment. One of the main restrictions initiated by these processes is the financial one: money turnover in global markets leads to its concentration in the certain financial centers, and local business communities suffer from the money lack. This work discusses the advantages of complementary currency introduction into a local economics. By the computer simulation with the engineered program model and the real economic experiment it was proved that the complementary currency does not compete with the traditional currency, furthermore, it acts in compliance with it, providing conditions for the sustainable business community development.
Okano, Kenji; Tanaka, Tsutomu; Ogino, Chiaki; Fukuda, Hideki; Kondo, Akihiko
Lactic acid (LA) is an important and versatile chemical that can be produced from renewable resources such as biomass. LA is used in the food, pharmaceutical, and polymers industries and is produced by microorganism fermentation; however, most microorganisms cannot directly utilize biomass such as starchy materials and cellulose. Here, we summarize LA production using several kinds of genetically modified microorganisms, such as LA bacteria, Escherichia coli, Corynebacterium glutamicum, and yeast. Using gene manipulation and metabolic engineering, the yield and optical purity of LA produced from biomass has been significantly improved. In this review, the drawbacks as well as improvements of LA production by fermentation is discussed.
Tina M. Slusher
Full Text Available Pediatric critical care is an important component of reducing morbidity and mortality globally. Currently, pediatric critical care in low middle-income countries (LMICs remains in its infancy in most hospitals. The majority of hospitals lack designated intensive care units, healthcare staff trained to care for critically ill children, adequate numbers of staff, and rapid access to necessary medications, supplies and equipment. In addition, most LMICs lack pediatric critical care training programs for healthcare providers or certification procedures to accredit healthcare providers working in their pediatric intensive care units (PICU and high dependency areas. PICU can improve the quality of pediatric care in general and, if properly organized, can effectively treat the severe complications of high burden diseases, such as diarrhea, severe malaria, and respiratory distress using low-cost interventions. Setting up a PICU in a LMIC setting requires planning, specific resources, and most importantly investment in the nursing and permanent medical staff. A thoughtful approach to developing pediatric critical care services in LMICs starts with fundamental building blocks: training healthcare professionals in skills and knowledge, selecting resource appropriate effective equipment, and having supportive leadership to provide an enabling environment for appropriate care. If these fundamentals can be built on in a sustainable manner, an appropriate critical care service will be established with the potential to significantly decrease pediatric morbidity and mortality in the context of public health goals as we reach toward the sustainable development goals.
Li, Jianbin; Wang, Shusen; Wang, Yongsheng; Wang, Xiaojia; Wang, Haibo; Feng, Jifeng; Zhang, Qingyuan; Sun, Tao; Ouyang, Quchang; Yin, Yongmei; Liu, Yinhua; Geng, Cuizhi; Yan, Min; Jiang, Zefei
Trastuzumab is a key component of therapy for human epidermal growth receptor 2 (HER2) positive breast cancer. Because real-world data are lacking, the present research was conducted to evaluate the actual use of and the effectiveness of trastuzumab in the real world in China. Inpatients with HER2 positive invasive breast cancer from 13 hospitals in Eastern China (2010-2015, n = 1,139) were included in this study. We aimed to assess the actual use of trastuzumab and to evaluate potential efficacy from trastuzumab in real-world research. Of 1,017 patients with early stage breast cancer (EBC), 40.5% (412/1,017) received trastuzumab therapy. Patients with EBC in resource-abundant regions (gross domestic product per capita >$15,000 and trastuzumab included in Medicare) are more likely to receive trastuzumab than those in resource-limited regions (37.3% vs. 13.0%, p course of therapy in resource-limited regions. Overall, the improvement in survival for trastuzumab versus non-trastuzumab was substantial in EBC (hazard ratio [HR] = 0.609, 95% confidence interval [CI]: 0.505-0.744) and in MBC (HR = 0.541, 95% CI: 0.418-0.606). This association was greater for patients with MBC who had never received trastuzumab (HR = 0.493, 95% CI: 0.372-0.576) than for those who had received adequate trastuzumab therapy in EBC stage (HR = 0.878, 95% CI: 0.506-1.431). This study showed great disparities in trastuzumab use in different regions and different treatment stages. Both EBC and MBC patients can benefit from trastuzumab, as the survival data show; however, when trastuzumab is adequate in the early stage, a further trastuzumab-based therapy in first-line treatment of MBC will be ineffective, especially for those with short disease-free survival, and a second line of anti-HER2 therapy will be recommended. (Research number: CSCO-BC RWS 15001). This article explores the disparities in the rates of trastuzumab use due to the inequitable allocation of medical
Asadzadeh, V.F.; Broeders, M.J.M.; Kiemeney, L.A.L.M.; Verbeek, A.L.M.
Young age at occurrence and advanced tumour stage at diagnosis should urge health policy makers to focus on strategies that will help to reduce breast cancer burden in Iran. However, fundamental knowledge to select the optimal control strategy is limited. In this review paper we summarize
Mitchell, Cedar L; Andrianaivoarimanana, Voahangy; Colman, Rebecca E; Busch, Joseph; Hornstra-O'Neill, Heidie; Keim, Paul S; Wagner, David M; Rajerison, Minoarisoa; Birdsell, Dawn N
resource constraint laboratories. This is a practical formula that reduces resource-driven limitations to genetic research and promises to advance global collective knowledge of infectious diseases emanating from resource limited regions of the world.
Agulnik, Asya; Méndez Aceituno, Alejandra; Mora Robles, Lupe Nataly; Forbes, Peter W; Soberanis Vasquez, Dora Judith; Mack, Ricardo; Antillon-Klussmann, Federico; Kleinman, Monica; Rodriguez-Galindo, Carlos
Pediatric oncology patients are at high risk of clinical deterioration, particularly in hospitals with resource limitations. The performance of pediatric early warning systems (PEWS) to identify deterioration has not been assessed in these settings. This study evaluates the validity of PEWS to predict the need for unplanned transfer to the pediatric intensive care unit (PICU) among pediatric oncology patients in a resource-limited hospital. A retrospective case-control study comparing the highest documented and corrected PEWS score before unplanned PICU transfer in pediatric oncology patients (129 cases) with matched controls (those not requiring PICU care) was performed. Documented and corrected PEWS scores were found to be highly correlated with the need for PICU transfer (area under the receiver operating characteristic, 0.940 and 0.930, respectively). PEWS scores increased 24 hours prior to unplanned transfer (P = .0006). In cases, organ dysfunction at the time of PICU admission correlated with maximum PEWS score (correlation coefficient, 0.26; P = .003), patients with PEWS results ≥4 had a higher Pediatric Index of Mortality 2 (PIM2) (P = .028), and PEWS results were higher in patients with septic shock (P = .01). The PICU mortality rate was 17.1%; nonsurvivors had higher mean PEWS scores before PICU transfer (P = .0009). A single-point increase in the PEWS score increased the odds of mechanical ventilation or vasopressors within the first 24 hours and during PICU admission (odds ratio 1.3-1.4). PEWS accurately predicted the need for unplanned PICU transfer in pediatric oncology patients in this resource-limited setting, with abnormal results beginning 24 hours before PICU admission and higher scores predicting the severity of illness at the time of PICU admission, need for PICU interventions, and mortality. These results demonstrate that PEWS aid in the identification of clinical deterioration in this high-risk population, regardless of a hospital
Will the future world be forever divided into an industrial, developed and 'rich' on one side, and primitive, undeveloped, and poor on the other? Is an industrial, affluent and sustainable world of 10-15 billion people owning 5-10 billion cars physically possible to exist. Can the world have enough food, minerals and energy to support such a widespread affluence in a sustainable manner? In previous papers i have argued that even without any major breakthroughs in science and technology, an industrialized, sustainable and affluent world can be created within the next half century, but only if breeder nuclear power is widely used throughout the world. In this paper i elaborate on the question of future availability of some basic natural resources. 18 refs. 3 figs. 1 tabs
Dias, Rubens A.; Mattos, Cristiano R.; Balestieri, Jose A.P.
The development of nations is an unquestionable requirement. A lot of challenges concerning health, education and economy are present. A discussion on these development models has occupied the minds of decision makers in recent years. When energy supply and demand is considered, the situation becomes critical and the crucial question is: how to improve the quality of life of developing countries based on available models of development that are related to the life style of developed countries, for which the necessary use and waste of energy are present? How much energy is essential to humanity for not so as to endangering the survival conditions of future generations? The human development index (HDI) establishes the relationship among energy use, economic growth and social growth. Here it can be seen that 75% of the world population has a significant energy consumption potential. This is a strong reason to consider that the sustainable development concepts on energy policies are strategic to the future of the planet. This paper deals with the importance of seeking alternative development models for human development balance, natural resources conservation and environment through rational energy use concepts
Linda M. Parsons
Full Text Available Laboratory systems worldwide are challenged not only by the need to compete for scarce resources with other sections of national health care programmes, but also with the lack of understanding of the critical role that laboratories play in the accurate diagnosis and monitoring of patients suffering from high-burdens of disease. An effective approach to establishing cost-effective laboratory systems that provide rapid and accurate test results for optimal impact on patient care is to move away from disease-specific programmes and establish integrated laboratory services. An integrated laboratory network provides all primary diagnostic services needed for care and treatment without requiring patients to go to different laboratory facilities for specific tests. Such a network focuses on providing quality-assured basic laboratory testing through the use of common specimen collection, reporting and diagnostic platforms that can be used across diseases. An integrated laboratory system also provides specimen transport to specialised laboratories and an environment conducive to the introduction and use of new and more complex technologies that would benefit the patient population and public health systems as a whole. As such, this article described various strategies for, and practical examples of, the successful integration of laboratory services.
Full Text Available Background: There is a worldwide shortage of qualified laboratory personnel to provide adequate testing for the detection and monitoring of diseases. In an effort to increase laboratory capacity in developing countries, new skills have been introduced into laboratory services. Curriculum revision with a focus on good laboratory practice is an important aspect of supplying entry-level graduates with the competencies needed to meet the current needs. Objectives: Gaps in application and problem-solving competencies of newly graduated laboratory personnel were discovered in Ethiopia, Tanzania and Kenya. New medical laboratory teaching content was developed in Ethiopia, Tanzania and Kenya using national instructors, tutors, and experts and consulting medical laboratory educators from the United States of America (USA. Method: Workshops were held in Ethiopia to create standardised biomedical laboratory science (BMLS lessons based on recently-revised course objectives with an emphasis on application of skills. In Tanzania, course-module teaching guides with objectives were developed based on established competency outcomes and tasks. In Kenya, example interactive presentations and lesson plans were developed by the USA medical laboratory educators prior to the workshop to serve as resources and templates for the development of lessons within the country itself. Results: The new teaching materials were implemented and faculty, students and other stakeholders reported successful outcomes. Conclusions: These approaches to updating curricula may be helpful as biomedical laboratory schools in other countries address gaps in the competencies of entry-level graduates.
Parsons, Linda M; Somoskovi, Akos; Lee, Evan; Paramasivan, Chinnambedu N; Schneidman, Miriam; Birx, Deborah; Roscigno, Giorgio; Nkengasong, John
Laboratory systems worldwide are challenged not only by the need to compete for scarce resources with other sections of national health care programmes, but also with the lack of understanding of the critical role that laboratories play in the accurate diagnosis and monitoring of patients suffering from high-burdens of disease. An effective approach to establishing cost-effective laboratory systems that provide rapid and accurate test results for optimal impact on patient care is to move away from disease-specific programmes and establish integrated laboratory services. An integrated laboratory network provides all primary diagnostic services needed for care and treatment without requiring patients to go to different laboratory facilities for specific tests. Such a network focuses on providing quality-assured basic laboratory testing through the use of common specimen collection, reporting and diagnostic platforms that can be used across diseases. An integrated laboratory system also provides specimen transport to specialised laboratories and an environment conducive to the introduction and use of new and more complex technologies that would benefit the patient population and public health systems as a whole. As such, this article described various strategies for, and practical examples of, the successful integration of laboratory services.
Mittelstädt, Victor; Miller, Jeff
We conducted 2 multitasking experiments to examine the finding that first-task reaction times (RTs) are slower in the psychological refractory period (PRP) paradigm than in the prioritized processing (PP) paradigm. To see whether this difference between the 2 paradigms could be explained entirely by differences in first-task preparation, which would be consistent with the standard response selection bottleneck (RSB) model for multitasking interference, we compared the size of this difference for trials in which a second-task stimulus actually occurred against the size of the difference for trials without any second-task stimulus. The slowing of first-task RTs in the PRP paradigm relative to the PP paradigm was larger when the second-task stimulus appeared than when it did not, indicating that the difference cannot be explained entirely by between-paradigm differences in first-task preparation. Instead, the results suggest that the slowing of first-task RTs in the PRP paradigm relative to the PP paradigm is partly because of differences between paradigms in the online reallocation of processing capacity to tasks. Thus, the present results provide new evidence supporting resource models over the RSB model. (PsycINFO Database Record (c) 2016 APA, all rights reserved).
Adamo, Shelley A; Baker, Jillian L; Lovett, Maggie M E; Wilson, Graham
Climate change will result in warmer temperatures and an increase in the frequency and severity of extreme weather events. Given that higher temperatures increase the reproductive rate of temperate zone insects, insect population growth rates are predicted to increase in the temperate zone in response to climate. This consensus, however, rests on the assumption that food is freely available. However, under conditions of limited food, the reproductive output of the Texan cricket Gryllus texensis (Cade and Otte) was highest at its current normal average temperature and declined with increasing temperature. Moreover, low food availability decreased survival during a simulated heat wave. Therefore, the effects of climate change on this species, and possibly on many others, are likely to hinge on food availability. Extrapolation from our data suggests that G. texensis will show larger yearly fluctuations in population size as climate change continues, and this will also have ecological repercussions. Only those temperate zone insects with a ready supply of food (e.g., agricultural pests) are likely to experience the predicted increase in population growth in response to climate change; food-limited species are likely to experience a population decline.
Agulnik, Asya; Mora Robles, Lupe Nataly; Forbes, Peter W; Soberanis Vasquez, Doris Judith; Mack, Ricardo; Antillon-Klussmann, Federico; Kleinman, Monica; Rodriguez-Galindo, Carlos
Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in resource-limited settings. Pediatric early warning systems (PEWS) aid in the early identification of clinical deterioration; however, there are limited data regarding their feasibility or impact in low-resource settings. This study describes the successful implementation of PEWS at the Unidad Nacional de Oncología Pediátrica (UNOP), a pediatric oncology hospital in Guatemala, resulting in improved inpatient outcomes. A modified PEWS was implemented at UNOP with systems to track errors, transfers to a higher level of care, and high scores. A retrospective cohort study was used to evaluate clinical deterioration events in the year before and after PEWS implementation. After PEWS implementation at UNOP, there was 100% compliance with PEWS documentation and an error rate of <10%. Implementation resulted in 5 high PEWS per week, with 30% of patients transferring to a higher level of care. Among patients requiring transfer to the pediatric intensive care unit (PICU), 93% had an abnormal PEWS before transfer. The rate of clinical deterioration events decreased after PEWS implementation (9.3 vs 6.5 per 1000-hospitalpatient-days, p = .003). Despite an 18% increase in total hospital patient-days, PICU utilization for inpatient transfers decreased from 1376 to 1088 PICU patient-days per year (21% decrease; P<.001). This study describes the successful implementation of PEWS in a pediatric oncology hospital in Guatemala, resulting in decreased inpatient clinical deterioration events and PICU utilization. This work demonstrates that PEWS is a feasible and effective quality improvement measure to improve hospital care for children with cancer in hospitals with limited resources. Cancer 2017;123:2965-74. © 2017 American Cancer Society. © 2017 American Cancer Society.
Schwartz, Noah G; Rattner, Adi; Schwartz, Alan R; Mokhlesi, Babak; Gilman, Robert H; Bernabe-Ortiz, Antonio; Miranda, J Jaime; Checkley, William
Sleep disordered breathing (SDB) is a highly prevalent condition in high-income countries, with major consequences for cardiopulmonary health, public safety, healthcare utilization, and mortality. However, its prevalence and effect in low- and middle-income countries are less well known. We sought to determine the prevalence, risk factors, and comorbidities of SDB symptoms in four resource-limited settings. Cross-sectional analysis of the CRONICAS Cohort, a population-based age- and sex-stratified sample. Four resource-limited settings in Peru varying in altitude, urbanization, and air pollution. There were 2,682 adults aged 35 to 92 y. Self-reported SDB symptoms (habitual snoring, observed apneas, Epworth Sleepiness Scale), sociodemographics, medical history, anthropometrics, spirometry, blood biomarkers were reported. We found a high prevalence of habitual snoring (30.2%, 95% confidence interval [CI] 28.5-32.0%), observed apneas (20.9%, 95% CI 19.4-22.5%) and excessive daytime sleepiness (18.6%, 95% CI 17.1-20.1%). SDB symptoms varied across sites; prevalence and adjusted odds for habitual snoring were greatest at sea level, whereas those for observed apneas were greatest at high altitude. In multivariable analysis, habitual snoring was associated with older age, male sex, body mass index (BMI), and higher socioeconomic status; observed apneas were associated with BMI; and excessive daytime sleepiness was associated with older age, female sex, and medium socioeconomic status. Adjusted odds of cardiovascular disease, depression, and hypertension and total chronic disease burden increased progressively with the number of SDB symptoms. A threefold increase in the odds of having an additional chronic comorbid disease (adjusted odds ratio 3.57, 95% CI 2.18-5.84) was observed in those with all three versus no SDB symptoms. Sleep disordered breathing symptoms were highly prevalent, varied widely across four resource-limited settings in Peru, and exhibited strong
Nyamtema Angelo S
Full Text Available Abstract Background Although clinical audit is an important instrument for quality care improvement, the concept has not yet been adequately taken on board in rural settings in most resource limited countries where the problem of maternal mortality is immense. Maternal mortality and morbidity audit was established at Saint Francis Designated District Hospital (SFDDH in rural Tanzania in order to generate information upon which to base interventions. Methods Methods are informed by the principles of operations research. An audit system was established, all patients fulfilling the inclusion criteria for maternal mortality and severe morbidity were reviewed and selected cases were audited from October 2008 to July 2010. The causes and underlying factors were identified and strategic action plans for improvement were developed and implemented. Results There were 6572 deliveries and 363 severe maternal morbidities of which 36 women died making institutional case fatality rate of 10%. Of all morbidities 341 (94% had at least one area of substandard care. Patients, health workers and administration related substandard care factors were identified in 50% - 61% of women with severe morbidities. Improving responsiveness to obstetric emergencies, capacity building of the workforce for health care, referral system improvement and upgrading of health centres located in hard to reach areas to provide comprehensive emergency obstetric care (CEmOC were proposed and implemented as a result of audit. Conclusions Our findings indicate that audit can be implemented in rural resource limited settings and suggest that the vast majority of maternal mortalities and severe morbidities can be averted even where resources are limited if strategic interventions are implemented.
William T Bean
Full Text Available Species distributions are known to be limited by biotic and abiotic factors at multiple temporal and spatial scales. Species distribution models, however, frequently assume a population at equilibrium in both time and space. Studies of habitat selection have repeatedly shown the difficulty of estimating resource selection if the scale or extent of analysis is incorrect. Here, we present a multi-step approach to estimate the realized and potential distribution of the endangered giant kangaroo rat. First, we estimate the potential distribution by modeling suitability at a range-wide scale using static bioclimatic variables. We then examine annual changes in extent at a population-level. We define "available" habitat based on the total suitable potential distribution at the range-wide scale. Then, within the available habitat, model changes in population extent driven by multiple measures of resource availability. By modeling distributions for a population with robust estimates of population extent through time, and ecologically relevant predictor variables, we improved the predictive ability of SDMs, as well as revealed an unanticipated relationship between population extent and precipitation at multiple scales. At a range-wide scale, the best model indicated the giant kangaroo rat was limited to areas that received little to no precipitation in the summer months. In contrast, the best model for shorter time scales showed a positive relation with resource abundance, driven by precipitation, in the current and previous year. These results suggest that the distribution of the giant kangaroo rat was limited to the wettest parts of the drier areas within the study region. This multi-step approach reinforces the differing relationship species may have with environmental variables at different scales, provides a novel method for defining "available" habitat in habitat selection studies, and suggests a way to create distribution models at spatial and
Abdominal closure. The intended purpose of our VAC technique of abdominal closure (adapting an Opsite sandwich) includes: • mechanical containment of abdominal contents. • active removal of wound and visceral exudates. • control of infection. • promotion of granulation tissue formation. • facilitation of delayed primary ...
Williams, Caitlin L; Witte, Tracy K
We evaluated the effects of exposure to a suicide news article on a variety of outcome variables and whether adhering to one specific media guideline (i.e., including psychoeducational information and preventative resources) buffered any of the negative effects of exposure. Participants were randomly assigned to read one of three articles and then asked to complete a battery of self-report questionnaires. Overall, we found no effect of exposure to a suicide news article, regardless of the inclusion of resources and information, with a few minor exceptions. Although researchers have demonstrated the effectiveness of media guidelines in the aggregate at reducing imitative suicidal behavior, it remains unclear which guidelines in particular are responsible for this effect. © 2017 The American Association of Suicidology.
Abdelaziz, Adel; Hany, Mohamed; Atwa, Hani; Talaat, Wagdy; Hosny, Somaya
In ordinary circumstances, objective structured clinical examination (OSCE) is a resource-intensive assessment method. In case of developing and implementing multidisciplinary OSCE, there is no doubt that the cost will be greater. Through this study a research project was conducted to develop, implement and evaluate a multidisciplinary OSCE model within limited resources. This research project went through the steps of blueprinting, station writing, resources reallocation, implementation and finally evaluation. The developed model was implemented in the Primary Health Care (PHC) program which is one of the pillars of the Community-Based undergraduate curriculum of the Faculty of Medicine, Suez Canal University (FOM-SCU). Data for evaluation of the implemented OSCE model were derived from two resources. First, feedback of the students and assessors through self-administered questionnaires was obtained. Second, evaluation of the OSCE psychometrics was done. The deliverables of this research project included a set of validated integrated multi-disciplinary and low cost OSCE stations with an estimated reliability index of 0.6. After having this experience, we have a critical mass of faculty members trained on blueprinting and station writing and a group of trained assessors, facilitators and role players. Also there is a state of awareness among students on how to proceed in this type of OSCE which renders future implementation more feasible.
TARCILA L. NADIA
Full Text Available Rhizophora mangle is considered as a self-compatible mangrove, and is pollinated by wind and insects. However, there is no information about fruit production by autogamy and agamospermy and on the foraging behavior of its flower visitors. Hence, the present study analyzed the pollination and reproductive systems of R. mangle in a mangrove community in northern Pernambuco, Brazil. Floral morphology, sequence of anthesis, and behavior of flower visitors were described; the proportion of flowers that resulted in mature propagules was also recorded. Autogamy, agamospermy, and wind pollination tests were performed, and a new anemophily index is proposed. The flowers of R. mangle are hermaphrodite, protandric, and have high P/O rate. Flies were observed on flowers only during the male phase, probably feeding on mites that consume pollen. Rhizophora mangle is not agamospermic and its fruit production rate by spontaneous self-pollination is low (2.56% compared to wind pollination (19.44%. The anemophily index was high 0.98, and thus it was considered as a good indicator. Only 13.79% of the flowers formed mature propagules. The early stages of fruit development are the most critical and susceptible to predation. Rhizophora mangle is, therefore, exclusively anemophilous in the study area and the propagule dispersal seems to be limited by herbivory.
Murthy, R Srinivasa; Lakshminarayana, Rashmi
This review covers the epidemiological research from developing countries to identify the scope of research in the various aspects of epidemiology and the strengths of research. The period covered is June 2004 to June 2005. The literature survey used searches of Medline, key psychiatric journals and personal correspondence with leading psychiatric researchers from developing countries. There is a new interest in epidemiological studies in developing countries. These studies have been driven by three factors, namely international collaboration; specific situations like disasters, terrorism and severe acute respiratory syndrome; and international attention to specific topics like maternal depression. There is limited long-term research on specific conditions. There are a number of leads suggesting local social-cultural factors contribute to the distribution of psychiatric problems. Child psychiatry continues to be low in priority. There is also lack of research in areas such as personality disorders and organic psychiatric disorders. It is possible to carry out high quality epidemiological research in developing countries. Such research has provided new insights into the distribution, causation, course and outcome of mental disorders. There is need for greater attention to the development of epidemiological assessment tools to suit local conditions. Specific centers/institutions developing long-term research interests on specific subjects would be valuable for future efforts. There is also need to widen the conditions to be studied.
Duan, M; Zhang, T; Hu, W; Sundström, L F; Wang, Y; Li, Z; Zhu, Z
Food consumption, number of movements and feeding hierarchy of juvenile transgenic common carp Cyprinus carpio and their size-matched non-transgenic conspecifics were measured under conditions of limited food supply. Transgenic fish exhibited 73.3% more movements as well as a higher feeding order, and consumed 1.86 times as many food pellets as their non-transgenic counterparts. After the 10 day experiment, transgenic C. carpio had still not realized their higher growth potential, which may be partly explained by the higher frequency of movements of transgenics and the 'sneaky' feeding strategy used by the non-transgenics. The results indicate that these transgenic fish possess an elevated ability to compete for limited food resources, which could be advantageous after an escape into the wild. It may be that other factors in the natural environment (i.e. predation risk and food distribution), however, would offset this advantage. Thus, these results need to be assessed with caution.
Cedar L Mitchell
financial cost for resource constraint laboratories. This is a practical formula that reduces resource-driven limitations to genetic research and promises to advance global collective knowledge of infectious diseases emanating from resource limited regions of the world.
Abubakar, Amina; Van de Vijver, Fons; Van Baar, Anneloes; Mbonani, Leonard; Kalu, Raphael; Newton, Charles; Holding, Penny
Sub-optimal physical growth has been suggested as a key pathway between the effect of environmental risk and developmental outcome. To determine if anthropometric status mediates the relation between socioeconomic status and psychomotor development of young children in resource-limited settings. A cross-sectional study design was used. A total of 204 (105 girls) children from two resource-limited communities in the Coast Province, Kenya. The mean age of these children was 29 months (SD = 3.43; range: 24-35 months). Psychomotor functioning was assessed using a locally developed and validated measure, the Kilifi Developmental Inventory. A significant association was found between anthropometric status (as measured by weight-for-age, height-for-age, mid-upper arm circumference, and head circumference) and psychomotor functioning and also between socioeconomic status and anthropometric status; no direct effects were found between socioeconomic status and developmental outcome. The models showed that weight, height and to a lesser extent mid-upper arm circumference mediate the relation between socioeconomic status and developmental outcome, while head circumference did not show the same effect. Among children under 3 years living in poverty, anthropometric status shows a clear association with psychomotor development while socioeconomic status may only have an indirect association.
Full Text Available The dynamical behavior of a Holling II predator-prey model with control measures as nonlinear pulses is proposed and analyzed theoretically and numerically to understand how resource limitation affects pest population outbreaks. The threshold conditions for the stability of the pest-free periodic solution are given. Latin hypercube sampling/partial rank correlation coefficients are used to perform sensitivity analysis for the threshold concerning pest extinction to determine the significance of each parameter. Comparing this threshold value with that without resource limitation, our results indicate that it is essential to increase the pesticide’s efficacy against the pest and reduce its effectiveness against the natural enemy, while enhancing the efficiency of the natural enemies. Once the threshold value exceeds a critical level, both pest and its natural enemies populations can oscillate periodically. Further-more, when the pulse period and constant stocking number as a bifurcation parameter, the predator-prey model reveals complex dynamics. In addition, numerical results are presented to illustrate the feasibility of our main results.
Daud, M.Y.; Qazi, R.A.
Pakistan is a resource limited society and gold standard parameters to monitor HIV disease activity are very costly. The objective of the study was to evaluate total lymphocyte count (TLC) as a surrogate to CD4 count to monitor disease activity in HIV/AIDS in resource limited society. Methods: This cross sectional study was carried out at HIV/AIDS treatment centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad. A total of seven hundred and seventy four (774) HIV positive patients were enrolled in this study, and their CD4 count and total lymphocyte count were checked to find any correlation between the two by using Spearman ranked correlation coefficient. Results: The mean CD4 count was (434.30 ± 269.23), with minimum CD4 count of (9.00), and maximum of (1974.00). The mean total lymphocyte count (TLC) was (6764.0052 ± 2364.02) with minimum TLC (1200.00) and maximum TLC was (20200.00). Using the Pearson's correlation (r) there was a significant and positive correlation between TLC and CD4 count. (r2=0.127 and p=0.000) at 0.01 level. Conclusion: Our study showed a significant positive correlation between CD4 count and total lymphocyte count (TLC), so TLC can be used as a marker of disease activity in HIV infected patients. (author)
Duke, Trevor; Kasa Tom, Sharon; Poka, Harry; Welch, Henry
In recent years, most of the focus on improving the quality of paediatric care in low-income countries has been on improving primary care using the Integrated Management of Childhood Illness, and improving triage and emergency treatment in hospitals aimed at reducing deaths in the first 24 hours. There has been little attention paid to improving the quality of care for children with chronic or complex diseases. Children with complicated forms of tuberculosis (TB), including central nervous system and chronic pulmonary TB, provide examples of acute and chronic multisystem paediatric illnesses that commonly present to district-level and second-level referral hospitals in low-income countries. The care of these children requires a holistic clinical and continuous quality improvement approach. This includes timely decisions on the commencement of treatment often when diagnoses are not certain, identification and management of acute respiratory, neurological and nutritional complications, identification and treatment of comorbidities, supportive care, systematic monitoring of treatment and progress, rehabilitation, psychological support, ensuring adherence, and safe transition to community care. New diagnostics and imaging can assist this, but meticulous attention to clinical detail at the bedside and having a clear plan for all aspects of care that is communicated well to staff and families are essential for good outcomes. The care is multidimensional: biomedical, rehabilitative, social and economic, and multidisciplinary: medical, nursing and allied health. In the era of the Sustainable Development Goals, approaches to these dimensions of healthcare are needed within the reach of the poorest people who access district hospitals in low-income countries. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Rutstein, S E; Golin, C E; Wheeler, S B; Kamwendo, D; Hosseinipour, M C; Weinberger, M; Miller, W C; Biddle, A K; Soko, A; Mkandawire, M; Mwenda, R; Sarr, A; Gupta, S; Mataya, R
Scale-up of viral load (VL) monitoring for HIV-infected patients on antiretroviral therapy (ART) is a priority in many resource-limited settings, and ART providers are critical to effective program implementation. We explored provider-perceived barriers and facilitators of VL monitoring. We interviewed all providers (n = 17) engaged in a public health evaluation of dried blood spots for VL monitoring at five ART clinics in Malawi. All ART clinics were housed within district hospitals. We grouped themes at patient, provider, facility, system, and policy levels. Providers emphasized their desire for improved ART monitoring strategies, and frustration in response to restrictive policies for determining which patients were eligible to receive VL monitoring. Although many providers pled for expansion of monitoring to include all persons on ART, regardless of time on ART, the most salient provider-perceived barrier to VL monitoring implementation was the pressure of work associated with monitoring activities. The work burden was exacerbated by inefficient data management systems, highlighting a critical interaction between provider-, facility-, and system-level factors. Lack of integration between laboratory and clinical systems complicated the process for alerting providers when results were available, and these communication gaps were intensified by poor facility connectivity. Centralized second-line ART distribution was also noted as a barrier: providers reported that the time and expenses required for patients to collect second-line ART frequently obstructed referral. However, provider empowerment emerged as an unexpected facilitator of VL monitoring. For many providers, this was the first time they used an objective marker of ART response to guide clinical management. Providers' knowledge of a patient's virological status increased confidence in adherence counseling and clinical decision-making. Results from our study provide unique insight into provider
Held, Christian; Liewald, Mathias; Schleich, Ralf; Sindel, Manfred
The use of lightweight materials offers substantial strength and weight advantages in car body design. Unfortunately such kinds of sheet material are more susceptible to wrinkling, spring back and fracture during press shop operations. For characterization of capability of sheet material dedicated to deep drawing processes in the automotive industry, mainly Forming Limit Diagrams (FLD) are used. However, new investigations at the Institute for Metal Forming Technology have shown that High Strength Steel Sheet Material and Aluminum Alloys show increased formability in case of bending loads are superposed to stretching loads. Likewise, by superposing shearing on in plane uniaxial or biaxial tension formability changes because of materials crystallographic texture. Such mixed stress and strain conditions including bending and shearing effects can occur in deep-drawing processes of complex car body parts as well as subsequent forming operations like flanging. But changes in formability cannot be described by using the conventional FLC. Hence, for purpose of improvement of failure prediction in numerical simulation codes significant failure criteria for these strain conditions are missing. Considering such aspects in defining suitable failure criteria which is easy to implement into FEA a new semi-empirical model has been developed considering the effect of bending and shearing in sheet metals formability. This failure criterion consists of the combination of the so called cFLC (combined Forming Limit Curve), which considers superposed bending load conditions and the SFLC (Shear Forming Limit Curve), which again includes the effect of shearing on sheet metal's formability.
Held, Christian; Liewald, Mathias; Schleich, Ralf; Sindel, Manfred
The use of lightweight materials offers substantial strength and weight advantages in car body design. Unfortunately such kinds of sheet material are more susceptible to wrinkling, spring back and fracture during press shop operations. For characterization of capability of sheet material dedicated to deep drawing processes in the automotive industry, mainly Forming Limit Diagrams (FLD) are used. However, new investigations at the Institute for Metal Forming Technology have shown that High Strength Steel Sheet Material and Aluminum Alloys show increased formability in case of bending loads are superposed to stretching loads. Likewise, by superposing shearing on in plane uniaxial or biaxial tension formability changes because of materials crystallographic texture. Such mixed stress and strain conditions including bending and shearing effects can occur in deep-drawing processes of complex car body parts as well as subsequent forming operations like flanging. But changes in formability cannot be described by using the conventional FLC. Hence, for purpose of improvement of failure prediction in numerical simulation codes significant failure criteria for these strain conditions are missing. Considering such aspects in defining suitable failure criteria which is easy to implement into FEA a new semi-empirical model has been developed considering the effect of bending and shearing in sheet metals formability. This failure criterion consists of the combination of the so called cFLC (combined Forming Limit Curve), which considers superposed bending load conditions and the SFLC (Shear Forming Limit Curve), which again includes the effect of shearing on sheet metal's formability.
Zongo, Nayi; Ouédraogo, Smaïla; Korsaga-Somé, Nina; Somé, Ollo Roland; Go, Naïma; Ouangré, Edgar; Zida, Maurice; Bonkoungou, Gilbert; Ouédraogo, Aimé Sosthène; Bambara, Aboubacar Hirrum; Tozoula, Bambara Augustin; Traoré, Si Simon; Dem, Ahmadou; Niamba, Pascal; Traoré, Adama; Sanou, Adama; Soares, Danielé Grazziotin; Lotz, Jean-Pierre
Male breast cancer is a rare and less known disease. Therapeutic modalities affect survival. In Burkina Faso, male breast cancers are diagnosed in everyday practice, but the prognosis at short-, middle-, and long-term remains unknown. The objective of this study is to study the diagnosis stages, therapeutic modalities, and 5-year survival in male breast cancer at the General Surgery Unit of Yalgado Ouedraogo University Hospital from 1990 to 2009. A cohort longitudinal study concerning cases of breast cancer diagnosed in man. Survival was assessed using the Kaplan-Meier method and survival curves were compared through the LogRank test. Fifty-one cases of male breast cancer were followed-up, i.e., 2.6% of all breast cancers. Stages III and IV represented 88% of cases. Eleven patients (21.6%) were at metastatic stage. Patients were operated in 60.8% of cases. The surgery included axillary dissection in 25 (80.6%) out of 31 cases. Lumpectomy was performed on 6.5% of patients (2 cases). Fifteen (29.4%) and 11 (21.6%) patients underwent chemotherapy and hormonal therapy, respectively. The FAC protocol was mostly used. Radiation therapy was possible in two cases. The median deadline for follow-up was 14.8 months. A local recurrence was noticed in 3.2% of cases. The overall 5-year survival rate was 49.9%. The median survival was over 5 years for stages I and II. It was 54 down to 36 months for stages III and IV. Diagnosis is late. The lack of immunohistochemistry makes it difficult to define the proportion of their hormonal dependence. Surgery is the basic treatment. Five-year survival is slow and the median survival depends on the diagnosis stage. It can be improved through awareness-raising campaigns and the conduct of individual screening.
Kakoma, Jean Baptiste
The area of Human Resources for Health (HRH) is the most critical challenge for the achievement of health related development goals in countries with limited resources. This is even exacerbated in a post conflict environment like Rwanda. The aim of this commentary is to report and share the genesis and outcomes of an exciting experience about training of qualified health workers in medicine and public health as well as setting - up of a research culture for the last nine years (2006 - 2014) in Rwanda. Many initiatives have been taken and concerned among others training of qualified health workers in medicine and public health. From 2006 to 2014, achievements were as follows: launching and organization of 8 Master of Medicine programmes (anesthesiology, family and community medicine, internal medicine, obstetrics & gynecology, otorhinolaryngology, pediatrics, psychiatry and surgery) and 4 Master programmes in public health (MPH, MSc Epidemiology, MSc Field Epidemiology & Laboratory Management, and Master in Hospital and Healthcare Administration); training to completion of more than 120 specialists in medicine, and 200 MPH, MSc Epidemiology, and MSc Field Epidemiology holders; revival of the Rwanda Medical Journal; organization of graduate research training (MPhil and PhD); 3 Master programmes in the pipeline (Global Health, Health Financing, and Supply Chain Management); partnerships with research institutions of great renown, which contributed to the reinforcement of the institutional research capacity and visibility towards excellence in leadership, accountability, and self sustainability. Even though there is still more to be achieved, the Rwanda experience about postgraduate and research programmes is inspiring through close interactions between main stakeholders. This is a must and could allow Rwanda to become one of the rare examples to other more well-to-do Sub - Saharan countries, should Rwanda carry on doing that.
Ford, Nathan; Arkinstall, James
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
Milner, K M; Neal, E F G; Roberts, G; Steer, A C; Duke, T
Improving outcomes beyond survival for high-risk newborns in resource-limited settings is an emerging challenge. Global estimates demonstrate the scale of this challenge and significant gaps in morbidity outcome data in high mortality contexts. A systematic review was conducted to document the prevalence of neurodevelopmental impairment in high-risk newborns who were followed up into childhood in low- and middle-income countries. High-risk newborns were defined as low, very or extremely low birthweight, preterm infants or those surviving birth asphyxia or serious infections. Electronic databases were searched and articles screened for eligibility. Included articles were appraised according to STROBE criteria. Narrative review was performed and median prevalence of key neurodevelopmental outcomes was calculated where data quality allowed. 6959 articles were identified with sixty included in final review. At follow-up in early childhood, median estimated prevalence (inter-quartile range) of overall neurodevelopmental impairment, cognitive impairment and cerebral palsy were: for survivors of prematurity/very low birthweight 21.4% (11.6-30.8), 16.3% (6.3-29.6) and 11.2% (5.9-16.1), respectively, and for survivors of birth asphyxia 34.6% (25.4-51.5), 11.3% (7.7-11.8) and 22.8% (15.7-31.4), respectively. Only three studies reporting outcomes following newborn serious bacterial infections were identified. There was limited reporting of important outcomes such as vision and hearing impairment. Major challenges with standardised reporting of key exposure and developmental outcome variables and lack of control data were identified. Understanding the limitations of the available data on neurodevelopmental outcome in newborns in resource-limited settings provides clear direction for research and efforts to improve long-term outcome in high-risk newborns in these settings.
Swain, JaBaris D; Sinnott, Colleen; Breakey, Suellen; Hasson Charles, Rian; Mody, Gita; Nyirimanzi, Napthal; Patton-Bolman, Ceeya; Come, Patricia; Ganza, Gapira; Rusingiza, Emmanuel; Ruhamya, Nathan; Mucumbitsi, Joseph; Borges, Jorge; Zammert, Martin; Muehlschlegel, Jochen D; Oakes, Robert; Leavitt, Bruce; Bolman, R Morton
Despite its near complete eradication in resource-rich countries, rheumatic heart disease remains the most common acquired cardiovascular disease in sub-Saharan Africa. With a ratio of physicians/population of 1 per 10,500, including only 4 cardiologists for a population of 11.4 million, Rwanda represents a resource-limited setting lacking the local capacity to detect and treat early cases of strep throat and perform lifesaving operations for advanced rheumatic heart disease. Humanitarian surgical outreach in this region can improve the delivery of cardiovascular care by providing sustainability through mentorship, medical expertise, training, and knowledge transfer, and ultimately the creation of a cardiac center. We describe the experience of consecutive annual visits to Rwanda since 2008 and report the outcomes of a collaborative approach to enable sustainable cardiac surgery in the region. The Ferrans and Powers Quality of Life Index tool's Cardiac Version (http://www.uic.edu/orgs/qli/) was administered to assess the postoperative quality of life. Ten visits have been completed, performing 149 open procedures, including 200 valve implantations, New York Heart Association class III or IV, with 4.7% 30-day mortality. All procedures were performed with the participation of local Rwandan personnel, expatriate physicians, nurses, residents, and support staff. Early complications included cerebrovascular accident (n = 4), hemorrhage requiring reoperation (n = 6), and death (n = 7). Quality of life was assessed to further understand challenges encountered after cardiac surgery in this resource-limited setting. Four major domains were considered: health and functioning, social and economic, psychologic/spiritual, and family. The mean total quality of life index was 20.79 ± 4.07 on a scale from 0 to 30, for which higher scores indicated higher quality of life. Women had significantly lower "social and economic" subscores (16.81 ± 4.17) than men (18.64 ± 4
Robertson, K; Jiang, H; Evans, SR; Marra, CM; Berzins, B; Hakim, J; Sacktor, N; Silva, M Tulius; Campbell, TB; Nair, A; Schouten, J; Kumwenda, J; Supparatpinyo, K; Tripathy, S.; Kumarasamy, N; La Rosa, A; Montano, S; Mwafongo, A; Firnhaber, C; Sanne, I; Naini, L.; Amod, F; Walawander, A
Summary ACTG A5271 collected neurocognitive normative comparison test data in 2400 at-risk HIV seronegative participants from Brazil, India, Malawi, Peru, South Africa, Thailand and Zimbabwe. The participants were enrolled in strata by site (10 levels), age (2 levels), education (2 levels), and gender (2 levels). These data provide necessary normative data infrastructure for future clinical research and care in these diverse resource limited settings. Infrastructure for conducting neurological research in resource limited settings (RLS) is limited. The lack of neurological and neuropsychological (NP) assessment, and normative data needed for clinical interpretation impede research and clinical care. Here we report on ACTG 5271, which provided neurological training of clinical site personnel, and collected neurocognitive normative comparison data in diverse settings. At 10 sites in seven RLS countries, we provided training for NP assessments. We collected normative comparison data on HIV- participants from Brazil (n=240), India (n=480), Malawi (n=481), Peru (n=239), South Africa (480), Thailand (n=240) and Zimbabwe (n=240). Participants had a negative HIV test within 30 days before standardized NP exams were administered at baseline, and 770 at six-months. Participants were enrolled in 8 strata, gender (female and male), education (<10 years and ≥ 10 years), and age (<35 years and ≥35 years). Of 2400 enrolled, 770 completed the six-month follow up. As expected, significant between-country differences were evident in all the neurocognitive test scores (p<.0001). There was variation between the age, gender and education strata on the neurocognitive tests. Age and education were important variables for all tests; older participants had poorer performance and those with higher education had better performance. Women had better performance on verbal learning/memory and speed of processing tests, while men performed better on motor tests. This study provides the
Thin Zaw Phyu Phyu
Full Text Available Abstract Background Inequity of accessibility to and utilization of reproductive health (RH services among youths is a global concern, especially in resource-limited areas. The level of inequity also varies by cultural and socio-economic contexts. To tailor RH services to the needs of youths, relevant solutions are required. This study aimed to assess baseline information on access to and utilization of RH services and unmet needs among youths living in resource-limited, suburban communities of Mandalay City, Myanmar. Methods A community-based, cross-sectional study was conducted in all resource-limited, suburban communities of Mandalay City, Myanmar. A total of 444 randomly selected youths aged between 15 and 24 years were interviewed for three main outcomes, namely accessibility to and utilization of RH services and youth's unmet needs for these services. Factors associated with these outcomes were determined using multivariate logistic regression. Results Although geographical accessibility was high (79.3%, financial accessibility was low (19.1% resulting in a low overall accessibility (34.5% to RH services. Two-thirds of youths used some kind of RH services at least once in the past. Levels of unmet needs for sexual RH information, family planning, maternal care and HIV testing were 62.6%, 31.9%, 38.7% and 56.2%, respectively. Youths living in the south or south-western suburbs, having a deceased parent, never being married or never exposed to mass media were less likely to access RH services. Being a young adult, current student, working as a waste recycler, having ever experienced a sexual relationship, ever being married, ever exposed to mass media, having a high knowledge of RH services and providers or a high level of accessibility to RH services significantly increased the likelihood of utilization of those services. In addition to youths’ socio-demographic characteristics, exposure to mass media, norm of peer exposure and knowledge
Teerawattananon, Yot; Luz, Alia; Pilasant, Songyot; Tangsathitkulchai, Suteenoot; Chootipongchaivat, Sarocha; Tritasavit, Nattha; Yamabhai, Inthira; Tantivess, Sripen
It is very challenging for resource-limited settings to introduce universal health coverage (UHC), particularly regarding the inclusion of high-cost renal dialysis as part of the UHC benefit package. This paper addresses three issues: (1) whether a setting commits to include renal dialysis in its UHC benefit package and if so, why and how; (2) how to ensure quality of renal dialysis services; and (3) how to improve the quality of life of patients using psychosocial and community interventions. This article reviews experiences of renal dialysis programs in seven settings based on presentations and discussions during the International Forum on Peritoneal Dialysis as a Priority Health Policy in Asia. A literature review was conducted to verify and validate the data as well as to fill information gaps presented in the forum. Five out of the seven settings implemented renal dialysis as part of their benefits package, while the other two have pilots or programs in their nascent stage. Renal replacement therapy has become part of the universal access package because these governments recognize the rising number of chronic kidney disease (CKD) cases, the catastrophically high costs of treatment, and that this is the only life-saving treatment available to patients. The recommendations are as follows: Governments should have a holistic approach to CKD interventions, including primary prevention as well as psychosocial interventions. Governments should consider subsidizing CKD treatment costs depending on their resources. Multi-stakeholder cooperation should be facilitated to enact these policies and conduct research and development for all aspects of interventions. International collaboration should be initiated to share experiences, good practices, and joint activities (e.g. capacity building and multinational procurement of medical supplies). This study provides practical recommendations to country governments as well as the international community on how to meet the
Rödiger, Tino; Magri, Fabien; Geyer, Stefan; Morandage, Shehan Tharaka; Ali Subah, H. E.; Alraggad, Marwan; Siebert, Christian
Both increasing aridity and population growth strongly stress freshwater resources in semi-arid areas such as Jordan. The country's second largest governorate, Irbid, with over 1 million inhabitants, is already suffering from an annual water deficit of 25 million cubic meters (MCM). The population is expected to double within the next 20 years. Even without the large number of refugees from Syria, the deficit will likely increase to more then 50 MCM per year by 2035 The Governorate's exclusive resource is groundwater, abstracted by the extensive Al Arab and Kufr Asad well fields. This study presents the first three-dimensional transient regional groundwater flow model of the entire Wadi al Arab to answer important questions regarding the dynamic quality and availability of water within the catchment. Emphasis is given to the calculation and validation of the dynamic groundwater recharge, derived from a multi-proxy approach, including (1) a hydrological model covering a 30-years dataset, (2) groundwater level measurements and (3) information about springs. The model enables evaluation of the impact of abstraction on the flow regime and the groundwater budget of the resource. Sensitivity analyses of controlling parameters indicate that intense abstraction in the southern part of the Wadi al Arab system can result in critical water-level drops of 10 m at a distance of 16 km from the production wells. Moreover, modelling results suggest that observed head fluctuations are strongly controlled by anthropogenic abstraction rather than variable recharge rates due to climate changes.
May, Philippa; Bowen, Asha; Tong, Steven; Steer, Andrew; Prince, Sam; Andrews, Ross; Currie, Bart; Carapetis, Jonathan
Impetigo, scabies, and fungal skin infections disproportionately affect populations in resource-limited settings. Evidence for standard treatment of skin infections predominantly stem from hospital-based studies in high-income countries. The evidence for treatment in resource-limited settings is less clear, as studies in these populations may lack randomisation and control groups for cultural, ethical or economic reasons. Likewise, a synthesis of the evidence for public health control within endemic populations is also lacking. We propose a systematic review of the evidence for the prevention, treatment and public health management of skin infections in resource-limited settings, to inform the development of guidelines for the standardised and streamlined clinical and public health management of skin infections in endemic populations. The protocol has been designed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols statement. All trial designs and analytical observational study designs will be eligible for inclusion. A systematic search of the peer-reviewed literature will include PubMed, Excertpa Medica and Global Health. Grey literature databases will also be systematically searched, and clinical trials registries scanned for future relevant studies. The primary outcome of interest will be the clinical cure or decrease in prevalence of impetigo, scabies, crusted scabies, tinea capitis, tinea corporis or tinea unguium. Two independent reviewers will perform eligibility assessment and data extraction using standardised electronic forms. Risk of bias assessment will be undertaken by two independent reviewers according to the Cochrane Risk of Bias tool. Data will be tabulated and narratively synthesised. We expect there will be insufficient data to conduct meta-analysis. The final body of evidence will be reported against the Grades of Recommendation, Assessment, Development and Evaluation grading system. The evidence
Full Text Available Thalassemias are the most common inherited genetic disorder in India and a major public health burden with bone marrow transplant (BMT considered the only established curative therapy. We describe outcomes for patients (n = 71 with standard-risk thalassemia (liver size 80 at the last follow up. 5 patients (7% died, mortality related to transplant. Enough data existed for 2 centers in India (36/71 transplants to analyze overall costs from admission up to one-year post-BMT which revealed a median cost of Rs 7,30,445 ($11519 [Range Rs 4,52,821–10,32,842 ($ 7079–16147]. In conclusion, children with thalassemia in resource limited settings can achieve good outcomes with BMT at a reasonable cost.
Ritchie, Allyson V; Ushiro-Lumb, Ines; Edemaga, Daniel; Joshi, Hrishikesh A; De Ruiter, Annemiek; Szumilin, Elisabeth; Jendrulek, Isabelle; McGuire, Megan; Goel, Neha; Sharma, Pia I; Allain, Jean-Pierre; Lee, Helen H
Routine viral-load (VL) testing of HIV-infected individuals on antiretroviral therapy (ART) is used to monitor treatment efficacy. However, due to logistical challenges, implementation of VL has been difficult in resource-limited settings. The aim of this study was to evaluate the performance of the SAMBA semi-Q (simple amplification-based assay semiquantitative test for HIV-1) in London, Malawi, and Uganda. The SAMBA semi-Q can distinguish between patients with VLs above and below 1,000 copies/ml. The SAMBA semi-Q was validated with diluted clinical samples and blinded plasma samples collected from HIV-1-positive individuals. SAMBA semi-Q results were compared with results from the Roche COBAS AmpliPrep/COBAS TaqMan HIV-1 test, v2.0. Testing of 96 2- to 10-fold dilutions of four samples containing HIV-1 subtype C as well as 488 samples from patients in the United Kingdom, Malawi, and Uganda yielded an overall accuracy for the SAMBA semi-Q of 99% (95% confidence interval [CI], 93.8 to 99.9%) and 96.9% (95% CI 94.9 to 98.3%), respectively, compared to to the Roche test. Analysis of VL data from patients in Malawi and Uganda showed that the SAMBA cutoff of 1,000 copies/ml appropriately distinguished treated from untreated individuals. Furthermore, analysis of the viral loads of 232 patients on ART in Malawi and Uganda revealed similar patterns for virological control, defined as either SAMBA cutoff) or SAMBA semi-Q has adequate concurrency with the gold standard measurements for viral load. This test can allow VL monitoring of patients on ART at the point of care in resource-limited settings. Copyright © 2014 Ritchie et al.
Wang, Linwei; Mohammad, Sohaib H.; Li, Qiaozhi; Rienthong, Somsak; Rienthong, Dhanida; Nedsuwan, Supalert; Mahasirimongkol, Surakameth; Yasui, Yutaka
There is an urgent need for simple, rapid, and affordable diagnostic tests for tuberculosis (TB) to combat the great burden of the disease in developing countries. The microscopic observation drug susceptibility assay (MODS) is a promising tool to fill this need, but it is not widely used due to concerns regarding its biosafety and efficiency. This study evaluated the automated MODS (Auto-MODS), which operates on principles similar to those of MODS but with several key modifications, making it an appealing alternative to MODS in resource-limited settings. In the operational setting of Chiang Rai, Thailand, we compared the performance of Auto-MODS with the gold standard liquid culture method in Thailand, mycobacterial growth indicator tube (MGIT) 960 plus the SD Bioline TB Ag MPT64 test, in terms of accuracy and efficiency in differentiating TB and non-TB samples as well as distinguishing TB and multidrug-resistant (MDR) TB samples. Sputum samples from clinically diagnosed TB and non-TB subjects across 17 hospitals in Chiang Rai were consecutively collected from May 2011 to September 2012. A total of 360 samples were available for evaluation, of which 221 (61.4%) were positive and 139 (38.6%) were negative for mycobacterial cultures according to MGIT 960. Of the 221 true-positive samples, Auto-MODS identified 212 as positive and 9 as negative (sensitivity, 95.9%; 95% confidence interval [CI], 92.4% to 98.1%). Of the 139 true-negative samples, Auto-MODS identified 135 as negative and 4 as positive (specificity, 97.1%; 95% CI, 92.8% to 99.2%). The median time to culture positivity was 10 days, with an interquartile range of 8 to 13 days for Auto-MODS. Auto-MODS is an effective and cost-sensitive alternative diagnostic tool for TB diagnosis in resource-limited settings. PMID:25378569
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Easterbrook, Philippa; Sands, Anita; Harmanci, Hande
Liver disease due to chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is now emerging as an increasing cause of morbidity and mortality in human immunodeficiency virus- (HIV-) infected persons in resource-limited settings (RLS). Existing management guidelines have generally focused on care in tertiary level facilities in developed countries. Less than half of low-income countries have guidance, and in those that do, there are important omissions or disparities in recommendations. There are multiple challenges to delivery of effective hepatitis care in RLS, but the most important remains the limited access to antiviral drugs and diagnostic tests. In 2010, the World Health Assembly adopted a resolution calling for a comprehensive approach for the prevention, control, and management of viral hepatitis. We describe activities at the World Health Organization (WHO) in three key areas: the establishment of a global hepatitis Program and interim strategy; steps toward the development of global guidance on management of coinfection for RLS; and the WHO prequalification program of HBV and HCV diagnostic assays. We highlight key research gaps and the importance of applying the lessons learned from the public health scale-up of ART to hepatitis care. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Ndayizigiye, M; Fawzi, M C Smith; Lively, C Thompson; Ware, N C
Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere. We investigated uptake of contraceptives among women of reproductive age in two rural districts of Burundi, using an explanatory sequential, mixed-methods research design. We first assessed availability and utilization rates of modern contraceptives through a facility-based survey in 39 health clinics. Barriers to uptake of contraceptives were then explored through qualitative interviews (N = 10) and focus groups (N = 7). Contraceptives were generally available in the 39 clinics studied, yet uptake of family planning averaged only 2.96%. Greater uptake was positively associated with the number of health professionals engaged and trained in family planning service provision, and with the number of different types of contraceptives available. Four uptake barriers were identified: (1) lack of providers to administer contraception, (2) lack of fit between available and preferred contraceptive methods, (3) a climate of fear surrounding contraceptive use, and (4) provider refusal to offer family planning services. Where resources are scarce, availability of modern contraceptives alone will likely not ensure uptake. Interventions addressing multiple uptake barriers simultaneously have the greatest chance of success. In rural Burundi, examples are community distribution of contraceptive methods, public information campaigns, improved training for health professionals and community health workers, and strengthening of the health infrastructure.
Salazar, Martin R; Espeche, Walter G; Stavile, Rodolfo N; Balbín, Eduardo; Leiva Sisnieguez, Betty C; Leiva Sisnieguez, Carlos E; March, Carlos E; Cor, Susana; Eugenio Acero, Irma; Carbajal, Horacio A
Blood pressure (BP) was assessed by patients themselves in recently published trials. Self-measured office blood pressure (SMOBP) seems particularly interesting for limited health resources regions. The aim of our study was to evaluate the relationship between SMOBP values and those estimated by ambulatory blood pressure monitoring (ABPM). Six hundred seventy-seven patients were evaluated using both, SMOBP and ABPM. The differences between SMOBP and daytime ABPM were evaluated with paired "t" test. The correlations among SMOBP and ABPM were estimated using Pearson's r. The accuracy of SMOBP to identify abnormal ABPM was determined using area under ROC curve (AUC). Sensitivity, specificity, and positive and negative predictive values were calculated for different SMOBP cut-points. Using the average of three readings, systolic SMOBP was higher (3.7 (14.2) mmHg, p ABPM. Both BP estimates had a significant correlation, r = 0.67 and r = 0.75 (p ABPM; the AUC were 0.80 (0.77-0.84) and 0.78 (0.74-0.81) for daytime and 24 h hypertension, respectively. Diastolic SMOBP predicted diastolic hypertension, AUC 0.86 (0.83-0.88) for both daytime and 24 h hypertension. Neither correlations nor AUCs improved significantly using the average of five readings. SMOBP ≥ 160/90 mmHg was highly specific (>95%) to identify individuals with hypertension in the ABPM; SMOBP ABPM. In conclusion, a high proportion of individuals could be classified adequately using SMOBP, reducing the necessity of healthcare resources and supporting its utility for screening purposes.
Craig A. Carr
Full Text Available Alterations in under-canopy resource availability associated with elevated ponderosa pine (Pinus ponderosa Dougl. abundance can negatively influence understory vegetation. Experimental evidence linking under-canopy resource availability and understory vegetation is scarce. Yet this information would be beneficial in developing management strategies to recover desired understory species. We tested the effects of varying nitrogen (N and light availability on Idaho fescue (Festuca idahoensis Elmer, the dominant understory species in ponderosa pine/Idaho fescue plant associations in eastern Oregon. In a greenhouse experiment, two levels of N (50 kg∙N∙ha−1 and 0 kg∙N∙ha−1 and shade (80% shade and 0% shade were applied in a split-plot design to individual potted plants grown in soil collected from high abundance pine stands. Plants grown in unshaded conditions produced greater root (p = 0.0027 and shoot (p = 0.0017 biomass and higher cover values (p = 0.0378 compared to those in the shaded treatments. The addition of N had little effect on plant growth (p = 0.1602, 0.5129, and 0.0853 for shoot biomass, root biomass, and cover, respectively, suggesting that soils in high-density ponderosa pine stands that lack understory vegetation were not N deficient and Idaho fescue plants grown in these soils were not N limited. Management activities that increase under-canopy light availability will promote the conditions necessary for Idaho fescue recovery. However, successful restoration may be constrained by a lack of residual fescue or the invasion of more competitive understory vegetation.
J.H. van Dijk (Janneke); C.G. Sutcliffe (Catherine); F. Hamangaba (Francis); C. Bositis (Christopher); D.C. Watson (Douglas); W.J. Moss (William)
textabstractBackground: Antiretroviral treatment (ART) options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV). Using available pharmacokinetic data, an EFV dosing schedule was developed for young
Leavy, Breiffni; Roaldsen, Kirsti Skavberg; Nylund, Kamilla; Hagströmer, Maria; Franzén, Erika
There is growing evidence for the positive effects of exercise training programs on balance control in Parkinson disease (PD). To be effective, balance training needs to be specific, progressive, and highly challenging. Little evidence exists, however, for how people with PD-related balance impairments perceive highly challenging and progressive balance training programs with dual-task components. The purpose of this study was to explore and describe perceptions of a highly challenging balance training program among people with mild to moderate PD. This study was qualitative in nature. In-depth interviews were conducted with 13 individuals with mild to moderate PD who had participated in a highly challenging balance training program. Interview transcripts were analyzed using qualitative content analysis, with an inductive approach. The analysis revealed 3 subthemes concerning participants' perceptions of highly challenging and progressive balance training: (1) movement to counter the disease, (2) dual-task training in contrast to everyday strategies, and (3) the struggle to maintain positive effects. The first subtheme reflects how physical activity was used as a short-term and long-term strategy for counteracting PD symptoms and their progression. The second subtheme incorporates the described experiences of being maximally challenged in a secure and supportive group environment, circumstances that stood in contrast to participants' everyday lives. The third subtheme describes participants' long-term struggle to maintain program effects on cognitive and physical function in the face of disease progression. Interpretation of the underlying patterns of these subthemes resulted in one overarching theme: training at the limits of balance capacity causes a rethinking motor and cognitive resources. The findings of this study cannot be considered to reflect the beliefs of those with weaker or negative beliefs concerning physical activity or be transferred to those at
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Full Text Available The ultimate goal of our multi-article series is to demonstrate the Allometric Scaling and Resource Limitation (ASRL approach for mapping tree heights and biomass. This third article tests the feasibility of the optimized ASRL model over China at both site (14 meteorological stations and continental scales. Tree heights from the Geoscience Laser Altimeter System (GLAS waveform data are used for the model optimizations. Three selected ASRL parameters (area of single leaf, α; exponent for canopy radius, η; and root absorption efficiency, γ are iteratively adjusted to minimize differences between the references and predicted tree heights. Key climatic variables (e.g., temperature, precipitation, and solar radiation are needed for the model simulations. We also exploit the independent GLAS and in situ tree heights to examine the model performance. The predicted tree heights at the site scale are evaluated against the GLAS tree heights using a two-fold cross validation (RMSE = 1.72 m; R2 = 0.97 and bootstrapping (RMSE = 4.39 m; R2 = 0.81. The modeled tree heights at the continental scale (1 km spatial resolution are compared to both GLAS (RMSE = 6.63 m; R2 = 0.63 and in situ (RMSE = 6.70 m; R2 = 0.52 measurements. Further, inter-comparisons against the existing satellite-based forest height maps have resulted in a moderate degree of agreements. Our results show that the optimized ASRL model is capable of satisfactorily retrieving tree heights over continental China at both scales. Subsequent studies will focus on the estimation of woody biomass after alleviating the discussed limitations.
Maiga, Almoustapha Issiaka; Fofana, Djeneba Bocar; Cisse, Mamadou; Diallo, Fodié; Maiga, Moussa Youssoufa; Traore, Hamar Alassane; Maiga, Issouf Alassane; Sylla, Aliou; Fofana, Dionke; Taiwo, Babafemi; Murphy, Robert; Katlama, Christine; Tounkara, Anatole; Calvez, Vincent; Marcelin, Anne-Geneviève
Objectives We describe the outcomes of second-line drug resistance profiles and predict the efficacy of drugs for third-line therapy in patients monitored without the benefit of plasma HIV-1 RNA viral load (VL) or resistance testing. Methods We recruited 106 HIV-1-infected patients after second-line treatment failure in Mali. VL was determined by the Abbott RealTime system and the resistance by the ViroSeq HIV-1 genotyping system. The resistance testing was interpreted using the latest version of the Stanford algorithm. Results Among the 106 patients, 93 had isolates successfully sequenced. The median age, VL and CD4 cells were respectively 35 years, 72 000 copies/mL and 146 cells/mm3. Patients were exposed to a median of 4 years of treatment and to six antiretrovirals. We found 20% of wild-type viruses. Resistance to etravirine was noted in 38%, to lopinavir in 25% and to darunavir in 12%. The duration of prior nucleos(t)ide reverse transcriptase inhibitor exposure was associated with resistance to abacavir (P < 0.0001) and tenofovir (P = 0.0001), and duration of prior protease inhibitor treatment with resistance to lopinavir (P < 0.0001) and darunavir (P = 0.06). Conclusion Long duration of therapy prior to failure was associated with high levels of resistance and is directly related to limited access to VL monitoring and delayed switches to second-line treatment, precluding efficacy of drugs for third-line therapy. This study underlines the need for governments and public health organizations to recommend the use of VL monitoring and also the availability of darunavir and raltegravir for third-line therapies in the context of limited-resource settings. PMID:22888273
Christopher R. Stark
Full Text Available Purpose: To describe the methodology and initial experience behind creation of an ultrasoundguided percutaneous breast core biopsy program in rural Uganda. Methods and Materials: Imaging the World Africa (ITWA is the registered non-governmental organization division of Imaging the World (ITW, a not-for-profit organization whose primary aim is the integration of affordable high-quality ultrasound into rural health centers. In 2013, ITWA began the pilot phase of an IRB-approved breast care protocol at a rural health center in Uganda. As part of the protocol’s diagnostic arm, an ultrasound-guided percutaneous breast core biopsy training curriculum was implemented in tandem with creation of regionally supplied biopsy kits. Results: A surgeon at a rural regional referral hospital was successfully trained and certified to perform ultrasound-guided percutaneous breast core biopsies. Affordable and safe biopsy kits were created using locally available medical supplies with the cost of each kit totaling $10.62 USD. Conclusion: Successful implementation of an ultrasound-guided percutaneous breast core biopsy program in the resource-limited setting is possible and can be made sustainable through incorporation of local health care personnel and regionally supplied biopsy materials. Our hope is that ITWA’s initial experience in rural Uganda can serve as a model for similar programs in the future.
Full Text Available BACKGROUND: Human Immunodeficiency Virus Type 1 (HIV-1 viral load testing at regular intervals is an integral component of disease management in Acquired Immunodeficiency Syndrome (AIDS patients. The need in countries like India is therefore an assay that is not only economical but efficient and highly specific for HIV-1 sub type C virus. This study reports a SYBR Green-based HIV-1 real time PCR assay for viral load testing and is designed for enhanced specificity towards HIV-1 sub type C viruses prevalent in India. RESULTS: Linear regression of the observed and reference concentration of standards used in this study generated a correlation coefficient of 0.998 (p 0.5 log value, a figure that is considered clinically significant by physicians. CONCLUSION: The HIV-1 viral load assay reported in this study was found to be robust, reliable, economical and effective in resource limited settings such as those existing in India. PCR probes specially designed from HIV-1 Subtype C-specific nucleotide sequences originating from India imparted specificity towards such isolates and demonstrated superior results when compared to two similar commercial assays widely used in India.
Risha, Peter Gasper; Msuya, Zera; Clark, Malcolm; Johnson, Keith; Ndomondo-Sigonda, Margareth; Layloff, Thomas
The Tanzania Food and Drugs Authority piloted the use of Minilab kits, a thin-layer-chromatographic based drug quality testing technique, in a two-tier quality assurance program. The program is intended to improve testing capacity with timely screening of the quality of medicines as they enter the market. After 1 week training of inspectors on Minilab screening techniques, they were stationed at key Ports-of-Entry (POE) to screen the quality of imported medicines. In addition, three non-Ports-of-Entry centres were established to screen samples collected during Post-Marketing-Surveillance. Standard operating procedures (SOPs) were developed to structure and standardize the implementation process. Over 1200 samples were tested using the Minilab outside the central quality control laboratory (QCL), almost doubling the previous testing capacity. The program contributed to increased regulatory reach and visibility of the Authority throughout the country, serving as a deterrent against entry of substandard medicines into market. The use of Minilab for quality screening was inexpensive and provided a high sample throughput. However, it suffers from the limitation that it can reliably detect only grossly substandard or wrong drug samples and therefore, it should not be used as an independent testing resource but in conjunction with a full-service quality control laboratory capable of auditing reported substandard results.
Stolz, Lori A; Muruganandan, Krithika M; Bisanzo, Mark C; Sebikali, Mugisha J; Dreifuss, Bradley A; Hammerstedt, Heather S; Nelson, Sara W; Nayabale, Irene; Adhikari, Srikar; Shah, Sachita P
To describe the outcomes and curriculum components of an educational programme to train non-physician clinicians working in a rural, Ugandan emergency department in the use of POC ultrasound. The use of point-of-care ultrasound was taught to emergency care providers through lectures, bedsides teaching and hands-on practical sessions. Lectures were tailored to care providers' knowledge base and available therapeutic means. Every ultrasound examination performed by these providers was recorded over 4.5 years. Findings of these examinations were categorised as positive, negative, indeterminate or procedural. Other radiologic studies ordered over this same time period were also recorded. A total of 22,639 patients were evaluated in the emergency department by emergency care providers, and 2185 point-of-care ultrasound examinations were performed on 1886 patients. Most commonly used were the focused assessment with sonography in trauma examination (53.3%) and echocardiography (16.4%). Point-of-care ultrasound studies were performed more frequently than radiology department-performed studies. Positive findings were documented in 46% of all examinations. We describe a novel curriculum for point-of-care ultrasound education of non-physician emergency practitioners in a resource-limited setting. These non-physician clinicians integrated ultrasound into clinical practice and utilised this imaging modality more frequently than traditional radiology department imaging with a large proportion of positive findings. © 2015 John Wiley & Sons Ltd.
Lawn, Stephen D; Meintjes, Graeme; McIlleron, Helen; Harries, Anthony D; Wood, Robin
The HIV-associated tuberculosis (TB) epidemic remains a huge challenge to public health in resource-limited settings. Reducing the nearly 0.5 million deaths that result each year has been identified as a key priority. Major progress has been made over the past 10 years in defining appropriate strategies and policy guidelines for early diagnosis and effective case management. Ascertainment of cases has been improved through a twofold strategy of provider-initiated HIV testing and counseling in TB patients and intensified TB case finding among those living with HIV. Outcomes of rifampicin-based TB treatment are greatly enhanced by concurrent co-trimoxazole prophylaxis and antiretroviral therapy (ART). ART reduces mortality across a spectrum of CD4 counts and randomized controlled trials have defined the optimum time to start ART. Good outcomes can be achieved when combining TB treatment with first-line ART, but use with second-line ART remains challenging due to pharmacokinetic drug interactions and cotoxicity. We review the frequency and spectrum of adverse drug reactions and immune reconstitution inflammatory syndrome (IRIS) resulting from combined treatment, and highlight the challenges of managing HIV-associated drug-resistant TB.
Rita O. Oladele
Full Text Available Cryptococcal disease remains a significant source of global morbidity and mortality for people living with HIV, especially in resource-limited settings. The recently updated estimate of cryptococcal disease revealed a global incidence of 223,100 cases annually with 73% of these cases being diagnosed in sub-Saharan Africa. Furthermore, 75% of the estimated 181,100 deaths associated with cryptococcal disease occur in sub-Saharan Africa. Point-of-care diagnostic assays have revolutionised the diagnosis of this deadly opportunistic infection. The theory of asymptomatic cryptococcal antigenaemia as a forerunner to symptomatic meningitis and death has been conclusively proven. Thus, cryptococcal antigenaemia screening coupled with pre-emptive antifungal therapy has been demonstrated as a cost-effective strategy with survival benefits and has been incorporated into HIV national guidelines in several countries. However, this is yet to be implemented in a number of other high HIV burden countries. Flucytosine-based combination therapy during the induction phase is associated with improved survival, faster cerebrospinal fluid sterilisation and fewer relapses. Flucytosine, however, is unavailable in many parts of the world. Studies are ongoing on the efficacy of shorter regimens of amphotericin B. Early diagnosis, proactive antifungal therapy with concurrent management of raised intracranial pressure creates the potential to markedly reduce mortality associated with this disease.
Campos, Daniel; Llebot, Josep E; Méndez, Vicenç
We present an agent-based model inspired by the Evolutionary Minority Game (EMG), albeit strongly adapted, to the case of competition for limited resources in ecology. The agents in this game become able, after some time, to predict the a priori best option as a result of an evolution-driven learning process. We show that a self-segregated social structure can emerge from this process, i.e., extreme learning strategies are always favoured while intermediate learning strategies tend to die out. This result may contribute to understanding some levels of organization and cooperative behaviour in ecological and social systems. We use the ideas and results reported here to discuss an issue of current interest in ecology: the mistimings in egg laying observed for some species of bird as a consequence of their slower rate of adaptation to climate change in comparison with that shown by their prey. Our model supports the hypothesis that habitat-specific constraints could explain why different populations are adapting differently to this situation, in agreement with recent experiments.
Flood, David; Douglas, Kate; Goldberg, Vera; Martinez, Boris; Garcia, Pablo; Arbour, MaryCatherine; Rohloff, Peter
Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients. Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care. This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework. A bundle of improvement activities were implemented at the home, clinic and institutional level. Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control. Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org
Full Text Available Objective. To assess the prevalence and identified associated risk factors for precancerous cervical cancer lesions among HIV-infected women in resource-limited settings in Kenya. Methods. HIV-infected women attending the ART clinic at the Nazareth Hospital ART clinic between June 2009 and September 2010. Multivariate logistic regression model with odds ratios and 95% confidence intervals (CI were estimated after controlling for important covariates. Result. A total of 715 women were screened for cervical cancer. The median age of the participants was 40 years (range 18–69 years. The prevalence of precancerous lesions (CINI, CINII, CIN III, ICC was 191 (26.7%. After controlling for other variables in logistic regression analysis, cervical precancerous lesions were associated with not being on ART therapy; whereby non-ART were 2.21 times more likely to have precancerous lesions than ART patients [(aOR=2.21, 95% CI (1.28–3.83]. Conclusion. The prevalence of precancerous cervical lesions was lower than other similar settings. It is recommended that cancer screening of HIV-infected women should be an established practice. Availability and accessibility of these services can be done through their integration into HIV. Prompt initiation of HAART through an early enrollment into care has an impact on reducing the prevalence and progression of cervical precancerous lesions.
Longuet, Christophe; Fenet, Solveig; Hirsch, François; Littler, Katherine
On the 5th of November 2015, the Inserm Ethics Committee, Fondation Mérieux and the Global Forum on Bioethics in Research (GFBR), organized a workshop at Les Pensières, Annecy, France, bringing together more than thirty scientists and ethicists, from twenty countries around the world, to debate the way to ensure better sharing of data and biological samples collected during trials in countries with limited resources.Propositions were made to improve the practices of different stakeholders of scientific research (researchers, members of ethics committees, key community representatives) and policy makers (ministers, funding agencies), on the following issues :How to foster equitable scientific collaborations in international research projects ?How to protect the interests of the study participants when sharing data and biological samples ?How to ensure appropriate information and obtain informed consent from individuals with different cultures and levels of education ?In this publication on the use of ?big data? in health, this report from the workshop of November 5, focuses on the aspects related to the sharing of research data.
Brentlinger, Paula E; Silva, Wilson P; Vermund, Sten H; Valverde, Emilio; Buene, Manuel; Moon, Troy D
Mozambique's updated guideline for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria. We prospectively evaluated this guideline in rural Zambézia Province. Likely cause(s) of anemia were determined through prespecified history, physical examination, and laboratory testing. Diagnoses were "etiologic" if laboratory confirmed (sputum microscopy, blood culture, Plasmodium falciparum malaria rapid test) or "syndromic" if not. To assess hemoglobin response, we used serial point-of-care measurements. We studied 324 ambulatory, anemic (hemoglobin management (iron supplementation, deworming, and/or antimalarials) alone. Thirty (9.3%) died and/or were hospitalized, and 125 (38.6%) were lost to follow-up. Multivariable linear and logistic regression models described better hemoglobin responses and/or outcomes in subjects with higher CD4(+) T-lymphocyte counts, pre-enrollment antiretroviral therapy and/or co-trimoxazole prophylaxis, discontinuation of zidovudine for suspected adverse reaction, and smear-positive tuberculosis. Adverse outcomes were associated with fever, low body mass index, bacteremia, esophageal candidiasis, and low or missing CD4(+) T cell counts. In this severely resource-limited setting, successful anemia management often required interventions other than conventional presumptive treatment, thus supporting Mozambique's guideline revision.
Declerck, Steven A J; Malo, Andrea R; Diehl, Sebastian; Waasdorp, Dennis; Lemmen, Kimberley D; Proios, Konstantinos; Papakostas, Spiros
Humans alter biogeochemical cycles of essential elements such as phosphorus (P). Prediction of ecosystem consequences of altered elemental cycles requires integration of ecology, evolutionary biology and the framework of ecological stoichiometry. We studied micro-evolutionary responses of a herbivorous rotifer to P-limited food and the potential consequences for its population demography and for ecosystem properties. We subjected field-derived, replicate rotifer populations to P-deficient and P-replete algal food, and studied adaptation in common garden transplant experiments after 103 and 209 days of selection. When fed P-limited food, populations with a P-limitation selection history suffered 37% lower mortality, reached twice the steady state biomass, and reduced algae by 40% compared to populations with a P-replete selection history. Adaptation involved no change in rotifer elemental composition but reduced investment in sex. This study demonstrates potentially strong eco-evolutionary feedbacks from shifting elemental balances to ecosystem properties, including grazing pressure and the ratio of grazer:producer biomass. © 2015 The Authors Ecology Letters published by John Wiley & Sons Ltd and CNRS.
Full Text Available Palliative care in India has made enormous advances in providing better care for patients and families living with progressive disease, and many clinical services are well placed to begin quality improvement initiatives, including clinical audit. Clinical audit is recognized globally to be essential in all healthcare, as a way of monitoring and improving quality of care. However, it is not common in developing country settings, including India. Clinical audit is a cyclical activity involving: identification of areas of care in need of improvement, through data collection and analysis utilizing an appropriate questionnaire; setting measurable quality of care targets in specific areas; designing and implementing service improvement strategies; and then re-evaluating quality of care to assess progress towards meeting the targets. Outcome measurement is an important component of clinical audit that has additional advantages; for example, establishing an evidence base for the effectiveness of services. In resource limited contexts, outcome measurement in clinical audit is particularly important as it enables service development to be evidence-based and ensures resources are allocated effectively. Key success factors in conducting clinical audit are identified (shared ownership, training, managerial support, inclusion of all members of staff and a positive approach. The choice of outcome measurement tool is discussed, including the need for a culturally appropriate and validated measure which is brief and simple enough to incorporate into clinical practice and reflects the holistic nature of palliative care. Support for clinical audit is needed at a national level, and development and validation of an outcome measurement tool in the Indian context is a crucial next step.
Kalisya, Luc Malemo; Bake, Jacques Fadhili; Bigabwa, Richard; Rothstein, David H; Cairo, Sarah B
faces a multitude of challenges. Access to surgical services for diagnosis and management as well as chemotherapeutic agents is prohibitively limited. Increased collaboration with local clinicians and remote specialist consultants is needed to deliver subspecialty care in resource-poor settings.
Li, B; Sahota, D S; Lao, T T; Xu, J; Hu, S Q; Zhang, L; Liu, Q Y; Sun, Q; Tang, D; Ma, R M
To assess the feasibility and performance of the first-trimester combined screening test for trisomy 21 in a resource-limited setting in mainland China. Prospective observational cohort study. First Affiliated Hospital of Kunming Medical University, China. Ten thousand four hundred and forty-two pregnant women requesting first-trimester screening. The combined screening test was performed from May 2012 to December 2014. Women with a high-risk result (≥1:600) were offered further confirmatory tests after counselling. The threshold for high risk was determined by Monte Carlo simulation to achieve a 5% false-positive rate according to the local age distribution. Pregnancy outcome and screening results were recorded for all women and monthly audits were conducted. Sensitivity, screen positive rate, cost per case of Down syndrome detected. Six hundred and ten women (5.8% of the total screened) had a high-risk screening test, of whom 274 (44.9%) underwent a diagnostic test and 169 (27.7%) opted for a noninvasive prenatal screening test (NIPT); 160 (26.2%) declined further testing after counselling. The pregnancy outcome was available for 10 174 (97.4%) of the women. The observed incidence of Down syndrome was 0.13% (1/750). All 14 women with a trisomy 21 pregnancy had a high-risk screening test result. The cost per Down syndrome detected was RMB596 686 compared with RMB1.79 million if all had been screened by NIPT. The combined screening test appears to be a more cost-effective strategy in mainland China. Screening performance in China would be improved by adopting Chinese-specific models, external quality control and assurance, and establishing risk thresholds appropriate for the age distribution of the population. Combined first-trimester Downs screening in China was improved by adopting Chinese-specific models and external QC. © 2016 Royal College of Obstetricians and Gynaecologists.
Becker, Torben K; Tafoya, Chelsea A; Osei-Ampofo, Maxwell; Tafoya, Matthew J; Kessler, Ross A; Theyyunni, Nikhil; Yakubu, Hussein A; Opuni, Daniel; Clauw, Daniel J; Cranford, James A; Oppong, Chris K; Oteng, Rockefeller A
To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource-limited setting. Approximately half of the emergency medicine resident physicians at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, were trained in a CPUS protocol. Adult patients triaged to the resuscitation area of the emergency department (ED) were enrolled if they exhibited signs or symptoms of shock or respiratory distress. Patients were assigned to the intervention group if their treating physician had completed the CPUS training. The physician's initial diagnostic impression was recorded immediately after the history and physical examination in the control group, and after an added CPUS examination in the intervention group. This was compared to a standardised final diagnosis derived from post hoc chart review of the patient's care at 24 h by two blinded, independent reviewers using a clearly defined and systematic process. Secondary outcomes were 24-h mortality and use of IV fluids, diuretics, vasopressors and bronchodilators. Of 890 patients presenting during the study period, 502 were assessed for eligibility, and 180 patients were enrolled. Diagnostic accuracy was higher for patients who received the CPUS examination (71.9% vs. 57.1%, Δ 14.8% [CI 0.5%, 28.4%]). This effect was particularly pronounced for patients with a 'cardiac' diagnosis, such as cardiogenic shock, congestive heart failure or acute valvular disease (94.7% vs. 40.0%, Δ 54.7% [CI 8.9%, 86.4%]). Secondary outcomes were not different between groups. In an urban ED in Ghana, a CPUS examination improved the accuracy of the treating physician's initial diagnostic impression. There were no differences in 24-h mortality and a number of patient care interventions. © 2017 John Wiley & Sons Ltd.
Lam, Christopher T.; Krieger, Marlee S.; Gallagher, Jennifer E.; Asma, Betsy; Muasher, Lisa C.; Schmitt, John W.; Ramanujam, Nimmi
Introduction Current guidelines by WHO for cervical cancer screening in low- and middle-income countries involves visual inspection with acetic acid (VIA) of the cervix, followed by treatment during the same visit or a subsequent visit with cryotherapy if a suspicious lesion is found. Implementation of these guidelines is hampered by a lack of: trained health workers, reliable technology, and access to screening facilities. A low cost ultra-portable Point of Care Tampon based digital colposcope (POCkeT Colposcope) for use at the community level setting, which has the unique form factor of a tampon, can be inserted into the vagina to capture images of the cervix, which are on par with that of a state of the art colposcope, at a fraction of the cost. A repository of images to be compiled that can be used to empower front line workers to become more effective through virtual dynamic training. By task shifting to the community setting, this technology could potentially provide significantly greater cervical screening access to where the most vulnerable women live. The POCkeT Colposcope’s concentric LED ring provides comparable white and green field illumination at a fraction of the electrical power required in commercial colposcopes. Evaluation with standard optical imaging targets to assess the POCkeT Colposcope against the state of the art digital colposcope and other VIAM technologies. Results Our POCkeT Colposcope has comparable resolving power, color reproduction accuracy, minimal lens distortion, and illumination when compared to commercially available colposcopes. In vitro and pilot in vivo imaging results are promising with our POCkeT Colposcope capturing comparable quality images to commercial systems. Conclusion The POCkeT Colposcope is capable of capturing images suitable for cervical lesion analysis. Our portable low cost system could potentially increase access to cervical cancer screening in limited resource settings through task shifting to community
Full Text Available Aims: To analyze whether outcome of neonates having esophageal atresia with or without tracheoesophageal fistula (EA±TEF associated with anorectal malformation (ARM can be improved by doing surgery in 2 stages. Materials and Methods : A prospective study of neonates having both EA±TEF and ARM from 2004 to 2011. The patients with favorable parameters were operated in a single stage, whereas others underwent first-stage decompression surgery for ARM. Thereafter, once septicemia was under control and ventilator care available, second-stage surgery for EA±TEF was performed. Results: Total 70 neonates (single stage = 20, 2 stages = 30, expired after colostomy = 9, only EA±TEF repair needed = 11 were enrolled. The admission rate for this association was 1 per 290. Forty-one percent (24/70 neonates had VACTERL association and 8.6% (6/70 neonates had multiple gastrointestinal atresias. Sepsis screen was positive in 71.4% (50/70. The survival was 45% (9/20 in neonates operated in a single stage and 53.3% (16/30 when operated in 2 stages (P = 0.04. Data analysis of 50 patients revealed that the survived neonates had significantly better birth weight, better gestational age, negative sepsis screen, no cardiac diseases, no pneumonia, and 2-stage surgery (P value 0.002, 0.003, 0.02, 0.02, 0.04, and 0.04, respectively. The day of presentation and abdominal distension had no significant effect (P value 0.06 and 0.06, respectively. This was further supported by stepwise logistic regression analysis. Conclusions: In a limited resources scenario, the survival rate of babies with this association can be improved by treating ARM first and then for EA±TEF in second stage, once mechanical ventilator care became available and sepsis was under control.
Petrillo, Francesca De; Gori, Emanuele; Truppa, Valentina; Ariely, Dan; Addessi, Elsa
Self-control failure has enormous personal and societal consequences. One of the most debated models explaining why self-control breaks down is the Strength Model, according to which self-control depends on a limited resource. Either previous acts of self-control or taking part in highly demanding cognitive tasks have been shown to reduce self-control, possibly due to a reduction in blood glucose levels. However, several studies yielded negative findings, and recent meta-analyses questioned the robustness of the depletion effect in humans. We investigated, for the first time, whether the Strength Model applies to a non-human primate species, the tufted capuchin monkey. We tested five capuchins in a self-control task (the Accumulation task) in which food items were accumulated within individual’s reach for as long as the subject refrained from taking them. We evaluated whether capuchins’ performance decreases: (i) when tested before receiving their daily meal rather than after consuming it (Energy Depletion Experiment), and (ii) after being tested in two tasks with different levels of cognitive complexity (Cognitive Depletion Experiment). We also tested, in both experiments, how implementing self-control in each trial of the Accumulation task affected this capacity within each session and/or across consecutive sessions. Repeated acts of self-control in each trial of the Accumulation task progressively reduced this capacity within each session, as predicted by the Strength Model. However, neither experiencing a reduction in energy level nor taking part in a highly demanding cognitive task decreased performance in the subsequent Accumulation task. Thus, whereas capuchins seem to be vulnerable to within-session depletion effects, to other extents our findings are in line with the growing body of studies that failed to find a depletion effect in humans. Methodological issues potentially affecting the lack of depletion effects in capuchins are discussed. PMID
Hyle, Emily P; Jani, Ilesh V; Lehe, Jonathan; Su, Amanda E; Wood, Robin; Quevedo, Jorge; Losina, Elena; Bassett, Ingrid V; Pei, Pamela P; Paltiel, A David; Resch, Stephen; Freedberg, Kenneth A; Peter, Trevor; Walensky, Rochelle P
Point-of-care CD4 tests at HIV diagnosis could improve linkage to care in resource-limited settings. Our objective is to evaluate the clinical and economic impact of point-of-care CD4 tests compared to laboratory-based tests in Mozambique. We use a validated model of HIV testing, linkage, and treatment (CEPAC-International) to examine two strategies of immunological staging in Mozambique: (1) laboratory-based CD4 testing (LAB-CD4) and (2) point-of-care CD4 testing (POC-CD4). Model outcomes include 5-y survival, life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs). Input parameters include linkage to care (LAB-CD4, 34%; POC-CD4, 61%), probability of correctly detecting antiretroviral therapy (ART) eligibility (sensitivity: LAB-CD4, 100%; POC-CD4, 90%) or ART ineligibility (specificity: LAB-CD4, 100%; POC-CD4, 85%), and test cost (LAB-CD4, US$10; POC-CD4, US$24). In sensitivity analyses, we vary POC-CD4-specific parameters, as well as cohort and setting parameters to reflect a range of scenarios in sub-Saharan Africa. We consider ICERs less than three times the per capita gross domestic product in Mozambique (US$570) to be cost-effective, and ICERs less than one times the per capita gross domestic product in Mozambique to be very cost-effective. Projected 5-y survival in HIV-infected persons with LAB-CD4 is 60.9% (95% CI, 60.9%-61.0%), increasing to 65.0% (95% CI, 64.9%-65.1%) with POC-CD4. Discounted life expectancy and per person lifetime costs with LAB-CD4 are 9.6 y (95% CI, 9.6-9.6 y) and US$2,440 (95% CI, US$2,440-US$2,450) and increase with POC-CD4 to 10.3 y (95% CI, 10.3-10.3 y) and US$2,800 (95% CI, US$2,790-US$2,800); the ICER of POC-CD4 compared to LAB-CD4 is US$500/year of life saved (YLS) (95% CI, US$480-US$520/YLS). POC-CD4 improves clinical outcomes and remains near the very cost-effective threshold in sensitivity analyses, even if point-of-care CD4 tests have lower sensitivity/specificity and higher cost than published
Emily P Hyle
Full Text Available Point-of-care CD4 tests at HIV diagnosis could improve linkage to care in resource-limited settings. Our objective is to evaluate the clinical and economic impact of point-of-care CD4 tests compared to laboratory-based tests in Mozambique.We use a validated model of HIV testing, linkage, and treatment (CEPAC-International to examine two strategies of immunological staging in Mozambique: (1 laboratory-based CD4 testing (LAB-CD4 and (2 point-of-care CD4 testing (POC-CD4. Model outcomes include 5-y survival, life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs. Input parameters include linkage to care (LAB-CD4, 34%; POC-CD4, 61%, probability of correctly detecting antiretroviral therapy (ART eligibility (sensitivity: LAB-CD4, 100%; POC-CD4, 90% or ART ineligibility (specificity: LAB-CD4, 100%; POC-CD4, 85%, and test cost (LAB-CD4, US$10; POC-CD4, US$24. In sensitivity analyses, we vary POC-CD4-specific parameters, as well as cohort and setting parameters to reflect a range of scenarios in sub-Saharan Africa. We consider ICERs less than three times the per capita gross domestic product in Mozambique (US$570 to be cost-effective, and ICERs less than one times the per capita gross domestic product in Mozambique to be very cost-effective. Projected 5-y survival in HIV-infected persons with LAB-CD4 is 60.9% (95% CI, 60.9%-61.0%, increasing to 65.0% (95% CI, 64.9%-65.1% with POC-CD4. Discounted life expectancy and per person lifetime costs with LAB-CD4 are 9.6 y (95% CI, 9.6-9.6 y and US$2,440 (95% CI, US$2,440-US$2,450 and increase with POC-CD4 to 10.3 y (95% CI, 10.3-10.3 y and US$2,800 (95% CI, US$2,790-US$2,800; the ICER of POC-CD4 compared to LAB-CD4 is US$500/year of life saved (YLS (95% CI, US$480-US$520/YLS. POC-CD4 improves clinical outcomes and remains near the very cost-effective threshold in sensitivity analyses, even if point-of-care CD4 tests have lower sensitivity/specificity and higher cost than published
O'Reilly-Shah, Vikas N; Kitzman, Jamie; Jabaley, Craig S; Lynde, Grant C
Electronic decision support tools in anesthesiology practice have great value, including the potential for mobile applications to simplify delivery of best-practice guidelines. We sought to combine demographics with usage information to elucidate important patterns in the rate of use of the Society of Pediatric Anesthesia Critical Events Checklist, as measured by in-app accesses of the checklist via the freely available anesthesia calculator app anesthesiologist. We performed a retrospective analytic observational case-control study using analytics and survey data collected from the app. Users of the app were classified on the basis of whether or not they had accessed the checklist. This classification was used to perform logistic regression against a number of independent variables, including frequency of app use, country income level, professional role, rating of app importance, length of time in practice, group size, practice model, community served, and primary practice environment. Individual app users practicing in low- and middle-income countries have a significantly higher rate of Society for Pediatric Anesthesia Critical Events Checklist utilization as compared with high-income countries. Rural practitioners had higher utilization of the checklist. Practice size did not affect the utilization of the checklist. The checklist was used for both provider learning and for just-in-time patient care. mHealth apps are invaluable resource in everyday clinical practice. Mobile app analytics and in-app survey data reveal variable penetration and applicability of such technology worldwide. mHealth apps may be particularly impactful in limited-resource areas, such as lower-income environments and rural communities. © 2017 John Wiley & Sons Ltd.
Bogoch, Isaac I; Brady, Oliver J; Kraemer, Moritz U G; German, Matthew; Creatore, Maria I; Brent, Shannon; Watts, Alexander G; Hay, Simon I; Kulkarni, Manisha A; Brownstein, John S; Khan, Kamran
As the epidemic of Zika virus expands in the Americas, countries across Africa and the Asia-Pacific region are becoming increasingly susceptible to the importation and possible local spread of the virus. To support public health readiness, we aim to identify regions and times where the potential health, economic, and social effects from Zika virus are greatest, focusing on resource-limited countries in Africa and the Asia-Pacific region. Our model combined transportation network analysis, ecological modelling of mosquito occurrences, and vector competence for flavivirus transmission, using data from the International Air Transport Association, entomological observations from Zika's primary vector species, and climate conditions using WorldClim. We overlaid monthly flows of airline travellers arriving to Africa and the Asia-Pacific region from areas of the Americas suitable for year-round transmission of Zika virus with monthly maps of climatic suitability for mosquito-borne transmission of Zika virus within Africa and the Asia-Pacific region. An estimated 2·6 billion people live in areas of Africa and the Asia-Pacific region where the presence of competent mosquito vectors and suitable climatic conditions could support local transmission of Zika virus. Countries with large volumes of travellers arriving from Zika virus-affected areas of the Americas and large populations at risk of mosquito-borne Zika virus infection include India (67 422 travellers arriving per year; 1·2 billion residents in potential Zika transmission areas), China (238 415 travellers; 242 million residents), Indonesia (13 865 travellers; 197 million residents), Philippines (35 635 travellers; 70 million residents), and Thailand (29 241 travellers; 59 million residents). Many countries across Africa and the Asia-Pacific region are vulnerable to Zika virus. Strategic use of available health and human resources is essential to prevent or mitigate the health, economic, and social
Full Text Available Of the 4 million neonatal deaths worldwide yearly, 98% occur in low and middle-income countries. Effective resuscitation reduces mortality and morbidity but long-term outcomes in resource-limited settings are poorly described. This study reports on newborn neurological outcomes following resuscitation at birth in a resource-limited setting where intensive newborn care including intubation is unavailable.Retrospective analysis of births records from 2008 to 2015 at Shoklo Malaria Research Unit (SMRU on the Thailand-Myanmar border.From 21,225 newbonrs delivered, 15,073 (71% met the inclusion criteria (liveborn, singleton, ≥28 weeks' gestation, delivered in SMRU. Neonatal resuscitation was performed in 460 (3%; 422 basic, 38 advanced cases. Overall early neonatal mortality was 6.6 deaths per 1000 live births (95% CI 5.40-8.06. Newborns receiving basic and advanced resuscitation presented an adjusted rate for death of 1.30 (95%CI 0.66-2.55; p = 0.442, and 6.32 (95%CI 3.01-13.26; p<0.001 respectively, compared to newborns given routine care. Main factors related to increased need for resuscitation were breech delivery, meconium, and fetal distress (p<0.001. Neurodevelopmental follow-up to one year was performed in 1,608 (10.5% of the 15,073 newborns; median neurodevelopmental scores of non-resuscitated newborns and those receiving basic resuscitation were similar (64 (n = 1565 versus 63 (n = 41; p = 0.732, while advanced resuscitation scores were significantly lower (56 (n = 5; p = 0.017.Newborns requiring basic resuscitation at birth have normal neuro-developmental outcomes at one year of age compared to low-risk newborns. Identification of risk factors (e.g., breech delivery associated with increased need for neonatal resuscitation may facilitate allocation of staff to high-risk deliveries. This work endorses the use of basic resuscitation in low-resource settings, and supports on-going staff training to maintain bag-and-mask ventilation skills.
Mtove, George; Kimani, Joshua; Kisinza, William; Makenga, Geofrey; Mangesho, Peter; Duparc, Stephan; Nakalembe, Miriam; Phiri, Kamija S; Orrico, Russell; Rojo, Ricardo; Vandenbroucke, Pol
Multinational clinical trials are logistically complex and require close coordination between various stakeholders. They must comply with global clinical standards and are accountable to multiple regulatory and ethical bodies. In resource-limited settings, it is challenging to understand how to apply global clinical standards to international, national, and local factors in clinical trials, making multiple-level stakeholder engagement an important element in the successful conduct of these clinical trials. During the planning and implementation of a large multinational clinical trial for intermittent preventive treatment of malaria in pregnancy in resource-limited areas of sub-Saharan Africa, we encountered numerous challenges, which required implementation of a range of engagement measures to ensure compliance with global clinical and regulatory standards. These challenges included coordination with ongoing global malaria efforts, heterogeneity in national regulatory structures, sub-optimal healthcare infrastructure, local practices and beliefs, and perspectives that view healthcare providers with undue trust or suspicion. In addition to engagement with international bodies, such as the World Health Organization, the Malaria in Pregnancy Consortium, the Steve Biko Centre for Bioethics, and the London School of Hygiene and Tropical Medicine, in order to address the challenges just described, Pfizer Inc. and Medicines for Malaria Venture (the "Sponsoring Entities" for these studies) and investigators liaised with national- and district-level stakeholders such as health ministers and regional/local community health workers. Community engagement measures undertaken by investigators included local meetings with community leaders to explain the research aims and answer questions and concerns voiced by the community. The investigators also engaged with family members of prospective trial participants in order to be sensitive to local practices and beliefs. Engagement
Andrea J Curtis
Full Text Available OBJECTIVES: To determine the incidence of WHO clinical stage 3 and 4 conditions during early anti-retroviral therapy (ART in resource limited settings (RLS. DESIGN/SETTING: A descriptive analysis of routine program data collected prospectively from 25 Médecins Sans Frontières supported HIV treatment programs in eight countries between 2002 and 2010. SUBJECTS/PARTICIPANTS: 35,349 study participants with median follow-up on ART of 1.33 years (IQR 0.51-2.41. OUTCOME MEASURES: Incidence in 100 person-years of WHO stage 3 or 4 conditions during 5 periods after ART initiation. Diagnoses of conditions were made according to WHO criteria and relied upon clinical assessments supported by basic laboratory investigations. RESULTS: The incidence of any WHO clinical stage 3 or 4 condition over 3 years was 40.02 per 100 person-years (31.77 for stage 3 and 8.25 for stage 4. The incidence of stage 3 and 4 conditions fell by over 97% between months 0-3 and months 25-36 (77.81 to 2.40 for stage 3 and 28.70 to 0.64 for stage 4. During months 0-3 pulmonary tuberculosis was the most common condition diagnosed in adults (incidence 22.24 per 100 person-years and children aged 5-14 years (25.76 and oral candidiasis was the most common in children <5 years (25.79. Overall incidences were higher in Africa compared with Asia (43.98 versus 12.97 for stage 3 and 8.98 versus 7.05 for stage 4 conditions, p<0.001. Pulmonary tuberculosis, weight loss, oral and oesophageal candidiasis, chronic diarrhoea, HIV wasting syndrome and severe bacterial infections were more common in Africa. Extra-pulmonary tuberculosis, non-tuberculous mycobacterial infection, cryptococcosis, penicilliosis and toxoplasmosis were more common in Asia. CONCLUSIONS: The incidence of WHO stage 3 and 4 conditions during the early period after ART initiation in RLS is high, but greatly reduces over time. This is likely due to both the benefits of ART and deaths of the sickest patients occurring shortly
Rochelle P Walensky
Full Text Available The new 2010 World Health Organization (WHO HIV treatment guidelines recommend earlier antiretroviral therapy (ART initiation (CD4<350 cells/µl instead of CD4<200 cells/µl, multiple sequential ART regimens, and replacement of first-line stavudine with tenofovir. This paper considers what to do first in resource-limited settings where immediate implementation of all of the WHO recommendations is not feasible.We use a mathematical model and local input data to project clinical and economic outcomes in a South African HIV-infected cohort (mean age = 32.8 y, mean CD4 = 375/µl. For the reference strategy, we assume that all patients initiate stavudine-based ART with WHO stage III/IV disease and receive one line of ART (stavudine/WHO/one-line. We rank-in survival, cost-effectiveness, and equity terms-all 12 possible combinations of the following: (1 stavudine replacement with tenofovir, (2 ART initiation (by WHO stage, CD4<200 cells/µl, or CD4<350 cells/µl, and (3 one or two regimens, or lines, of available ART. Projected life expectancy for the reference strategy is 99.0 mo. Considering each of the guideline components separately, 5-y survival is maximized with ART initiation at CD4<350 cells/µl (stavudine/<350/µl/one-line, 87% survival compared with stavudine/WHO/two-lines (66% and tenofovir/WHO/one-line (66%. The greatest life expectancies are achieved via the following stepwise programmatic additions: stavudine/<350/µl/one-line (124.3 mo, stavudine/<350/µl/two-lines (177.6 mo, and tenofovir/<350/µl/two-lines (193.6 mo. Three program combinations are economically efficient: stavudine/<350/µl/one-line (cost-effectiveness ratio, US$610/years of life saved [YLS], tenofovir/<350/µl/one-line (US$1,140/YLS, and tenofovir/<350/µl/two-lines (US$2,370/YLS.In settings where immediate implementation of all of the new WHO treatment guidelines is not feasible, ART initiation at CD4<350 cells/µl provides the greatest short- and long
Wells, Katie M; Lee, Yu-Jin; Erdene, Sarnai; Erdene, Sandag; Sanchin, Urjin; Sergelen, Orgoi; Presson, Angela; Zhang, Chong; Rodriguez, Brandon; deVries, Catherine; Price, Raymond
received laparoscopic training in 19 of 21 Aimags. On average 60% of cholecystectomies are done laparoscopically in urban surgical centres, up from 2%, versus 55% in rural surgical centres, up from 0%, in 2005. Laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide in 2011. By 2013, 62% of cholecystectomies countrywide were done laparoscopically, a great increase from 9 years ago. Despite being a resource limited country, the expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia. The University of Utah Center for Global Surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.
Khachani, Imane; Harmouche, Hicham; Ammouri, Wafa; Rhoufrani, Fatima; Zerouali, Latifa; Abouqal, Redouane; Tazi-Mezalek, Zoubida; Adnaoui, Mohamed; Aouni, Mohamed; Maouni, Abdelaziz
Research has demonstrated that strict adherence is necessary to maximize highly active antiretroviral therapy (HAART) benefits. This is particularly challenging for low-literacy populations in resource-limited settings like Morocco and motivated the implementation of a psychoeducative program for patients under HAART at Rabat University Hospital. The study aimed at assessing the program's impact on adherence to antiretroviral medication, knowledge of HIV/AIDS and HAART, quality of life, and biological parameters. It included patients under treatment for at least 2 months that benefited from 3 to 5 educational and psychological support sessions. Data were collected at baseline, 3 and 6 months. In all, 50 patients were included. The mean age was 38 years; 52% were illiterate and 62% unemployed. Adherence scores were high at baseline (98%) and showed no significant change throughout the study. Knowledge of HAART and HIV/AIDS, and quality of life improved significantly both at months 3 and 6. Significant increase for CD4 count rates and decrease for viral load rates were also reported. The program had no significant impact on adherence but substantively developed patients' knowledge of HIV/AIDS and HAART and improved their quality of life.
Ikeda, Andrea J; Grabowski, Alena M; Lindsley, Alida; Sadeghi-Demneh, Ebrahim; Reisinger, Kim D
Literature Review We estimate that over 29 million people worldwide in resource-limited environments (RLEs) are in need of orthotic and prosthetic (O&P) devices and services. Our goal was to ascertain the current state of O&P provision in RLEs and identify factors that may lead to more successful O&P provision. We conducted a comprehensive scoping literature review of all information related to O&P provision in RLEs published from 2000 to 2010. We targeted Vietnam, Cambodia, Tanzania, Malawi, Colombia, and the Navajo Nation, but also included information about developing countries in general. We searched academic databases and grey literature. We extracted information from each article in the areas of design, manufacturing, distribution, service provision, and technology transfer. We identified commonly reported considerations and strategies for O&P provision from 431 articles. Analysis of expert consensus documents revealed recurring themes for improving O&P provision. We found that some suggestions from the consensus documents are being followed, but many are overlooked or have not yet been implemented. Areas for improvement include conducting field testing during the design process, providing services to rural environments, offering follow-up services, considering government collaboration, and encouraging an active role of the orthosis/prosthesis user. Outcomes and research studies will be further discussed in Part Two. © The International Society for Prosthetics and Orthotics 2013.
Aquatic ecosystems are affected by changes in both temperature and resource availability. While higher temperatures may result in increased food consumption and increased mercury (Hg) accumulation, they may also increase growth and reduce Hg tissue concentration through somatic d...
Agulnik, Asya; Nadkarni, Anisha; Mora Robles, Lupe Nataly; Soberanis Vasquez, Dora Judith; Mack, Ricardo; Antillon-Klussmann, Federico; Rodriguez-Galindo, Carlos
Pediatric oncology patients hospitalized in resource-limited settings are at high risk for clinical deterioration resulting in mortality. Intermediate care units (IMCUs) provide a cost-effective alternative to pediatric intensive care units (PICUs). Inappropriate IMCU triage, however, can lead to poor outcomes and suboptimal resource utilization. In this study, we sought to characterize patients with clinical deterioration requiring unplanned transfer to the IMCU in a resource-limited pediatric oncology hospital. Patients requiring subsequent early PICU transfer had longer PICU length of stay. PEWS results prior to IMCU transfer were higher in patients requiring early PICU transfer, suggesting PEWS can aid in triage between IMCU and PICU care. © 2018 Wiley Periodicals, Inc.
Conclusions: We postulate that this method incorporates most of the features of all the available modalities (i.e., National Institute of Health-complement dependent lymphocytotoxicity, FCXM, cytotoxic FCXM and C4d-flowPRA yet cost-effective and best suited for resource-limited laboratory/ies which is a common scenario in developing countries.
Revell, A. D.; Wang, D.; Wood, R.; Morrow, C.; Tempelman, H.; Hamers, R. L.; Alvarez-Uria, G.; Streinu-Cercel, A.; Ene, L.; Wensing, A. M. J.; DeWolf, F.; Nelson, M.; Montaner, J. S.; Lane, H. C.; Larder, B. A.
Genotypic HIV drug-resistance testing is typically 6065 predictive of response to combination antiretroviral therapy (ART) and is valuable for guiding treatment changes. Genotyping is unavailable in many resource-limited settings (RLSs). We aimed to develop models that can predict response to ART
Celia Regina Pierantoni
Full Text Available As transformações observadas a partir da implementação da reforma do Estado brasileiro destacam antigos problemas e introduzem outros novos para a área de recursos humanos em saúde. Este trabalho examina o desenvolvimento da área de recursos humanos (RH nas políticas públicas, tendo como referencial as reformas da política nacional de saúde na década de 1990 no Brasil. Aponta para a necessidade de ampliação e aprofundamento do conhecimento sobre o trabalho desenvolvido na área de saúde que envolve a abordagem da administração geral, da sociologia do trabalho e das profissões e especialidades, do desenvolvimento tecnológico, das análises econômicas, dos processos de aprendizagem, entre outras. Identifica dimensões críticas para a abordagem de recursos humanos em saúde que necessitam ser analisadas e acompanhadas de mecanismos de intervenção específica e não excludentes: a dimensão gerencial, a dimensão estrutural e a dimensão regulatória. Destaca a necessidade de intervenções que reintroduzam os profissionais de saúde na centralidade do debate como participantes da implementação das políticas em seus aspectos político, administrativo, técnico e social.The transformations brought by the Brazilian State reforms detach old problems and present new ones to health human resources. This paper examines the development of human resources in public policy concerning the State reforms in the 90's. It points out the need of enlargement and improvement of the knowledge about the work developed in health which envolves general administration, professional sociology, technologic knowledge, economical analyses, learning processes, among others. It identifies three critical dimensions to the approach of health human resources that need to be analyzed and followed by special mechanisms of specific and not excluding intervention: the management, the structural and the regulatory dimensions. It emphasizes the need to
Pfeil, Alena; Mütsch, Margot; Hatz, Christoph; Szucs, Thomas D
Influenza is one of the most common vaccine-preventable diseases in travellers. By performing two cross-sectional questionnaire surveys during winter 2009 and winter 2010 among European travellers to resource-limited destinations, we aimed to investigate knowledge, attitudes and practices (KAP) regarding seasonal influenza vaccination. Questionnaires were distributed in the waiting room to the visitors of the University of Zurich Centre for Travel' Health (CTH) in January and February 2009 and January 2010 prior to travel health counselling (CTH09 and CTH10). Questions included demographic data, travel-related characteristics and KAP regarding influenza vaccination. Data were analysed by using SPSS version 14.0 for Windows. Differences in proportions were compared using the Chi-square test and the significance level was set at p Job-related purposes (44, 37%), age > 64 yrs (25, 21%) and recommendations of the family physician (27, 22.7%) were the most often reported reasons for being vaccinated. In the multiple logistic regression analyses of the pooled data increasing age (OR = 1.03, 95% CI 1.01 - 1.04), a business trip (OR = 0.39, 95% CI 0.17 - 0.92) and seasonal influenza vaccination in the previous winter seasons (OR = 12.91, 95% CI 8.09 - 20.58) were independent predictors for seasonal influenza vaccination in 2009 or 2010.Influenza vaccination recommended by the family doctor (327, 37.7%), travel to regions with known high risk of influenza (305, 35.1%), and influenza vaccination required for job purposes (233, 26.8%) were most frequently mentioned to consider influenza vaccination. Risk perception and vaccination coverage concerning seasonal and pandemic influenza was very poor among travellers to resource-limited destinations when compared to traditional at-risk groups. Previous access to influenza vaccination substantially facilitated vaccinations in the subsequent year. Information strategies about influenza should be intensified and include health
Ariyo, Promise; Trelles, Miguel; Helmand, Rahmatullah; Amir, Yama; Hassani, Ghulam Haidar; Mftavyanka, Julien; Nzeyimana, Zenon; Akemani, Clemence; Ntawukiruwabo, Innocent Bagura; Charles, Adelin; Yana, Yanang; Moussa, Kalla; Kamal, Mustafa; Suma, Mohamed Lamin; Ahmed, Mowlid; Abdullahi, Mohamed; Wong, Evan G; Kushner, Adam; Latif, Asad
Anesthesia is integral to improving surgical care in low-resource settings. Anesthesia providers who work in these areas should be familiar with the particularities associated with providing care in these settings, including the types and outcomes of commonly performed anesthetic procedures. The authors conducted a retrospective analysis of anesthetic procedures performed at Médecins Sans Frontières facilities from July 2008 to June 2014. The authors collected data on patient demographics, procedural characteristics, and patient outcome. The factors associated with perioperative mortality were analyzed. Over the 6-yr period, 75,536 anesthetics were provided to adult patients. The most common anesthesia techniques were spinal anesthesia (45.56%) and general anesthesia without intubation (33.85%). Overall perioperative mortality was 0.25%. Emergent procedures (0.41%; adjusted odds ratio [AOR], 15.86; 95% CI, 2.14 to 115.58), specialized surgeries (2.74%; AOR, 3.82; 95% CI, 1.27 to 11.47), and surgical duration more than 6 h (9.76%; AOR, 4.02; 95% CI, 1.09 to 14.88) were associated with higher odds of mortality than elective surgeries, minor surgeries, and surgical duration less than 1 h, respectively. Compared with general anesthesia with intubation, spinal anesthesia, regional anesthesia, and general anesthesia without intubation were associated with lower perioperative mortality rates of 0.04% (AOR, 0.10; 95% CI, 0.05 to 0.18), 0.06% (AOR, 0.26; 95% CI, 0.08 to 0.92), and 0.14% (AOR, 0.29; 95% CI, 0.18 to 0.45), respectively. A wide range of anesthetics can be carried out safely in resource-limited settings. Providers need to be aware of the potential risks and the outcomes associated with anesthesia administration in these settings.
Gonzalez Ruiz, W.; Vanacore, E. A.; Gomez, G.; Martinez Colon, J. F.; Perez, F.; Baez-Sanchez, G.; Flores Hots, V. E.; Lopez, A. M.; Huerfano, V.; Figueroa, J. M.
Given the limited human resources available to interact directly with the public and disseminate information on earthquake and tsunami safety, the Puerto Rico Seismic Network has developed the Train the Trainers course, designed exclusively for emergency management officers (EMOs). This three-day training course provides a complete package of educational tools that will allow EMOs to present standard conferences, and lectures, with the appropriate and accurate information for different audiences on earthquake and tsunami hazard and safety. Here we present preliminary observations and lessons learned from the pilot program that was offered in July 2017 to 20 EMOs from the twelve Puerto Rico Emergency Management Agency (PREMA) zones and two students from the University of Puerto Rico Mayaguez. To ensure sufficient preparation, the training course provided evaluation tools including written and practical exams that participants were required to score 80% or more to complete the training successfully. Of the 20 EMO participants, 18 EMOs passed the final exam. Preliminary analysis of the pre-test scores and the post-test scores, show a score improvement between 8% to 46% amongst the participants. These 18 participants will receive a certificate as well as tools and resources to offer earthquakes and tsunamis conferences for up to two years across Puerto Rico and its outlying islands. To ensure that the pilot participants will provide conferences to the public PRSN required a signed commitment to give at least 5 conferences in one year from each participant and PRSN will monitor the participants for the next two years to evaluate the efficacy of the program. However, based on the preliminary data this program appears to be an effective method to increase the amount of outreach professionals on the Island.
Ybarra, Michele; Biringi, Ruth; Prescott, Tonya; Bull, Sheana S.
Use of Internet is growing in Sub Saharan Africa. Evidence of computer and Internet effectiveness for reduction in risk behaviors associated with HIV shown in U.S. settings has yet to be replicated in Africa. We describe the development, usability and navigability testing of an Internet-based HIV prevention program for secondary school students in Uganda, called CyberSenga. For this work, we used four data collection activities, including observation of (a) computer skills and (b) navigation, (c) focus group discussions, and (d) field assessments to document comprehension and usability of program content. We document limited skills among students, but youth with basic computers skills were able to navigate the program after instruction. Youth were most interested in activities with more interaction. Field-testing illustrated the importance of using a stand-alone electrical source during program delivery. This work suggests delivery of Internet-based health promotion content in Africa requires attention to user preparedness and literacy, bandwidth, Internet connection, and electricity. PMID:22918136
Uemura, Hiroji; DiBonaventura, Marco; Wang, Ed; Ledesma, Dianne Athene; Concialdi, Kristen; Aitoku, Yasuko
Real-world treatment patterns of bone metastatic castration-resistant prostate cancer (mCRPC) in Japan were examined, focusing on treatment patterns and resource use differences attributed to symptomatic skeletal events (SSEs). Urologists (N = 176) provided retrospective chart data for patients with mCRPC (N = 445) via online surveys. Descriptive analyses and chi-square tests evaluated treatment patterns and their differences by SSE presence; generalized linear mixed models examined healthcare resource utilization differences as a function of SSEs. Patients were on average 73.6 years old (SD = 8.3), diagnosed with prostate cancer 5.1 years (SD = 6.2), castration-resistant 2.3 years (SD=2.0), and had 7.9 bone metastases sites (SD=12.4). Novel anti-hormones showed increased adoption as mCRPC treatment. Simultaneously, luteinizing hormone-releasing hormone (LHRH) agonist/antagonist use was common (43.6% of patients in 1 st line), even as CRPC treatment had started. SSEs were uncommon (2-3% per treatment line; 5% at any time), but were associated with increased opioids, strontium-89, bisphosphonates, and NSAIDs use, plus increased healthcare visits (all p < .05). LHRH agonist/antagonist treatment combinations remain the mCRPC treatment mainstay in Japan. However, novel anti-hormone therapies are becoming well-accepted in practice. SSEs were associated with increased healthcare resource and analgesic use, highlighting the need for efficient symptom management.
Hanna, Mina; Minga, Albert; Fao, Paulin; Borand, Laurence; Diouf, Assane; Mben, Jean-Marc; Gad, Rita R; Anglaret, Xavier; Bazin, Brigitte; Chene, Geneviève
Since 1994, the French National Agency for Research on AIDS and Viral Hepatitis (ANRS) has funded research sites in resource-limited countries (RLCs). These sites implement research on human immunodeficiency virus (HIV) infection and Hepatitis C. In parallel, international regulations and recommendations for clinical trials have evolved and proliferated. However, little guidance exists on how these should be interpreted and applied within academic trials and in the context of RLCs. After developing a specific Ethical Charter for research in developing countries in 2002, ANRS developed a set of quality indicators (QIs) as a monitoring tool for assessing compliance to international guidelines. We describe here the development process, QIs adopted, and areas for improvement. In 2008, a group of experts was convened that included a researcher representing each ANRS site (Cote d'Ivoire, Senegal, Cameroun, Burkina Faso, Egypt, and Cambodia). Our structuring interaction development process combined evidence and expert opinion in two nominal group meetings to identify (1) clinical trial processes involved, (2) issues specific to RLCs in terms of Good Clinical Practice (GCP) and the application of ethical recommendations, and (3) checklists of QIs adapted to clinical trials conducted in RLCs. The trial process reviewed and proposed for RLCs was mostly similar to the one produced in wealthier countries. The scheme generated by our work group added two further processes: 'drug management' and 'biological investigations'. Specific issues regarding trial management in RLCs were therefore described for eight trial steps (1) protocol conception and seeking authorizations, (2) participant enrollment and follow-up, (3) site monitoring, (4) drug management, (5) biological investigations, (6) record management, (7) data management, and (8) site closeout. A total of 58 indicators were identified with at least one indicator for each trial process. Some trial activities require further
Srirangaraj, S; Venkatesha, D
Owing to the ever-expanding access to HAART (highly active anti-retroviral therapy) in resource-limited settings, there is a need to evaluate alternate markers like absolute lymphocyte count (ALC) as a surrogate for CD4 counts. This study was done to assess the usefulness of ALC as a surrogate marker for CD4 counts in monitoring HIV-infected patients after HAART initiation. In this study, 108 HIV-positive adult patients of both sexes fulfilling the inclusion criteria were included. CD4 and ALC were recorded at baseline. After initiation on HAART, these patients were followed up at three month intervals. ALC and CD4 counts were positively correlated (Spearman correlation coefficient= 0.553). After six months of HAART, the sensitivity of an ALC increase as a marker for CD4 count increase at six months was 82 per cent, specificity was 100 per cent, PPV was 100 per cent and NPV was 31 per cent. Area under the corresponding ROC curve for CD4 increase of >100 cells/μl was 0. 825 ± 0.053. ALC may be a useful surrogate marker in predicting an increase in CD4 counts as a response to HAART, but of questionable value in predicting a decrease in CD4 counts.
Abuogi, Lisa L; Smith, Christiana; McFarland, Elizabeth J
Current UNAIDS goals aimed to end the AIDS epidemic set out to ensure that 90% of all people living with HIV know their status, 90% initiate and continue life-long anti-retroviral therapy (ART), and 90% achieve viral load suppression. In 2014 there were an estimated 2.6 million children under 15 years of age living with HIV, of which only one-third were receiving ART. Little literature exists describing retention of HIV-infected children in the first year on ART. We conducted a systematic search for English language publications reporting on retention of children with median age at ART initiation less than ten years in resource limited settings. The proportion of children retained in care on ART and predictors of attrition were identified. Twelve studies documented retention at one year ranging from 71-95% amongst 31877 African children. Among the 5558 children not retained, 4082 (73%) were reported as lost to follow up (LFU) and 1476 (27%) were confirmed to have died. No studies confirmed the outcomes of children LFU. Predictors of attrition included younger age, shorter duration of time on ART, and severe immunosuppression. In conclusion, significant attrition occurs in children in the first 12 months after ART initiation, the majority attributed to LFU, although true outcomes of children labeled as LFU are unknown. Focused efforts to ensure retention and minimize early mortality are needed as universal ART for children is scaled up.
Sluis-Cremer, Nicolas; Jordan, Michael R; Huber, Kelly; Wallis, Carole L; Bertagnolio, Silvia; Mellors, John W; Parkin, Neil T; Harrigan, P Richard
The nonnucleoside reverse transcriptase (RT) inhibitor rilpivirine (RPV) has been co-formulated with emtricitabine and tenofovir disoproxil fumarate for initial therapy of HIV-1-infected individuals. RPV, formulated as a long-acting nanosuspension, will also be assessed for its ability to prevent HIV-1 infection in resource limited settings. In this study, we determined whether any pre-existing genetic differences occurred among different HIV-1 subtypes at residues in RT associated with decreased virologic response to RPV. We found that the E138A substitution occurs more frequently in subtype C (range: 5.9-7.5%) than B (range: 0-2.3%) sequences from both treatment-naïve and -experienced individuals (pE138K and E138Q were also more common in RTI-experienced subtype C sequences (1.0% and 1.1%, respectively) than in subtype B sequences (0.3% and 0.6%, respectively). E138A/K/Q in subtype C decreased RPV susceptibility 2.9-, 5.8-, and 5.4-fold, respectively. Taken together, these data suggest that E138A could impact treatment or prevention strategies that include RPV in geographic areas where subtype C infection is prevalent. Copyright © 2014 Elsevier B.V. All rights reserved.
L.A. Serino (Leandro)
textabstractThe debate on the pattern of specialization in natural resource abundant countries has re-emerged as demand for raw materials and food products from the rapidly growing East Asian countries, speculation in financial markets, and changes in production techniques augmented the
Dravid, Ameet; Kulkarni, Milind; Borkar, Amit; Dhande, Sachin
Bone mineral density (BMD) assessment in HIV patients is sparsely done in resource limited settings. We conducted a cross-sectional study of BMD amongst HIV patients following up in our clinic from 1 June to 1 December 2013 by performing dual-energy X-ray absorptiometry scan (Lunar Prodigy Advanced DXA System, GE Healthcare) of lumbar spine and hip. Patients on long term (≥12 months), virologically suppressive antiretroviral therapy (ART) were included. Patients who were ART naïve were included as control population. Virologic failures were excluded. Low BMD was defined by WHO T-score criteria (normal: T score ≥-1;osteopenia: T score between -1 and -2.5 SD; osteoporosis: T score ≤-2.5 SD). Baseline risk factors associated with low BMD like age, low BMI, lipoatrophy, diabetes mellitus, current smoking, current alcohol intake, steroid exposure and menopause were recorded. ART-related factors associated with low BMD like ART duration, exposure to tenofovir and exposure to protease inhibitors (PI) were studied. A total of 536 patients (66% males, 496 ART experienced and 40 ART naïve) were included in this analysis. Median age was 42 years, mean BMI 23.35 kg/m(2) and median CD4 count 146 cells/mm(3). All ART experienced patients had plasma viral loadpatients in our cohort is a matter of deep concern due to its association with pathological fractures. Bone mineral loss was seen irrespective of ART used. Association of low BMD with low baseline CD4 count strengthens the case for early ART.
Koller, Manuel; Fatti, Geoffrey; Chi, Benjamin H; Keiser, Olivia; Hoffmann, Christopher J; Wood, Robin; Prozesky, Hans; Stinson, Kathryn; Giddy, Janet; Mutevedzi, Portia; Fox, Matthew P; Law, Matthew; Boulle, Andrew; Egger, Matthias
HIV-1 RNA viral load (VL) testing is recommended to monitor antiretroviral therapy (ART) but not available in many resource-limited settings. We developed and validated CD4-based risk charts to guide targeted VL testing. We modeled the probability of virologic failure up to 5 years of ART based on current and baseline CD4 counts, developed decision rules for targeted VL testing of 10%, 20%, or 40% of patients in 7 cohorts of patients starting ART in South Africa, and plotted cutoffs for VL testing on colour-coded risk charts. We assessed the accuracy of risk chart-guided VL testing to detect virologic failure in validation cohorts from South Africa, Zambia, and the Asia-Pacific. In total, 31,450 adult patients were included in the derivation and 25,294 patients in the validation cohorts. Positive predictive values increased with the percentage of patients tested: from 79% (10% tested) to 98% (40% tested) in the South African cohort, from 64% to 93% in the Zambian cohort, and from 73% to 96% in the Asia-Pacific cohort. Corresponding increases in sensitivity were from 35% to 68% in South Africa, from 55% to 82% in Zambia, and from 37% to 71% in Asia-Pacific. The area under the receiver operating curve increased from 0.75 to 0.91 in South Africa, from 0.76 to 0.91 in Zambia, and from 0.77 to 0.92 in Asia-Pacific. CD4-based risk charts with optimal cutoffs for targeted VL testing maybe useful to monitor ART in settings where VL capacity is limited.
Koller, Manuel; Fatti, Geoffrey; Chi, Benjamin H; Keiser, Olivia; Hoffmann, Christopher J; Wood, Robin; Prozesky, Hans; Stinson, Kathryn; Giddy, Janet; Mutevedzi, Portia; Fox, Matthew; Law, Matthew; Boulle, Andrew; Egger, Matthias
Background HIV-1 RNA viral load (VL) testing is recommended to monitor antiretroviral therapy (ART) but not available in many resource-limited settings. We developed and validated CD4-based risk charts to guide targeted VL testing. Methods We modeled the probability of virologic failure up to 5 years of ART based on current and baseline CD4 counts, developed decision rules for targeted VL testing of 10%, 20% or 40% of patients in seven cohorts of patients starting ART in South Africa, and plotted cut-offs for VL testing on colour-coded risk charts. We assessed the accuracy of risk chart-guided VL testing to detect virologic failure in validation cohorts from South Africa, Zambia and the Asia-Pacific. Findings 31,450 adult patients were included in the derivation and 25,294 patients in the validation cohorts. Positive predictive values increased with the percentage of patients tested: from 79% (10% tested) to 98% (40% tested) in the South African, from 64% to 93% in the Zambian and from 73% to 96% in the Asia-Pacific cohorts. Corresponding increases in sensitivity were from 35% to 68% in South Africa, from 55% to 82% in Zambia and from 37% to 71% in Asia-Pacific. The area under the receiver-operating curve increased from 0.75 to 0.91 in South Africa, from 0.76 to 0.91 in Zambia and from 0.77 to 0.92 in Asia Pacific. Interpretation CD4-based risk charts with optimal cut-offs for targeted VL testing may be useful to monitor ART in settings where VL capacity is limited. PMID:26470034
Thorneloe, R J; Bundy, C; Griffiths, C E M; Ashcroft, D M; Cordingley, L
Medication nonadherence is known to limit the effectiveness of available therapies; however, little is known specifically about medication adherence in people with psoriasis. Medicines self-management can feel onerous to those with dermatological conditions due to the nature of therapies prescribed and many individuals with psoriasis experience additional challenges such as physical and psychological comorbidities that place significant additional demands on individuals and may undermine adherence. Viewing nonadherence to medication as an outcome of limited personal coping resources and conflicting goals may help to explain medication nonadherence. To explore individuals' perspectives of their psoriasis, medication and its management. Twenty people with psoriasis were recruited from community samples in England and interviewed in-depth about their perceptions of their psoriasis, medication, and adherence to medication and self-management advice. Data were analysed using Framework Analysis. Participants reported that adhering to recommended treatment regimens conflicted with the management of the physical and psychological demands of living with psoriasis. Medication usage was viewed as a source of unresolved emotional distress and, for some, resulted in poor self-reported adherence, which included medication overuse, underuse and rejection of prescribed therapies. Perceived lack of engagement by clinicians with participants' self-management difficulties was viewed as an additional source of stress and distress. Adhering to medication in psoriasis can be an additional source of considerable emotional distress. We interpreted some episodes of nonadherence to psoriasis medication as rational attempts by individuals to minimize distress and to gain control over their life. © 2016 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.
Vanderploeg, Henry A.; Pothoven, Steven A.; Fahnenstiel, Gary L.; Cavaletto, Joann F.; Liebig, James R.; Stow, Craig Stow; Nalepa, Thomas F.; Madenjian, Charles P.; Bunnell, David B.
We examined seasonal dynamics of zooplankton at an offshore station in Lake Michigan from 1994 to 2003 and 2007 to 2008. This period saw variable weather, declines in planktivorous fish abundance, the introduction and expansion of dreissenid mussels, and a slow decline in total phosphorus concentrations. After the major expansion of mussels into deep water (2007–2008), chlorophyll in spring declined sharply, Secchi depth increased markedly in all seasons, and planktivorous fish biomass declined to record-low levels. Overlaying these dramatic ecosystem-level changes, the zooplankton community exhibited complex seasonal dynamics between 1994–2003 and 2007–2008. Phenology of the zooplankton maximum was affected by onset of thermal stratification, but there was no other discernable effect due to temperature. Interannual variability in zooplankton biomass during 1994 and 2003 was strongly driven by planktivorous fish abundance, particularly age-0 and age-1 alewives. In 2007–2008, there were large decreases in Diacyclops thomasi and Daphnia mendotae possibly caused by food limitation as well as increased predation and indirect negative effects from increases in Bythotrephes longimanus abundance and in foraging efficiency associated with increased light penetration. The Bythotrephes increase was likely driven in part by decreased predation from yearling and older alewife. While there was a major decrease in epilimnetic–metalimnetic herbivorous cladocerans in 2007–2008, there was an increase in large omnivorous and predacious calanoid copepods, especially those in the hypolimnion. Thus, changes to the zooplankton community are the result of cascading, synergistic interactions, including a shift from vertebrate to invertebrate planktivory and mussel ecosystem impacts on light climate and chlorophyll.
The results of the Global Survey of Physicists draw attention to the need to focus on factors other than representation when discussing the situation of women in physics. Previous studies of women in physics have mostly focused on the lack of women in the field. This study goes beyond the obvious shortage of women and shows that there are much deeper issues. For the first time, a multinational study was conducted with 15000 respondents from 130 countries, showing that problems for women in physics transcend national borders. Across all countries, women have fewer resources and opportunities and are more affected by cultural expectations concerning child care. We show that limited resources and opportunities hurt career progress, and because women have fewer opportunities and resources, their careers progress more slowly. We also show the disproportionate effects of children on women physicists' careers. Cultural expectations about home and family are difficult to change. However, for women to have successful ...
Full Text Available Neonates and infants are more vulnerable to infections and show reduced responses to vaccination. Consequently, repeated immunizations are required to induce protection and early life vaccines against major pathogens such as influenza are yet unavailable. Formulating antigens with potent adjuvants, including immunostimulators and delivery systems, is a demonstrated approach to enhance vaccine efficacy. Yet, adjuvants effective in adults may not meet the specific requirements for activating the early life immune system. Here, we assessed the neonatal adjuvanticity of three novel adjuvants including TLR4 (glucopyranosyl lipid adjuvant-squalene emulsion, TLR9 (IC31®, and Mincle (CAF01 agonists, which all induce germinal centers (GCs and potent antibody responses to influenza hemagglutinin (HA in adult mice. In neonates, a single dose of HA formulated into each adjuvant induced T follicular helper (TFH cells. However, only HA/CAF01 elicited significantly higher and sustained antibody responses, engaging neonatal B cells to differentiate into GCs already after a single dose. Although antibody titers remained lower than in adults, HA-specific responses induced by a single neonatal dose of HA/CAF01 were sufficient to confer protection against influenza viral challenge. Postulating that the neonatal adjuvanticity of CAF01 may result from the functionality of the C-type lectin receptor (CLR Mincle in early life we asked whether other C-type lectin agonists would show a similar neonatal adjuvanticity. Replacing the Mincle agonist trehalose 6,6′-dibehenate by Curdlan, which binds to Dectin-1, enhanced antibody responses through the induction of similar levels of TFH, GCs and bone marrow high-affinity plasma cells. Thus, specific requirements of early life B cells may already be met after a single vaccine dose using CLR-activating agonists, identified here as promising B cell immunostimulators for early life vaccines when included into cationic liposomes.
Valtis, Yannis K; Rosenberg, Julie; Bhandari, Sudip; Wachter, Keri; Teichman, Marie; Beauvais, Sophie; Weintraub, Rebecca
The rapidly changing landscape of medical knowledge and guidelines requires health professionals to have immediate access to current, reliable clinical resources. Access to evidence is instrumental in reducing diagnostic errors and generating better health outcomes. UpToDate, a leading evidence-based clinical resource is used extensively in the USA and other regions of the world and has been linked to lower mortality and length of stay in US hospitals. In 2009, the Global Health Delivery Project collaborated with UpToDate to provide free subscriptions to qualifying health workers in resource-limited settings. We evaluated the provision of UpToDate access to health workers by analysing their usage patterns. Since 2009, ∼2000 individual physicians and healthcare institutions from 116 countries have received free access to UpToDate through our programme. During 2013-2014, users logged into UpToDate ∼150 000 times; 61% of users logged in at least weekly; users in Africa were responsible for 54% of the total usage. Search patterns reflected local epidemiology with 'clinical manifestations of malaria' as the top search in Africa, and 'management of hepatitis B' as the top search in Asia. Our programme demonstrates that there are barriers to evidence-based clinical knowledge in resource-limited settings we can help remove. Some assumed barriers to its expansion (poor internet connectivity, lack of training and infrastructure) might pose less of a burden than subscription fees.
U.S. Environmental Protection Agency — 2006 303d List of Water Quality Limited Segments that: 1) Require Total Maximum Daily Loads (TMDLS), 2) Are being addressed by USEPA approved TMDLs 3) Are being...
Kossoff, Eric H; Al-Macki, Nabil; Cervenka, Mackenzie C; Kim, Heung D; Liao, Jianxiang; Megaw, Katherine; Nathan, Janak K; Raimann, Ximena; Rivera, Rocio; Wiemer-Kruel, Adelheid; Williams, Emma; Zupec-Kania, Beth A
Despite the increasing use of dietary therapies for children and adults with refractory epilepsy, the availability of these treatments in developing countries with limited resources remains suboptimal. One possible contributory factor may be the costs. There is often reported a significant perceived need for a large ketogenic diet team, supplements, laboratory studies, and follow-up visits to provide this treatment. The 2009 Epilepsia Consensus Statement described ideal requirements for a ketogenic diet center, but in some situations this is not feasible. As a result, the International League Against Epilepsy (ILAE) Task Force on Dietary Therapy was asked to convene and provide practical, cost-effective recommendations for new ketogenic diet centers in resource-limited regions of the world. Wiley Periodicals, Inc. © 2015 International League Against Epilepsy.
Jane W. Muchiri
Full Text Available Diabetes self-management education is crucial in diabetes care. Education that is tailored to the needs of the patient is considered the most effective in improving health outcomes. Diet, a critical element of diabetes treatment, is reported as the most difficult to adhere to by both patients and health professionals. Tailored nutrition education (NE could benefit diabetic individuals with low socio-economic status, who are amongst those noted to have poor health outcomes. This qualitative interpretive phenomenological study aimed to explore and describe the NE needs of adults with type 2 diabetes mellitus to guide development of a tailored NE programme for resource-poor settings. Participants were 31 non-insulin-dependent type 2 diabetic patients (convenience sample and 10 health professionals. Focus group discussions using semi-structured questions were held with the diabetics, and open-ended self-administered questionnaires were used with the health professionals. Data analysis was done using Krueger’s framework approach. Disease-related knowledge deficits and inappropriate self-reported dietary practices, including intake of unbalanced meals, problems with food portion control and unsatisfactory intake of fruits and vegetables, were observed. Recommendations for the NE programme included topics related to the disease and others related to diet. Group education at the clinic, a competent educator and comprehensive education were indicated by the patients. Participation of family and provision of pamphlets were aspects recommended by patients and health professionals. Barriers that could impact the NE included financial constraints, food insecurity, conflict in family meal arrangements and access to appropriate foods. Support from family and health professionals and empowerment through education were identified as facilitators to following dietary recommendations by both groups of participants. Knowledge deficits, inappropriate dietary
Jane W. Muchiri
Full Text Available Diabetes self-management education is crucial in diabetes care. Education that is tailored to the needs of the patient is considered the most effective in improving health outcomes. Diet, a critical element of diabetes treatment, is reported as the most difficult to adhere to by both patients and health professionals. Tailored nutrition education (NE could benefit diabetic individuals with low socio-economic status, who are amongst those noted to have poor health outcomes. This qualitative interpretive phenomenological study aimed to explore and describe the NE needs of adults with type 2 diabetes mellitus to guide development of a tailored NE programme for resource-poor settings. Participants were 31 non-insulin-dependent type 2 diabetic patients (convenience sample and 10 health professionals. Focus group discussions using semi-structured questions were held with the diabetics, and open-ended self-administered questionnaires were used with the health professionals. Data analysis was done using Krueger’s framework approach. Disease-related knowledge deficits and inappropriate self-reported dietary practices, including intake of unbalanced meals, problems with food portion control and unsatisfactory intake of fruits and vegetables, were observed. Recommendations for the NE programme included topics related to the disease and others related to diet. Group education at the clinic, a competent educator and comprehensive education were indicated by the patients. Participation of family and provision of pamphlets were aspects recommended by patients and health professionals. Barriers that could impact the NE included financial constraints, food insecurity, conflict in family meal arrangements and access to appropriate foods. Support from family and health professionals and empowerment through education were identified as facilitators to following dietary recommendations by both groups of participants. Knowledge deficits, inappropriate dietary
Full Text Available Billy M Tsima,1 Vincent Setlhare,1 Oathokwa Nkomazana2 1Department of Family Medicine and Public Health, 2Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana Background: Botswana’s health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers.Methods: The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list.Results: Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed.Conclusion: The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better
VanDeusen, Adam; Paintsil, Elijah; Agyarko-Poku, Thomas; Long, Elisa F
Achieving the goal of eliminating mother-to-child HIV transmission (MTCT) necessitates increased access to antiretroviral therapy (ART) for HIV-infected pregnant women. Option B provides ART through pregnancy and breastfeeding, whereas Option B+ recommends continuous ART regardless of CD4 count, thus potentially reducing MTCT during future pregnancies. Our objective was to compare maternal and pediatric health outcomes and cost-effectiveness of Option B+ versus Option B in Ghana. A decision-analytic model was developed to simulate HIV progression in mothers and transmission (in utero, during birth, or through breastfeeding) to current and all future children. Clinical parameters, including antenatal care access and fertility rates, were estimated from a retrospective review of 817 medical records at two hospitals in Ghana. Additional parameters were obtained from published literature. Modeled outcomes include HIV infections averted among newborn children, quality-adjusted life-years (QALYs), and cost-effectiveness ratios. HIV-infected women in Ghana have a lifetime average of 2.3 children (SD 1.3). Projected maternal life expectancy under Option B+ is 16.1 years, versus 16.0 years with Option B, yielding a gain of 0.1 maternal QALYs and 3.2 additional QALYs per child. Despite higher initial ART costs, Option B+ costs $785/QALY gained, a value considered very cost-effective by World Health Organization benchmarks. Widespread implementation of Option B+ in Ghana could theoretically prevent up to 668 HIV infections among children annually. Cost-effectiveness estimates remained favorable over robust sensitivity analyses. Although more expensive than Option B, Option B+ substantially reduces MTCT in future pregnancies, increases both maternal and pediatric QALYs, and is a cost-effective use of limited resources in Ghana.
Triaud, A. H. M. J.; Hebb, L.; Anderson, D. R.; Cargile, P.; Collier Cameron, A.; Doyle, A. P.; Faedi, F.; Gillon, M.; Gomez Maqueo Chew, Y.; Hellier, C.; Jehin, E.; Maxted, P.; Naef, D.; Pepe, F.; Pollacco, D.; Queloz, D.; Ségransan, D.; Smalley, B.; Stassun, K.; Udry, S.; West, R. G.
This paper introduces a series of papers aiming to study the dozens of low-mass eclipsing binaries (EBLM), with F, G, K primaries, that have been discovered in the course of the WASP survey. Our objects are mostly single-line binaries whose eclipses have been detected by WASP and were initially followed up as potential planetary transit candidates. These have bright primaries, which facilitates spectroscopic observations during transit and allows the study of the spin-orbit distribution of F, G, K+M eclipsing binaries through the Rossiter-McLaughlin effect. Here we report on the spin-orbit angle of WASP-30b, a transiting brown dwarf, and improve its orbital parameters. We also present the mass, radius, spin-orbit angle and orbital parameters of a new eclipsing binary, J1219-39b (1SWAPJ121921.03-395125.6, TYC 7760-484-1), which, with a mass of 95 ± 2 Mjup, is close to the limit between brown dwarfs and stars. We find that both objects have projected spin-orbit angles aligned with their primaries' rotation. Neither primaries are synchronous. J1219-39b has a modestly eccentric orbit and is in agreement with the theoretical mass-radius relationship, whereas WASP-30b lies above it. Using WASP-South photometric observations (Sutherland, South Africa) confirmed with radial velocity measurement from the CORALIE spectrograph, photometry from the EulerCam camera (both mounted on the Swiss 1.2 m Euler Telescope), radial velocities from the HARPS spectrograph on the ESO's 3.6 m Telescope (prog ID 085.C-0393), and photometry from the robotic 60 cm TRAPPIST telescope, all located at ESO, La Silla, Chile. The data is publicly available at the CDS Strasbourg and on demand to the main author.Tables A.1-A.3 are available in electronic form at http://www.aanda.orgPhotometry tables are only available at the CDS via anonymous ftp to cdsarc.u-strasbg.fr (126.96.36.199) or via http://cdsarc.u-strasbg.fr/viz-bin/qcat?J/A+A/549/A18
Foley, Alan R; Masingila, Joanna O
In this paper, the authors explore the use of mobile devices as assistive technology for students with visual impairments in resource-limited environments. This paper provides initial data and analysis from an ongoing project in Kenya using tablet devices to provide access to education and independence for university students with visual impairments in Kenya. The project is a design-based research project in which we have developed and are refining a theoretically grounded intervention--a model for developing communities of practice to support the use of mobile technology as an assistive technology. We are collecting data to assess the efficacy and improve the model as well as inform the literature that has guided the design of the intervention. In examining the impact of the use of mobile devices for the students with visual impairments, we found that the devices provide the students with (a) access to education, (b) the means to participate in everyday life and (c) the opportunity to create a community of practice. Findings from this project suggest that communities of practice are both a viable and a valuable approach for facilitating the diffusion and support of mobile devices as assistive technology for students with visual impairments in resource-limited environments. Implications for Rehabilitation The use of mobile devices as assistive technology in resource-limited environments provides students with visual impairments access to education and enhanced means to participate in everyday life. Communities of practice are both a viable and a valuable approach for facilitating the diffusion and support of mobile devices as assistive technology for students with visual impairments in resource-limited environments. Providing access to assistive technology early and consistently throughout students' schooling builds both their skill and confidence and also demonstrates the capabilities of people with visual impairments to the larger society.
Barr, Margo L; Ferguson, Raymond A; Hughes, Phil J; Steel, David G
In 2012 mobile phone numbers were included into the ongoing New South Wales Population Health Survey (NSWPHS) using an overlapping dual-frame design. Previously in the NSWPHS the sample was selected using random digit dialing (RDD) of landline phone numbers. The survey was undertaken using computer assisted telephone interviewing (CATI). The weighting strategy needed to be significantly expanded to manage the differing probabilities of selection by frame, including that of children of mobile-only phone users, and to adjust for the increased chance of selection of dual-phone users. This paper describes the development of the final weighting strategy to properly combine the data from two overlapping sample frames accounting for the fact that population benchmarks for the different sampling frames were not available at the state or regional level. Estimates of the number of phone numbers for the landline and mobile phone frames used to calculate the differing probabilities of selection by frame, for New South Wales (NSW) and by stratum, were obtained by apportioning Australian estimates as none were available for NSW. The weighting strategy was then developed by calculating person selection probabilities, selection weights, applying a constant composite factor to the dual-phone users sample weights, and benchmarking to the latest NSW population by age group, sex and stratum. Data from the NSWPHS for the first quarter of 2012 was used to test the weighting strategy. This consisted of data on 3395 respondents with 2171 (64%) from the landline frame and 1224 (36%) from the mobile frame. However, in order to calculate the weights, data needed to be available for all core weighting variables and so 3378 respondents, 2933 adults and 445 children, had sufficient data to be included. Average person weights were 3.3 times higher for the mobile-only respondents, 1.3 times higher for the landline-only respondents and 1.7 times higher for dual-phone users in the mobile frame
Bartsch-Winkler, S.; Dickerson, R.P.; Barton, H.W.; McCafferty, A.E.; Grauch, V.J.S.; Koyuncu, H.; Lee, K.; Duval, J.S.; Munts, S.R.; Benjamin, D.A.; Close, T.J.; Lipton, D.A.; Neumann, T.R.; Willet, S.L.
This paper reports on the San Rafael Swell Wilderness Study areas, which includes the Muddy Creek, Crack Canyon, San Rafael Reef, Mexican Mountain, and Sids Mountain Wilderness Study Areas, in Emery County, south-central Utah. Within and near the Crack Canyon Wilderness Study Area are identified subeconomic uranium and vanadium resources. Within the Carmel Formation are inferred subeconomic resources of gypsum in the Muddy Creek, San Rafael Reef, and Sids Mountain Wilderness Study Areas. Other commodities evaluated include geothermal energy, gypsum, limestone, oil and gas, sand and gravel, sandstone, semiprecious gemstones, sulfur petrified wood, and tar sand
Hamilton, David W.; Torraco, Richard J.
Adults with limited education and skills--those who lack the education and skills needed for full participation in U.S. culture and economy--are increasing in numbers. However, the knowledge base addressing this population and their educational needs is fragmented across the literature of several disciplines. A comprehensive review and critique of…
Kerbiriou, P.J.; Stomph, T.J.; Putten, van der P.E.L.; Lammerts Van Bueren, E.; Struik, P.C.
Background and aims - To improve vegetable crops adapted to low input and variable resource availability, better understanding is needed of root system functioning, including nitrogen and water capture. Methods - This study quantified shoot and root development and patterns of water and nitrate
Dennehy, Patricia; White, Mary P; Hamilton, Andrew; Pohl, Joanne M; Tanner, Clare; Onifade, Tiffiani J; Zheng, Kai
To present a partnership-based and community-oriented approach designed to ease provider anxiety and facilitate the implementation of electronic health records (EHR) in resource-limited primary care settings. The approach, referred to as partnership model, was developed and iteratively refined through the research team's previous work on implementing health information technology (HIT) in over 30 safety net practices. This paper uses two case studies to illustrate how the model was applied to help two nurse-managed health centers (NMHC), a particularly vulnerable primary care setting, implement EHR and get prepared to meet the meaningful use criteria. The strong focus of the model on continuous quality improvement led to eventual implementation success at both sites, despite difficulties encountered during the initial stages of the project. There has been a lack of research, particularly in resource-limited primary care settings, on strategies for abating provider anxiety and preparing them to manage complex changes associated with EHR uptake. The partnership model described in this paper may provide useful insights into the work shepherded by HIT regional extension centers dedicated to supporting resource-limited communities disproportionally affected by EHR adoption barriers. NMHC, similar to other primary care settings, are often poorly resourced, understaffed, and lack the necessary expertise to deploy EHR and integrate its use into their day-to-day practice. This study demonstrates that implementation of EHR, a prerequisite to meaningful use, can be successfully achieved in this setting, and partnership efforts extending far beyond the initial software deployment stage may be the key.
Coal and petroleum resources in the Appalachian basin: index maps of included studies: Chapter B.1 in Coal and petroleum resources in the Appalachian basin: distribution, geologic framework, and geochemical character
Ruppert, Leslie F.; Trippi, Michael H.; Kinney, Scott A.; Ruppert, Leslie F.; Ryder, Robert T.
This chapter B.1 of U.S. Geological Survey (USGS) Professional Paper 1708 provides index maps for many of the studies described in other chapters of the report. Scientists of the USGS and State geological surveys studied coal and petroleum resources in the central and southern Appalachian structural basins. In the southern Appalachian basin, studies focused on the coal-bearing parts of the Black Warrior basin in Alabama. The scientists used new and existing geologic data sets to create a common spatial geologic framework for the fossil-fuel-bearing strata of the central Appalachian basin and the Black Warrior basin in Alabama.
Jovanovich, Jovan V.
Will the future world be forever divided into an industrial, developed and 'rich' on one side, and the primitive, undeveloped, and poor on the other? Is an industrial, affluent and sustainable world of 10-15 billion people owning 5-10 billion cars physically possible to exist? Can the world have enough food, minerals and energy to support such a widespread affluence in a sustainable manner? In previous papers I have argued that even without any major breakthroughs in science and technology, an industrialized, sustainable and affluent world can be created within the next half a century to a century, but only if breeder nuclear power is widely used throughout the world. In this paper I elaborate on the question of future availability of some basic natural resources. (author)
McDermid, Robert C; Bagshaw, Sean M
Critical care is in an emerging crisis of conflict between what individuals expect and the economic burden society and government are prepared to provide. The goal of critical care support is to prevent suffering and premature death by intensive therapy of reversible illnesses within a reasonable timeframe. Recently, it has become apparent that early support in an intensive care environment can improve patient outcomes. However, life support technology has advanced, allowing physicians to prolong life (and postpone death) in circumstances that were not possible in the recent past. This has been recognized by not only the medical community, but also by society at large. One corollary may be that expectations for recovery from critical illness have also become extremely high. In addition, greater numbers of patients are dying in intensive care units after having receiving prolonged durations of life-sustaining therapy. Herein lies the emerging crisis -- critical care therapy must be available in a timely fashion for those who require it urgently, yet its provision is largely dependent on a finite availability of both capital and human resources. Physicians are often placed in a troubling conflict of interest by pressures to use health resources prudently while also promoting the equitable and timely access to critical care therapy. In this commentary, these issues are broadly discussed from the perspective of the individual clinician as well as that of society as a whole. The intent is to generate dialogue on the dynamic between individual clinicians navigating the complexities of how and when to use critical care support in the context of end-of-life issues, the increasing demands placed on finite critical care capacity, and the reasonable expectations of society.
Bagshaw Sean M
Full Text Available Abstract Critical care is in an emerging crisis of conflict between what individuals expect and the economic burden society and government are prepared to provide. The goal of critical care support is to prevent suffering and premature death by intensive therapy of reversible illnesses within a reasonable timeframe. Recently, it has become apparent that early support in an intensive care environment can improve patient outcomes. However, life support technology has advanced, allowing physicians to prolong life (and postpone death in circumstances that were not possible in the recent past. This has been recognized by not only the medical community, but also by society at large. One corollary may be that expectations for recovery from critical illness have also become extremely high. In addition, greater numbers of patients are dying in intensive care units after having receiving prolonged durations of life-sustaining therapy. Herein lies the emerging crisis – critical care therapy must be available in a timely fashion for those who require it urgently, yet its provision is largely dependent on a finite availability of both capital and human resources. Physicians are often placed in a troubling conflict of interest by pressures to use health resources prudently while also promoting the equitable and timely access to critical care therapy. In this commentary, these issues are broadly discussed from the perspective of the individual clinician as well as that of society as a whole. The intent is to generate dialogue on the dynamic between individual clinicians navigating the complexities of how and when to use critical care support in the context of end-of-life issues, the increasing demands placed on finite critical care capacity, and the reasonable expectations of society.
Havers, Fiona P.; Detrick, Barbara; Cardoso, Sandra W.; Berendes, Sima; Lama, Javier R.; Sugandhavesa, Patcharaphan; Mwelase, Noluthando H.; Campbell, Thomas B.; Gupta, Amita
Study Background Vitamin D has wide-ranging effects on the immune system, and studies suggest that low serum vitamin D levels are associated with worse clinical outcomes in HIV. Recent studies have identified an interaction between antiretrovirals used to treat HIV and reduced serum vitamin D levels, but these studies have been done in North American and European populations. Methods Using a prospective cohort study design nested in a multinational clinical trial, we examined the effect of three combination antiretroviral (cART) regimens on serum vitamin D levels in 270 cART-naïve, HIV-infected adults in nine diverse countries, (Brazil, Haiti, Peru, Thailand, India, Malawi, South Africa, Zimbabwe and the United States). We evaluated the change between baseline serum vitamin D levels and vitamin D levels 24 and 48 weeks after cART initiation. Results Serum vitamin D levels decreased significantly from baseline to 24 weeks among those randomized to efavirenz/lamivudine/zidovudine (mean change: −7.94 [95% Confidence Interval (CI) −10.42, −5.54] ng/ml) and efavirenz/emtricitabine/tenofovir-DF (mean change: −6.66 [95% CI −9.40, −3.92] ng/ml) when compared to those randomized to atazanavir/emtricitabine/didanosine-EC (mean change: −2.29 [95% CI –4.83, 0.25] ng/ml). Vitamin D levels did not change significantly between week 24 and 48. Other factors that significantly affected serum vitamin D change included country (p<0.001), season (p<0.001) and baseline vitamin D level (p<0.001). Conclusion Efavirenz-containing cART regimens adversely affected vitamin D levels in patients from economically, geographically and racially diverse resource-limited settings. This effect was most pronounced early after cART initiation. Research is needed to define the role of Vitamin D supplementation in HIV care. PMID:24752177
Wells, Katie M; Lee, Yu-Jin; Erdene, Sandag; Erdene, Sarnai; Sanchin, Urjin; Sergelen, Orgoi; Zhang, Chong; Rodriguez, Brandon P; deVries, Catherine R; Price, Raymond R
The benefits of laparoscopic cholecystectomy, including rapid recovery and fewer infections, have been largely unavailable to the majority of people in developing countries. Compared to other countries, Mongolia has an extremely high incidence of gallbladder disease. In 2005, only 2% of cholecystectomies were performed laparoscopically. This is a retrospective review of the transition from open to laparoscopic cholecystectomy throughout Mongolia. A cross-sectional, retrospective review was conducted of demographic patient data, diagnosis type, and operation performed (laparoscopic versus open cholecystectomy) from 2005-2013. Trends were analyzed from 6 of the 21 provinces (aimags) throughout Mongolia, and data were culled from 7 regional diagnostic referral and treatment centers and 2 tertiary academic medical centers. The data were analyzed by individual training center and by year before being compared between rural and urban centers. We analyzed and compared 14,522 cholecystectomies (n = 4,086 [28%] men, n = 10,436 [72%] women). Men and women were similar in age (men 52.2, standard deviation 14.8; women 49.4, standard deviation 15.7) and in the percentage undergoing laparoscopic cholecystectomy (men 39%, women 42%). By 2013, 58% of gallbladders were removed laparoscopically countrywide compared with only 2% in 2005. In 2011, laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide. More than 315 Mongolian health care practitioners received laparoscopic training in 19 of the country's 21 aimags (states). By 2013, 58% of cholecystectomies countrywide were performed laparoscopically, a dramatic increase over 9 years. The expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia despite the country's limited resources. Copyright © 2016 Elsevier Inc. All rights reserved.
Nakanjako, Damalie; Namagala, Elizabeth; Semeere, Aggrey; Kigozi, Joanitor; Sempa, Joseph; Ddamulira, John Bosco; Katamba, Achilles; Biraro, Sam; Naikoba, Sarah; Mashalla, Yohana; Farquhar, Carey; Sewankambo, Nelson
Due to a limited health workforce, many health care providers in Africa must take on health leadership roles with minimal formal training in leadership. Hence, the need to equip health care providers with practical skills required to lead high-impact health care programs. In Uganda, the Afya Bora Global Health Leadership Fellowship is implemented through the Makerere University College of Health Sciences (MakCHS) and her partner institutions. Lessons learned from the program, presented in this paper, may guide development of in-service training opportunities to enhance leadership skills of health workers in resource-limited settings. The Afya Bora Consortium, a consortium of four African and four U.S. academic institutions, offers 1-year global health leadership-training opportunities for nurses and doctors. Applications are received and vetted internationally by members of the consortium institutions in Botswana, Kenya, Tanzania, Uganda, and the USA. Fellows have 3 months of didactic modules and 9 months of mentored field attachment with 80% time dedicated to fellowship activities. Fellows' projects and experiences, documented during weekly mentor-fellow meetings and monthly mentoring team meetings, were compiled and analyzed manually using pre-determined themes to assess the effect of the program on fellows' daily leadership opportunities. Between January 2011 and January 2015, 15 Ugandan fellows (nine doctors and six nurses) participated in the program. Each fellow received 8 weeks of didactic modules held at one of the African partner institutions and three online modules to enhance fellows' foundation in leadership, communication, monitoring and evaluation, health informatics, research methodology, grant writing, implementation science, and responsible conduct of research. In addition, fellows embarked on innovative projects that covered a wide spectrum of global health challenges including critical analysis of policy formulation and review processes
Tibaijuka, Leevan; Odongo, Robert; Welikhe, Emma; Mukisa, Wilber; Kugonza, Lilian; Busingye, Imelda; Nabukalu, Phelomena; Ngonzi, Joseph; Asiimwe, Stephen B; Bajunirwe, Francis
Unplanned pregnancy remains a common problem in many resource-limited settings, mostly due to limited access to modern family planning (FP) services. In particular, use of the more effective long-acting reversible contraceptive (LARC) methods (i.e., intrauterine devices and hormonal implants) remains low compared to the short-acting methods (i.e., condoms, hormonal pills, injectable hormones, and spermicides). Among reproductive-age women attending FP and antenatal care clinics in Uganda, we assessed perceptions and practices regarding the use of modern contraceptive methods. We specifically aimed to evaluate factors influencing method selection. We performed a mixed-methods cross-sectional study, in which we administered structured interviews to 180 clients, and conducted 4 focus group discussions (FGDs) with 36 clients and 8 in-depth personal qualitative interviews with health service providers. We summarized quantitative data and performed latent content analysis on transcripts from the FGDs and qualitative interviews. The prevalence of ever use for LARC methods was 23%. Method characteristics (e.g., client control) appeared to drive method selection more often than structural factors (such as method availability) or individual client characteristics (such as knowledge and perceptions). The most common reasons for choosing LARC methods were: longer protection; better child-spacing; and effectiveness. The most common reasons for not choosing LARC methods included requiring a client-controlled method and desiring to conceive in the near future. The most common reasons for choosing short-acting methods were ease of access; lower cost; privacy; perceived fewer side effects; and freedom to stop using a method without involving the health provider. The personal characteristics of clients, which appeared to be important were client knowledge and number of children. The structural factor which appeared to be important was method availability. Our results suggest that
Walter, Jane; Loshchenov, Maxim; Zhilkin, Vladimir; Peake, Rachel; Stone, Jennifer; Lilge, Lothar
Background: In excess of 60% of all cancers are detected in low and middle-income countries, with breast cancer (BC) the dominant malignancy for women. Incidence rates continue to climb, most noticeably in the less than 50-year-old population. Expansion of mammography infrastructure and resources is lacking, resulting in over 60% of women diagnosed with stage III/IV BC in the majority of these countries. Optical Breast Spectroscopy (OBS) was shown to correlate well with mammographic breast density (MBD). OBS could aid breast screening programs in low- and middle-income countries by lowering the number of mammographs required for complete population coverage. However, its performance needs to be tested in large population trails to ensure high sensitivity and acceptable specificity. Methods: For the planned studies in low- and middle-income countries in different continents, online methods need to be implemented to monitor the performance and data collection by these devices, operated by trained nurses. Based on existing datasets, procedures were developed to validate an individual woman's data integrity and to identify operator errors versus system malfunctions. Results: Using a dataset comprising spectra from 360 women collected by 2 instruments in different locations and with 3 different trained operators, automated methods were developed to identify 100% of the source or photodetector malfunctions as well as incorrect calibrations and 96% of instances of insufficient tissue contact. Conclusions: Implementing the dataset validation locally in each instrument and tethered to a cloud database will allow the planned clinical trials to proceed.
Matimba, Alice; Woodward, Richmond; Tambo, Ernest; Ramsay, Michele; Gwanzura, Lovemore; Guramatunhu, Solomon
Tele-ophthalmology using portable retinal imaging technology, mobile phone and Internet connectivity offers a solution to improve access to diabetic retinopathy (DR) screening services in sub-Saharan African (SSA) countries where the burden of diabetes is increasing and there is limited access to eye care services and specialists. The Zimbabwe Retinopathy Telemedicine Project (ZRTP) established routine DR screening at a hospital-based diabetic clinic in the urban capital city, Harare. A handheld 'point and shoot' digital camera operated by a trained nurse was used to acquire retina images of 203 diabetic patients. A secured 'store-and forward' approach was set up and used for sharing and transfer of images to a retinal specialist at a remote site for reading. This method enabled detection of non-macular DR (11%), diabetic macular oedema (5%), cataract (5%) and glaucoma (6%) among the patients screened. ZRTP demonstrated the utility of tele-ophthalmology for routine retinal screening for diabetic patients in Zimbabwe who have limited access to eye care services. In addition, ZRTP showed how tele-ophthalmology services can provide an empirical framework for providing patient education, and a platform for research in the detection of DR. This approach could be used as a model to address the DR challenges in other countries in SSA. © The Author(s) 2015.
Vitoria, Marco; Ford, Nathan; Doherty, Meg; Flexner, Charles
The global scale-up of antiretroviral therapy (ART) over the past decade represents one of the great public health and human rights achievements of recent times. Moving from an individualized treatment approach to a simplified and standardized public health approach has been critical to ART scale-up, simplifying both prescribing practices and supply chain management. In terms of the latter, the risk of stock-outs can be reduced and simplified prescribing practices support task shifting of care to nursing and other non-physician clinicians; this strategy is critical to increase access to ART care in settings where physicians are limited in number. In order to support such simplification, successive World Health Organization guidelines for ART in resource-limited settings have aimed to reduce the number of recommended options for first-line ART in such settings. Future drug and regimen choices for resource-limited settings will likely be guided by the same principles that have led to the recommendation of a single preferred regimen and will favour drugs that have the following characteristics: minimal risk of failure, efficacy and tolerability, robustness and forgiveness, no overlapping resistance in treatment sequencing, convenience, affordability, and compatibility with anti-TB and anti-hepatitis treatments.
Full Text Available Current trends in Enterprise Resource Planning (ERP suggest that supply chain management and tight control over scheduling jobs within the supply chain are key tactical planning issues. Modern ERP software packages, in conjunction with the World Wide Web, allow for automated exchange of information within a company and also between two or more companies (i.e., conveyance of customer information to suppliers of parts and components for the purposes of effective planning and control. While ease of information exchange between a customer and supplier is increasingly critical to the success of modern-day planning and control efforts, the issue of information security is also a very real concern. Suppliers can benefit from gaining access to a customer's dispatch list and material requirements plan (MRP in order to determine real-time priority of jobs in queue at various work centers within their own organization. Other customer information, however, should remain secure and unavailable to supplier firms for competitive reasons such as threat of forward integration. This paper presents a previously tested priority-sequencing rule that explicitly considers downstream shop conditions in determining which job to run next The rule proves to perform well on mean flow time and lateness as well as on variability of these measures. The rule is extended here to incorporate the case where a downstream work center is outside official corporate boundaries. With the call for free exchange of information comes the threat of other, perhaps proprietary, information being accessed by vendors or others outside the official corporate boundaries. The paper will propose information that should be freely exchanged between customers and suppliers and information that should remain secure. Finally, practical measures to manage access to web-enabled ERP information will be proposed.
Ngugi, Anthony K; Agoi, Felix; Mahoney, Megan R; Lakhani, Amyn; Mang'ong'o, David; Nderitu, Esther; Armstrong, Robert; Macfarlane, Sarah
Knowledge of utilization of health services and associated factors is important in planning and delivery of interventions to improve health services coverage. We determined the prevalence and factors associated with health services utilization in a rural area of Kenya. Our findings inform the local health management in development of appropriately targeted interventions. We used a cluster sample survey design and interviewed household key informants on history of illness for household members and health services utilization in the preceding month. We estimated prevalence and performed random effects logistic regression to determine the influence of individual and household level factors on decisions to utilize health services. 1230/6,440 (19.1%, 95% CI: 18.3%-20.2%) household members reported an illness. Of these, 76.7% (95% CI: 74.2%-79.0%) sought healthcare in a health facility. The majority (94%) of the respondents visited dispensary-level facilities and only 60.1% attended facilities within the study sub-counties. Of those that did not seek health services, 43% self-medicated by buying non-prescription drugs, 20% thought health services were too costly, and 10% indicated that the sickness was not serious enough to necessitate visiting a health facility. In the multivariate analyses, relationship to head of household was associated with utilization of health services. Relatives other than the nuclear family of the head of household were five times less likely to seek medical help (Odds Ratio 0.21 (95% CI: 0.05-0.87)). Dispensary level health facilities are the most commonly used by members of this community, and relations at the level of the household influence utilization of health services during an illness. These data enrich the perspective of the local health management to better plan the allocation of healthcare resources according to need and demand. The findings will also contribute in the development of community-level health coverage interventions that
Begum, Jasmina; Samal, Sunil Kumar; Ghose, Seetesh; Niranjan, Gopal
Objective: Diagnosis of premature rupture of membranes (PROM) is difficult in equivocal cases with traditional methods. This study aimed to evaluate the reliability of vaginal washing fluid urea and creatinine for diagnosis of PROM and to determine the cut off value. Materials and methods: The current study was a prospective case control. Women having gestational age of 28 to 42 weeks were divided into two equal groups: Fifty with history of leaking per vagina (study group) and an equal number with gestation matched none leaking (control group) were recruited. Data analysis was done by Student's t-test, receiver operator curve and chi square test. Results: The demographic data of both groups were comparable at the time of sampling (p > 0.05).Vaginal fluid urea and creatinine was significantly higher in study group (p 6mg/dl and creatinine with a cut off value of > 0.3 mg/dl to diagnose PROM were all more than 90%. The sensitivity, specificity, PPV, NPV and accuracy of amniotic fluid index (AFI) to diagnose PROM were 30%, 91.8%, 83.33%, 57.32% and 62 % respectively, with a cut-off value of ≤ 7 cm. The areas under the curves are 0.952 for creatinine, 0.999 for urea and 0.635 for AFI. Conclusion: Detection of vaginal fluid urea and creatinine to diagnose PROM is a simple, reliable and rapid test. Introduction of this method into routine use even in low resource community setting is feasible, practical and cost effective.
Full Text Available Objective: Diagnosis of premature rupture of membranes (PROM is difficult in equivocal cases with traditional methods. This study aimed to evaluate the reliability of vaginal washing fluid urea and creatinine for diagnosis of PROM and to determine the cut off value.Materials and methods: The current study was a prospective case control. Women having gestational age of 28 to 42 weeks were divided into two equal groups: Fifty with history of leaking per vagina (study group and an equal number with gestation matched none leaking (control group were recruited. Data analysis was done by Student’s t-test, receiver operator curve and chi square test.Results: The demographic data of both groups were comparable at the time of sampling (p > 0.05.Vaginal fluid urea and creatinine was significantly higher in study group (p < 0.001. The sensitivity, specificity, positive predictive value (PPV, negative predictive value (NPV, and accuracy of vaginal fluid urea with a cut off value > 6mg/dl and creatinine with a cut off value of > 0.3 mg/dl to diagnose PROM were all more than 90%. The sensitivity, specificity, PPV, NPV and accuracy of amniotic fluid index (AFI to diagnose PROM were 30%, 91.8%, 83.33%, 57.32% and 62 % respectively, with a cut-off value of ≤ 7 cm. The areas under the curves are 0.952 for creatinine, 0.999 for urea and 0.635 for AFI.Conclusion: Detection of vaginal fluid urea and creatinine to diagnose PROM is a simple, reliable and rapid test. Introduction of this method into routine use even in low resource community setting is feasible, practical and cost effective.
Full Text Available IntroductionUnder five mortality rates (UFMR remain high for children in low- and middle-income countries (LMICs in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities. In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal.Materials and methodsThe WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment, and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation.ResultsInfectious diseases (respiratory illnesses and diarrheal disease were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations.Discussion and conclusionEpidemiology of disease
Basavaraju, S V; Mwangi, J; Kellogg, T A; Odawo, L; Marum, L H
Blood services in sub-Saharan Africa experience blood shortages and low retention of voluntary, non-remunerated donors. To boost collections by encouraging repeat donations, the Kenya National Blood Transfusion Service is exploring the likelihood of reaching previous donors through targeted print, radio and television advertising. We analysed data from a national AIDS Indicator Survey to determine whether previous donors have significant exposure to media. Respondents reporting history of blood donation had significantly higher exposure to print, radio and television media than those without history of blood donation. Targeted media campaigns encouraging repeat donation are likely to reach previous donors even in resource-limited settings.
Hunsperger, Elizabeth A; Sharp, Tyler M; Lalita, Paul; Tikomaidraubuta, Kini; Cardoso, Yolanda Rebello; Naivalu, Taina; Khan, Aalisha Sahu; Marfel, Maria; Hancock, W Thane; Tomashek, Kay M; Margolis, Harold S
Dengue is major public health problem, globally. Timely verification of suspected dengue outbreaks allows for public health response, leading to the initiation of appropriate clinical care. Because the clinical presentation of dengue is nonspecific, dengue diagnosis would benefit from a sensitive rapid diagnostic test (RDT). We evaluated the diagnostic performance of an RDT that detects dengue virus (DENV) nonstructural protein 1 (NS1) and anti-DENV IgM during suspected acute febrile illness (AFI) outbreaks in four countries. Real-time reverse transcription-PCR and anti-DENV IgM enzyme-linked immunosorbent assay were used to verify RDT results. Anti-DENV IgM RDT sensitivity and specificity ranged from 55.3 to 91.7% and 85.3 to 98.5%, respectively, and NS1 sensitivity and specificity ranged from 49.7 to 92.9% and 22.2 to 89.0%, respectively. Sensitivity varied by timing of specimen collection and DENV serotype. Combined test results moderately improved the sensitivity. The use of RDTs identified dengue as the cause of AFI outbreaks where reference diagnostic testing was limited or unavailable. Copyright © 2016, American Society for Microbiology. All Rights Reserved.
Fahmi, Fahmi; Nasution, Tigor H; Anggreiny, Anggreiny
The use of medical imaging in diagnosing brain disease is growing. The challenges are related to the big size of data and complexity of the image processing. High standard of hardware and software are demanded, which can only be provided in big hospitals. Our purpose was to provide a smart cloud system to help diagnosing brain diseases for hospital with limited infrastructure. The expertise of neurologists was first implanted in cloud server to conduct an automatic diagnosis in real time using image processing technique developed based on ITK library and web service. Users upload images through website and the result, in this case the size of tumor was sent back immediately. A specific image compression technique was developed for this purpose. The smart cloud system was able to measure the area and location of tumors, with average size of 19.91 ± 2.38 cm2 and an average response time 7.0 ± 0.3 s. The capability of the server decreased when multiple clients accessed the system simultaneously: 14 ± 0 s (5 parallel clients) and 27 ± 0.2 s (10 parallel clients). The cloud system was successfully developed to process and analyze medical images for diagnosing brain diseases in this case for tumor.
Kute, Vivek B; Vanikar, Aruna V; Shah, Pankaj R; Gumber, Manoj R; Patel, Himanshu V; Engineer, Divyesh P; Modi, Pranjal R; Shah, Veena R; Trivedi, Hargovind L
According to the Indian chronic kidney disease registry, in 2010 only 2% of end stage kidney disease patients were managed with kidney transplantation, 37% were managed with dialysis and 61% were treated conservatively without renal replacement therapy. In countries like India, where a well-organized deceased donor kidney transplantation program is not available, living donor kidney transplantation is the major source of organs for kidney transplantation. The most common reason to decline a donor for directed living donation is ABO incompatibility, which eliminates up to one third of the potential living donor pool. Because access to transplantation with human leukocyte antigen (HLA)-desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD) promises hope to a growing number of end stage kidney disease patients. KPD is a rapidly growing and cost-effective living donor kidney transplantation strategy for patients who are incompatible with their healthy, willing living donor. In principle, KPD is feasible for any centre that performs living donor kidney transplantation. In transplant centres with a large living donor kidney transplantation program KPD does not require extra infrastructure, decreases waiting time, avoids transplant tourism and prevents commercial trafficking. Although KPD is still underutilized in India, it has been performed more frequently in recent times. To substantially increase donor pool and transplant rates, transplant centres should work together towards a national KPD program and frame a uniform acceptable allocation policy. © 2014 Asian Pacific Society of Nephrology.
Full Text Available Abstract Background Mentoring is a core component of medical education and career success. There is increasing global emphasis on mentorship of young scientists in order to train and develop the next leaders in global health. However, mentoring efforts are challenged by the high clinical, research and administrative demands. We evaluated the status and nature of mentoring practices at Makerere University College of Health Sciences (MAKCHS. Methods Pre-tested, self-administered questionnaires were sent by email to all Fogarty alumni at the MAKCHS (mentors and each of them was requested to complete and email back the questionnaire. In addition to training level and number of mentors, the questionnaires had open-ended questions covering themes such as; status of mentorship, challenges faced by mentors and strategies to improve and sustain mentorship within MAKCHS. Similarly, open-ended questionnaires were sent and received by email from all graduate students (mentees registered with the Uganda Society for Health Scientists (USHS. Qualitative data from mentors and mentees was analyzed manually according to the pre-determined themes. Results Twenty- two out of 100 mentors responded (14 email and 8 hard copy responses. Up to 77% (17/22 of mentors had Master's-level training and only 18% (4/22 had doctorate-level training. About 40% of the mentors had ≥ two mentees while 27% had none. Qualitative results showed that mentors needed support in terms of training in mentoring skills and logistical/financial support to carry out successful mentorship. Junior scientists and students reported that mentorship is not yet institutionalized and it is currently occurring in an adhoc manner. There was lack of awareness of roles of mentors and mentees. The mentors mentioned the limited number of practicing mentors at the college and thus the need for training courses and guidelines for faculty members in regard to mentorship at academic institutions. Conclusions
De Silva, A Pubudu; Stephens, Tim; Welch, John; Sigera, Chathurani; De Alwis, Sunil; Athapattu, Priyantha; Dharmagunawardene, Dilantha; Olupeliyawa, Asela; de Abrew, Ashwini; Peiris, Lalitha; Siriwardana, Somalatha; Karunathilake, Indika; Dondorp, Arjen; Haniffa, Rashan
To assess the impact of a nurse-led, short, structured training program for intensive care unit (ICU) nurses in a resource-limited setting. A training program using a structured approach to patient assessment and management for ICU nurses was designed and delivered by local nurse tutors in partnership with overseas nurse trainers. The impact of the course was assessed using the following: pre-course and post-course self-assessment, a pre-course and post-course Multiple Choice Questionnaire (MCQ), a post-course Objective Structured Clinical Assessment station, 2 post-course Short Oral Exam (SOE) stations, and post-course feedback questionnaires. In total, 117 ICU nurses were trained. Post-MCQ scores were significantly higher when compared with pre-MCQ (P electrocardiogram analysis). The course was highly rated by participants, with 98% believing that this was a useful experience. Nursing Intensive Care Skills Training was highly rated by participants and was effective in improving the knowledge of the participants. This sustainable short course model may be adaptable to other resource-limited settings. Copyright © 2014 Elsevier Inc. All rights reserved.
Andrew D. Revell
Full Text Available Objective. Antiretroviral drug selection in resource-limited settings is often dictated by strict protocols as part of a public health strategy. The objective of this retrospective study was to examine if the HIV-TRePS online treatment prediction tool could help reduce treatment failure and drug costs in such settings. Methods. The HIV-TRePS computational models were used to predict the probability of response to therapy for 206 cases of treatment change following failure in India. The models were used to identify alternative locally available 3-drug regimens, which were predicted to be effective. The costs of these regimens were compared to those actually used in the clinic. Results. The models predicted the responses to treatment of the cases with an accuracy of 0.64. The models identified alternative drug regimens that were predicted to result in improved virological response and lower costs than those used in the clinic in 85% of the cases. The average annual cost saving was $364 USD per year (41%. Conclusions. Computational models that do not require a genotype can predict and potentially avoid treatment failure and may reduce therapy costs. The use of such a system to guide therapeutic decision-making could confer health economic benefits in resource-limited settings.
Fernandez, Nestor; Garcia, Monica; Gil, Esperanza
of the herbivore diet has been insufficiently tested. We hypothesized that in drylands, where water availability is a prime control of ecosystem functioning, remote sensing indicators of vegetation drought stress are critical to predict the nutritional quality of herbivore habitats. This hypothesis was analyzed...... by measuring the dynamics in diet quality for the European rabbit, a key prey in Mediterranean communities. Rabbit nutrition was measured in six habitats throughout a year using faecal nitrogen (FN) content, an indicator of the levels of ingested protein. Then we tested the accuracy for predicting diet quality...... contributed to explain the dynamics of diet quality: models including either TVDI or Hr shower a better fit than those exclusively based in EVI (R2 = 0.43—0.60). Whereas FN showed a positive relationship with EVI, the effect of TVDI and Hr was negative. Extracting the temporal component further allowed us...
Gudina, Esayas Kebede; Tesfaye, Markos; Adane, Aynishet; Lemma, Kinfe; Shibiru, Tamiru; Wieser, Andreas; Pfister, Hans-Walter; Klein, Matthias
Bacterial meningitis is associated with significant morbidity and mortality despite advances in medical care. The main objective of this study was to assess the association of adjunctive dexamethasone treatment with discharge outcome of patients treated as bacterial meningitis in low income setting. A retrospective study was conducted at four teaching hospitals across Ethiopia. Patients of age 14 years and older treated as cases of bacterial meningitis between January 1, 2011 and April 30, 2015 were included in this study. Information regarding sociodemographic data, clinical presentations, laboratory data, treatments given and status at hospital discharge were retrieved from patients' medical records using a structured questionnaire. Predefined outcome variables at discharge were analysed using descriptive statistics. Multivariable logistic regression was used to identify factors independently associated with poor outcome. A total of 425 patients treated with the presumptive clinical diagnosis of bacterial meningitis were included in this study (lumbar puncture done in 56 %; only 19 % had CSF findings compatible with bacterial meningitis, and only 3 % had proven etiology). The overall in hospital mortality rate was 20.2 %. Impaired consciousness, aspiration pneumonia, and cranial nerve palsy at admission were independently associated with increased mortality. Adjuvant dexamethasone, which was used in 50.4 % of patients, was associated with increased in-hospital mortality (AOR = 3.38; 95 % CI 1.87-6.12, p bacterial meningitis. Most patients treated for suspected bacterial meningitis did not receive proper diagnostic workup. Adjuvant dexamethasone use in clinically suspected but unproven cases of bacterial meningitis was associated with an increased mortality and poor discharge GOS. These findings show that there are potential deleterious effects in unconfirmed cases in this setting. Physicians practising under such circumstances should thus abide with
Ortiz, Justin R; Neuzil, Kathleen M; Ahonkhai, Vincent I; Gellin, Bruce G; Salisbury, David M; Read, Jennifer S; Adegbola, Richard A; Abramson, Jon S
Immunization of pregnant women against influenza is a promising strategy to protect the mother, fetus, and young infant from influenza-related diseases. The burden of influenza during pregnancy, the vaccine immunogenicity during this period, and the robust influenza vaccine safety database underpin recommendations that all pregnant women receive the vaccine to decrease complications of influenza disease during their pregnancies. Recent data also support maternal immunization for the additional purpose of preventing disease in the infant during the first six months of life. In April 2012, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization recommended revisions to the WHO position paper on influenza vaccines. For the first time, SAGE recommended pregnant women should be made the highest priority for inactivated seasonal influenza vaccination. However, the variable maternal influenza vaccination coverage in countries with pre-existing maternal influenza vaccine recommendations underscores the need to understand and to address the discrepancy between recommendations and implementation success. We present the outcome of a multi-stakeholder expert consultation on inactivated influenza vaccination in pregnancy. The creation and implementation of vaccine policies and regulations require substantial resources and capacity. As with all public health interventions, the existence of perceived and real risks of vaccination will necessitate effective and transparent risk communication. Potential risk allocation and sharing mechanisms should be addressed by governments, vaccine manufacturers, and other stakeholders. In resource-limited settings, vaccine-related issues concerning supply, formulation, regulation, evidence evaluation, distribution, cost-utility, and post-marketing safety surveillance need to be addressed. Lessons can be learned from the Maternal and Neonatal Tetanus Elimination Initiative as well as efforts to increase vaccine coverage among pregnant
Revell, A D; Wang, D; Wood, R; Morrow, C; Tempelman, H; Hamers, R L; Alvarez-Uria, G; Streinu-Cercel, A; Ene, L; Wensing, A M J; DeWolf, F; Nelson, M; Montaner, J S; Lane, H C; Larder, B A
Genotypic HIV drug-resistance testing is typically 60%-65% predictive of response to combination antiretroviral therapy (ART) and is valuable for guiding treatment changes. Genotyping is unavailable in many resource-limited settings (RLSs). We aimed to develop models that can predict response to ART without a genotype and evaluated their potential as a treatment support tool in RLSs. Random forest models were trained to predict the probability of response to ART (≤400 copies HIV RNA/mL) using the following data from 14 891 treatment change episodes (TCEs) after virological failure, from well-resourced countries: viral load and CD4 count prior to treatment change, treatment history, drugs in the new regimen, time to follow-up and follow-up viral load. Models were assessed by cross-validation during development, with an independent set of 800 cases from well-resourced countries, plus 231 cases from Southern Africa, 206 from India and 375 from Romania. The area under the receiver operating characteristic curve (AUC) was the main outcome measure. The models achieved an AUC of 0.74-0.81 during cross-validation and 0.76-0.77 with the 800 test TCEs. They achieved AUCs of 0.58-0.65 (Southern Africa), 0.63 (India) and 0.70 (Romania). Models were more accurate for data from the well-resourced countries than for cases from Southern Africa and India (P < 0.001), but not Romania. The models identified alternative, available drug regimens predicted to result in virological response for 94% of virological failures in Southern Africa, 99% of those in India and 93% of those in Romania. We developed computational models that predict virological response to ART without a genotype with comparable accuracy to genotyping with rule-based interpretation. These models have the potential to help optimize antiretroviral therapy for patients in RLSs where genotyping is not generally available.
Bejiqi, Ramush; Retkoceri, Ragip; Zeka, Naim; Bejiqi, Hana; Vuqiterna, Armend; Maloku, Arlinda
Background Protein-losing enteropathy (PLE) is a disorder characterized by abnormal and often profound enteric protein loss. It’s relatively uncommon complication of Fontan and other complex congenital heart disease (CCHD) procedures. Because of the complexity and rarity of this disease process, the pathogenesis and pathophysiology of protein-losing enteropathy remain poorly understood, and attempts at treatment seldom yield long-term success. Aim of presentation is to describe single centre experience in diagnosis, evaluation, management and treatment of children with protein-losing enteropathy after Fontan and other CCHD procedures in the current era and in centre with limited human and technical resources, follows with a comprehensive review of protein-losing enteropathy publications, and concludes with suggestions for prevention and treatment. Material and methodology Retrospectively we analyzed patients with CCHD and protein-losing enteropathy in our institution, starting from January 2000 to December 2012. The including criteria were age between two and 17 years, to have a complex congenital heart disease and available complete documentation of cardiac surgery under cardiopulmonary bypass. Results Of all patients we evaluated 18 cases with protein-losing enteropathy, aged 6 to 19 years (mean 14±9); there were three children who had undergone screening procedure for D-transposition, one Tetralogy of Fallot, and remaining 14 patients had undergone Fontan procedures; (anatomic diagnosis are: six with tricuspid atresia, seven with d-transposition, double outlet right ventricle and pulmonary atresia and two with hypoplastic left heart syndrome). The diagnosis of protein-losing enteropathy was made at median age of 5.6 years, ranging from 13 months to 15 years. Diagnosis was made using alpha 1-antitrypsin as a gold marker in stool. By physical examination in 14 patients edema was found, in three ascites, and six patients had pleural effusion. Laboratory findings
Elmusharaf, Khalifa; Byrne, Elaine; O'Donovan, Diarmuid
Universal health access will not be achieved unless women are cared for in their own communities and are empowered to take decisions about their own health in a supportive environment. This will only be achieved by community-based demand side interventions for maternal health access. In this review article, we highlight three common strategies to increase demand-side barriers to maternal healthcare access and identify the main challenges that still need to be addressed for these strategies to be effective. Common demand side strategies can be grouped into three categories:(i) Financial incentives/subsidies; (ii) Enhancing patient transfer, and; (iii) Community involvement. The main challenges in assessing the effectiveness or efficacy of these interventions or strategies are the lack of quality evidence on their outcome and impact and interventions not integrated into existing health or community systems. However, what is highlighted in this review and overlooked in most of the published literature on this topic is the lack of knowledge about the context in which these strategies are to be implemented. We suggest three challenges that need to be addressed to create a supportive environment in which these demand-side strategies can effectively improve access to maternal health services. These include: addressing decision-making norms, engaging in intergenerational dialogue, and designing contextually appropriate communication strategies.
Kpobi, Lily; Swartz, Leslie; Ofori-Atta, Angela L
One of the most successful modes of record-keeping and data collection is the use of health management information systems, where patient information and management plans are uniformly entered into a database to streamline the information and for ease of further patient management. For mental healthcare, a Mental Health Information System (MHIS) has been found most successful since a properly established and operational MHIS is helpful for developing equitable and appropriate mental health care systems. Until 2010, the system of keeping patient records and information in the Accra Psychiatric Hospital of Ghana was old and outdated. In light of this and other factors, a complete reforming of the mental health information systems in three psychiatric hospitals in Ghana was undertaken in 2010. Four years after its implementation, we explored user experiences with the new system, and report here the challenges that were identified with use of the new MHIS. Individual semi-structured interviews were conducted with nine clinical and administrative staff of the Accra Psychiatric Hospital to examine their experiences with the new MHIS. Participants in the study were in three categories: clinical staff, administrator, and records clerk. Participants' knowledge of the system and its use, as well as the challenges they had experienced in its use were explored using an interpretative phenomenological approach. The data suggest that optimal use of the current MHIS had faced significant implementation challenges in a number of areas. Central challenges reported by users included increased workload, poor staff involvement and training, and absence of logistic support to keep the system running. Setting up a new system does not guarantee its success. As important as it is to have a mental health information system, its usefulness is largely dependent on proper implementation and maintenance. Further, the system can facilitate policy transformation only when the place of mental
Kim, Rebecca Y; Kwakye, Gifty; Kwok, Alvin C; Baltaga, Ruslan; Ciobanu, Gheorghe; Merry, Alan F; Funk, Luke M; Lipsitz, Stuart R; Gawande, Atul A; Berry, William R; Haynes, Alex B
Little is known about the sustainability and long-term effect of surgical safety checklists when implemented in resource-limited settings. A previous study demonstrated the marked, short-term effect of a structured hospital-wide implementation of a surgical safety checklist in Moldova, a lower-middle-income country, as have studies in other low-resource settings. To assess the long-term reduction in perioperative harm following the introduction of a checklist-based surgical quality improvement program in a resource-limited setting and to understand the long-term effects of such programs. Twenty months after the initial implementation of a surgical safety checklist and the provision of pulse oximetry at a referral hospital in Moldova, a lower-middle-income, resource-limited country in Eastern Europe, we conducted a prospective study of perioperative care and outcomes of 637 consecutive patients undergoing noncardiac surgery (the long-term follow-up group), and we compared the findings with those from 2106 patients who underwent surgery shortly after implementation (the short-term follow-up group). Preintervention data were collected from March to July 2010. Data collection during the short-term follow-up period was performed from October 2010 to January 2011, beginning 1 month after the implementation of the launch period. Data collection during the long-term follow-up period took place from May 25 to July 6, 2012, beginning 20 months after the initial intervention. The primary end points of interest were surgical morbidity (ie, the complication rate), adherence to safety process measures, and frequency of hypoxemia. Between the short- and long-term follow-up groups, the complication rate decreased 30.7% (P = .03). Surgical site infections decreased 40.4% (P = .05). The mean (SD) rate of completion of the checklist items increased from 88% (14%) in the short-term follow-up group to 92% (11%) in the long-term follow-up group (P < .001). The rate of
Full Text Available Accurate measurement of adherence is necessary to ensure that therapeutic outcomes can be attributed to the recommended treatment. Phone-based unannounced pill counts were shown to be feasible and reliable measures of adherence in developed settings; and have been further used as part of medication adherence interventions. However, it is not clear whether this method can be implemented successfully in resource-limited settings, where cellular network and mobile phone coverage may be low. Our objective is to describe operational issues surrounding the use of phone-based unannounced pill counts in Lesotho and Ethiopia.Phone-based monthly unannounced pill counts, using an adaptation of a standardized protocol from previous US-based studies, were utilized to measure anti-TB and antiretroviral medication adherence in two implementation science studies in resource-limited settings, START (Lesotho and ENRICH (Ethiopia.In START, 19.6% of calls were completed, with 71.9% of participants reached at least once; majority of failed call attempts were due to phones not being available (54.8% or because participants were away from the pills (32.7%. In ENRICH, 33.5% of calls were completed, with 86.7% of participants reached at least once; the main reasons for failed call attempts were phones being switched off (31.5%, participants not answering (27.3%, participants' discomfort speaking on the phone (15.4%, and network problems (13.2%. Structural, facility-level, participant-level, and data collection challenges were encountered in these settings.Phone-based unannounced pill counts were found to be challenging, and response rates suboptimal. While some of these challenges were specific to local contexts, most of them are generalizable to resource-limited settings. In a research study context, a possible solution to ease operational challenges may be to focus phone-based unannounced pill count efforts on a randomly selected sample from participants who are
Kirkpatrick, Bettie M.
The media specialist in a small organization should enlist the support of top management, describe the program fully, obtain detailed cost estimates, promote use of media, and realistically start small. (CMV)
Recanati, Francesca; Castelletti, Andrea; Dotelli, Giovanni; Melià, Paco
Enhancing local production is key to promoting food security, especially in rural households of low-income countries, but may conflict with limited natural resources and ecosystems preservation. We propose a framework integrating the water-food nexus and a sustainable livelihoods perspective to assess small-scale food production in water-poor regions. We demonstrate it by assessing alternative production scenarios in the Gaza Strip at different spatial scales. At the scale of a single farm, there is a clear conflict among objectives: while cash crops ensure good incomes but contribute scarcely to domestic protein supply, crops performing well from the nutritional and environmental viewpoint are among the worst from the economic one. At the regional scale, domestic production might cover an important fraction of nutritional needs while contributing to household income, but water scarcity impairs the satisfaction of food demand by domestic production alone. Pursuing food security under multiple constraints thus requires a holistic perspective: we discuss how a multidimensional approach can promote the engagement of different stakeholders and allow the exploration of trade-offs between food security, sustainable exploitation of natural resources and economic viability.
Improved Neuropsychological and Neurological Functioning Across Three Antiretroviral Regimens in Diverse Resource-Limited Settings: AIDS Clinical Trials Group Study A5199, the International Neurological Study
Robertson, K.; Jiang, H.; Kumwenda, J.; Supparatpinyo, K.; Evans, S.; Campbell, T. B.; Price, R.; Tripathy, S.; Kumarasamy, N.; La Rosa, A.; Santos, B.; Silva, M. T.; Montano, S.; Kanyama, C.; Faesen, S.; Murphy, R.; Hall, C.; Marra, C. M.; Marcus, C.; Berzins, B.; Allen, R.; Housseinipour, M.; Amod, F.; Sanne, I.; Hakim, J.; Walawander, A.; Nair, A.
Background. AIDS Clinical Trials Group (ACTG) A5199 compared the neurological and neuropsychological (NP) effects of 3 antiretroviral regimens in participants infected with human immunodeficiency virus type 1 (HIV-1) in resource-limited settings. Methods. Participants from Brazil, India, Malawi, Peru, South Africa, Thailand, and Zimbabwe were randomized to 3 antiretroviral treatment arms: A (lamivudine-zidovudine plus efavirenz, n = 289), B (atazanavir, emtricitabine, and didanosine-EC, n = 293), and C (emtricitabine-tenofovir-disoproxil fumarate plus efavirenz, n = 278) as part of the ACTG PEARLS study (A5175). Standardized neurological and neuropsychological (NP) screening examinations (grooved pegboard, timed gait, semantic verbal fluency, and finger tapping) were administered every 24 weeks from February 2006 to May 2010. Associations with neurological and neuropsychological function were estimated from linear and logistic regression models using generalized estimating equations. Results. The median weeks on study was 168 (Q1 = 96, Q3 = 192) for the 860 participants. NP test scores improved (P .10). Significant country effects were noted on all NP tests and neurological outcomes (P < .01). Conclusions. The study detected no significant differences in neuropsychological and neurological outcomes between randomized ART regimens. Significant improvement occurred in neurocognitive and neurological functioning over time after initiation of ARTs. The etiology of these improvements is likely multifactorial, reflecting reduced central nervous system HIV infection, better general health, and practice effects. This study suggests that treatment with either of the World Health Organization –recommended first-line antiretroviral regimens in resource-limited settings will improve neuropsychological functioning and reduce neurological dysfunction. Clinical trials registration. NCT00096824. PMID:22661489
Dumas, Jerald E; Platt, Manu O
Cysteine cathepsins are a family of proteases identified in cancer, atherosclerosis, osteoporosis, arthritis, and a number of other diseases. As this number continues to rise, so does the need for low cost, broad use quantitative assays to detect their activity and can be translated to the clinic in the hospital or in low resource settings. Multiplex cathepsin zymography is one such assay that detects subnanomolar levels of active cathepsins K, L, S, and V in cell or tissue preparations observed as clear bands of proteolytic activity after gelatin substrate SDS-PAGE with conditions optimal for cathepsin renaturing and activity. Densitometric analysis of the zymogram provides quantitative information from this low cost assay. After systematic modifications to optimize cathepsin zymography, we describe reduced electrophoresis time from 2 h to 10 min, incubation assay time from overnight to 4 h, and reduced minimal tissue protein necessary while maintaining sensitive detection limits; an evaluation of the pros and cons of each modification is also included. We further describe image acquisition by Smartphone camera, export to Matlab, and densitometric analysis code to quantify and report cathepsin activity, adding portability and replacing large scale, darkbox imaging equipment that could be cost prohibitive in limited resource settings.
Dumas, Jerald E.; Platt, Manu O.
Cysteine cathepsins are a family of proteases identified in cancer, atherosclerosis, osteoporosis, arthritis and a number of other diseases. As this number continues to rise, so does the need for low cost, broad use quantitative assays to detect their activity and can be translated to the clinic in the hospital or in low resource settings. Multiplex cathepsin zymography is one such assay that detects subnanomolar levels of active cathepsins K, L, S, and V in cell or tissue preparations observed as cleared bands of proteolytic activity after gelatin substrate SDS-PAGE with conditions optimal for cathepsin renaturing and activity. Densitometric analysis of the zymogram provides quantitative information from this low cost assay. After systematic modifications to optimize cathepsin zymography, we describe reduced electrophoresis time from 2 hours to 10 minutes, incubation assay time from overnight to 4 hours, and reduced minimal tissue protein necessary while maintaining sensitive detection limits; an evaluation of the pros and cons of each modification is also included. We further describe image acquisition by smartphone camera, export to Matlab, and densitometric analysis code to quantify and report cathepsin activity, adding portability and replacing large scale, darkbox imaging equipment that could be cost prohibitive in limited resource settings. PMID:23532386
Methods of analysis by the U.S. Geological Survey National Water Quality Laboratory; determination of 86 volatile organic compounds in water by gas chromatography/mass spectrometry, including detections less than reporting limits
Connor, Brooke F.; Rose, Donna L.; Noriega, Mary C.; Murtaugh, Lucinda K.; Abney, Sonja R.
This report presents precision and accuracy data for volatile organic compounds (VOCs) in the nanogram-per-liter range, including aromatic hydrocarbons, reformulated fuel components, and halogenated hydrocarbons using purge and trap capillary-column gas chromatography/mass spectrometry. One-hundred-four VOCs were initially tested. Of these, 86 are suitable for determination by this method. Selected data are provided for the 18 VOCs that were not included. This method also allows for the reporting of semiquantitative results for tentatively identified VOCs not included in the list of method compounds. Method detection limits, method performance data, preservation study results, and blank results are presented. The authors describe a procedure for reporting low-concentration detections at less than the reporting limit. The nondetection value (NDV) is introduced as a statistically defined reporting limit designed to limit false positives and false negatives to less than 1 percent. Nondetections of method compounds are reported as ?less than NDV.? Positive detections measured at less than NDV are reported as estimated concentrations to alert the data user to decreased confidence in accurate quantitation. Instructions are provided for analysts to report data at less than the reporting limits. This method can support the use of either method reporting limits that censor detections at lower concentrations or the use of NDVs as reporting limits. The data-reporting strategy for providing analytical results at less than the reporting limit is a result of the increased need to identify the presence or absence of environmental contaminants in water samples at increasingly lower concentrations. Long-term method detection limits (LTMDLs) for 86 selected compounds range from 0.013 to 2.452 micrograms per liter (?g/L) and differ from standard method detection limits (MDLs) in that the LTMDLs include the long-term variance of multiple instruments, multiple operators, and multiple
The REVAMP trial to evaluate HIV resistance testing in sub-Saharan Africa: a case study in clinical trial design in resource limited settings to optimize effectiveness and cost effectiveness estimates.
Siedner, Mark J; Bwana, Mwebesa B; Moosa, Mahomed-Yunus S; Paul, Michelle; Pillay, Selvan; McCluskey, Suzanne; Aturinda, Isaac; Ard, Kevin; Muyindike, Winnie; Moodley, Pravikrishnen; Brijkumar, Jaysingh; Rautenberg, Tamlyn; George, Gavin; Johnson, Brent; Gandhi, Rajesh T; Sunpath, Henry; Marconi, Vincent C
In sub-Saharan Africa, rates of sustained HIV virologic suppression remain below international goals. HIV resistance testing, while common in resource-rich settings, has not gained traction due to concerns about cost and sustainability. We designed a randomized clinical trial to determine the feasibility, effectiveness, and cost-effectiveness of routine HIV resistance testing in sub-Saharan Africa. We describe challenges common to intervention studies in resource-limited settings, and strategies used to address them, including: (1) optimizing generalizability and cost-effectiveness estimates to promote transition from study results to policy; (2) minimizing bias due to patient attrition; and (3) addressing ethical issues related to enrollment of pregnant women. The study randomizes people in Uganda and South Africa with virologic failure on first-line therapy to standard of care virologic monitoring or immediate resistance testing. To strengthen external validity, study procedures are conducted within publicly supported laboratory and clinical facilities using local staff. To optimize cost estimates, we collect primary data on quality of life and medical resource utilization. To minimize losses from observation, we collect locally relevant contact information, including Whatsapp account details, for field-based tracking of missing participants. Finally, pregnant women are followed with an adapted protocol which includes an increased visit frequency to minimize risk to them and their fetuses. REVAMP is a pragammatic randomized clinical trial designed to test the effectiveness and cost-effectiveness of HIV resistance testing versus standard of care in sub-Saharan Africa. We anticipate the results will directly inform HIV policy in sub-Saharan Africa to optimize care for HIV-infected patients.
van Dijk, Janneke H; Sutcliffe, Catherine G; Hamangaba, Francis; Bositis, Christopher; Watson, Douglas C; Moss, William J
Antiretroviral treatment (ART) options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV). Using available pharmacokinetic data, an EFV dosing schedule was developed for young co-infected children and implemented as the standard of care at Macha Hospital in Southern Province, Zambia. Treatment outcomes in children younger than 3 years of age or weighing less than 10 kg receiving either EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP) ART were compared. Treatment outcomes were measured in a cohort of HIV-infected children seeking care at Macha Hospital in rural Zambia from 2007 to 2010. Information on the diagnosis and treatment of tuberculosis was abstracted from medical records. Forty-five children treated for tuberculosis initiated an EFV-based regimen and 69 children initiated a NVP-based regimen, 7 of whom also were treated for tuberculosis. Children receiving both regimens were comparable in age, but children receiving EFV started ART with a lower CD4(+) T-cell percentage and weight-for-age z-score. Children receiving EFV experienced increases in both CD4(+) T-cell percentage and weight-for-age z-score during follow-up, such that levels were comparable to children receiving NVP after two years of ART. Cumulative survival after 12 months of ART did not differ between groups (NVP:87%;EFV:80%;p = 0.25). Eleven children experienced virologic failure during follow-up.The adjusted hazard ratio of virologic failure comparing EFV to NVP was 0.25 (95% CI:0.05,1.24) and 0.13 (95% CI:0.03,0.62) using thresholds of 5000 and 400 copies/mL, respectively.Five children receiving EFV were reported to have had convulsions after ART initiation compared to only one child receiving NVP (p = 0.04). Despite poorer health at ART initiation, children treated for tuberculosis and receiving EFV-based regimens showed significant improvements comparable to children
Janneke H van Dijk
Full Text Available Antiretroviral treatment (ART options for young children co-infected with HIV and tuberculosis are limited in resource-poor settings due to limited data on the use of efavirenz (EFV. Using available pharmacokinetic data, an EFV dosing schedule was developed for young co-infected children and implemented as the standard of care at Macha Hospital in Southern Province, Zambia. Treatment outcomes in children younger than 3 years of age or weighing less than 10 kg receiving either EFV-based ART plus anti-tuberculous treatment or nevirapine-based (NVP ART were compared.Treatment outcomes were measured in a cohort of HIV-infected children seeking care at Macha Hospital in rural Zambia from 2007 to 2010. Information on the diagnosis and treatment of tuberculosis was abstracted from medical records.Forty-five children treated for tuberculosis initiated an EFV-based regimen and 69 children initiated a NVP-based regimen, 7 of whom also were treated for tuberculosis. Children receiving both regimens were comparable in age, but children receiving EFV started ART with a lower CD4(+ T-cell percentage and weight-for-age z-score. Children receiving EFV experienced increases in both CD4(+ T-cell percentage and weight-for-age z-score during follow-up, such that levels were comparable to children receiving NVP after two years of ART. Cumulative survival after 12 months of ART did not differ between groups (NVP:87%;EFV:80%;p = 0.25. Eleven children experienced virologic failure during follow-up.The adjusted hazard ratio of virologic failure comparing EFV to NVP was 0.25 (95% CI:0.05,1.24 and 0.13 (95% CI:0.03,0.62 using thresholds of 5000 and 400 copies/mL, respectively.Five children receiving EFV were reported to have had convulsions after ART initiation compared to only one child receiving NVP (p = 0.04.Despite poorer health at ART initiation, children treated for tuberculosis and receiving EFV-based regimens showed significant improvements comparable to children
© 2015, Springer-Verlag Berlin Heidelberg. In this paper we analyse stochastic models of the competition between two resource-limited cell populations which differ in their response to nutrient availability: the resident population exhibits a switch-like response behaviour while the invading population exhibits a bistable response. We investigate how noise in the intracellular regulatory pathways and cell motility influence the fate of the incumbent and invading populations. We focus initially on a spatially homogeneous system and study in detail the role of intracellular noise. We show that in such well-mixed systems, two distinct regimes exist: In the low (intracellular) noise limit, the invader has the ability to invade the resident population, whereas in the high noise regime competition between the two populations is found to be neutral and, in accordance with neutral evolution theory, invasion is a random event. Careful examination of the system dynamics leads us to conclude that (i) even if the invader is unable to invade, the distribution of survival times, PS(t), has a fat-tail behaviour (PS(t)∼t-1) which implies that small colonies of mutants can coexist with the resident population for arbitrarily long times, and (ii) the bistable structure of the invading population increases the stability of the latent population, thus increasing their long-term likelihood of survival, by decreasing the intensity of the noise at the population level. We also examine the effects of spatial inhomogeneity. In the low noise limit we find that cell motility is positively correlated with the aggressiveness of the invader as defined by the time the invader takes to invade the resident population: the faster the invasion, the more aggressive the invader.
Jonas, Stephan Michael; Deserno, Thomas Martin; Buhimschi, Catalin Sorin; Makin, Jennifer; Choma, Michael Andrew; Buhimschi, Irina Alexandra
Morbidity and mortality due to preeclampsia in settings with limited resources often results from delayed diagnosis. The Congo Red Dot (CRD) test, a simple modality to assess the presence of misfolded proteins in urine, shows promise as a diagnostic and prognostic tool for preeclampsia. We propose an innovative mobile health (mHealth) solution that enables the quantification of the CRD test as a batch laboratory test, with minimal cost and equipment. A smartphone application that guides the user through seven easy steps, and that can be used successfully by non-specialized personnel, was developed. After image acquisition, a robust analysis runs on a smartphone, quantifying the CRD test response without the need for an internet connection or additional hardware. In the first stage, the basic image processing algorithms and supporting test standardizations were developed using urine samples from 218 patients. In the second stage, the standardized procedure was evaluated on 328 urine specimens from 273 women. In the third stage, the application was tested for robustness using four different operators and 94 altered samples. In the first stage, the image processing chain was set up with high correlation to manual analysis (z-test P < 0.001). In the second stage, a high agreement between manual and automated processing was calculated (Lin's concordance coefficient ρc = 0.968). In the last stage, sources of error were identified and remedies were developed accordingly. Altered samples resulted in an acceptable concordance with the manual gold-standard (Lin's ρc = 0.914). Combining smartphone-based image analysis with molecular-specific disease features represents a cost-effective application of mHealth that has the potential to fill gaps in access to health care solutions that are critical to reducing adverse events in resource-poor settings. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights
Ssengooba, Willy; Gelderbloem, Sebastian J; Mboowa, Gerald; Wajja, Anne; Namaganda, Carolyn; Musoke, Philippa; Mayanja-Kizza, Harriet; Joloba, Moses Lutaakome
Despite the recent innovations in tuberculosis (TB) and multi-drug resistant TB (MDR-TB) diagnosis, culture remains vital for difficult-to-diagnose patients, baseline and end-point determination for novel vaccines and drug trials. Herein, we share our experience of establishing a BSL-3 culture facility in Uganda as well as 3-years performance indicators and post-TB vaccine trials (pioneer) and funding experience of sustaining such a facility. Between September 2008 and April 2009, the laboratory was set-up with financial support from external partners. After an initial procedure validation phase in parallel with the National TB Reference Laboratory (NTRL) and legal approvals, the laboratory registered for external quality assessment (EQA) from the NTRL, WHO, National Health Laboratories Services (NHLS), and the College of American Pathologists (CAP). The laboratory also instituted a functional quality management system (QMS). Pioneer funding ended in 2012 and the laboratory remained in self-sustainability mode. The laboratory achieved internationally acceptable standards in both structural and biosafety requirements. Of the 14 patient samples analyzed in the procedural validation phase, agreement for all tests with NTRL was 90% (P 80% in all years from NTRL, CAP, and NHLS, and culture was 100% for CAP panels and above regional average scores for all years with NHLS. Quarterly DST scores from WHO-EQA ranged from 78% to 100% in 2010, 80% to 100% in 2011, and 90 to 100% in 2012. From our experience, it is feasible to set-up a BSL-3 TB culture laboratory with acceptable quality performance standards in resource-limited countries. With the demonstrated quality of work, the laboratory attracted more research groups and post-pioneer funding, which helped to ensure sustainability. The high skilled experts in this research laboratory also continue to provide an excellent resource for the needed national discussion of the laboratory and quality management systems.
Lawn Stephen D
Full Text Available Abstract Background Viral load monitoring is not available for the vast majority of patients receiving antiretroviral therapy in resource-limited settings. However, the practical utility of CD4 cell count measurements as an alternative monitoring strategy has not been rigorously assessed. Methods In this study, we used a novel modelling approach that accounted for all CD4 cell count and VL values measured during follow-up from the first date that VL suppression was achieved. We determined the associations between CD4 counts (absolute values and changes during ART, VL measurements and risk of virological failure (VL > 1,000 copies/ml following initial VL suppression in 330 patients in South Africa. CD4 count changes were modelled both as the difference from baseline (ΔCD4 count and the difference between consecutive values (CD4 count slope using all 3-monthly CD4 count measurements during follow-up. Results During 7093.2 patient-months of observation 3756 paired CD4 count and VL measurements were made. In patients who developed virological failure (n = 179, VL correlated significantly with absolute CD4 counts (r = - 0.08, P = 0.003, ΔCD4 counts (r = - 0.11, P P P = 0.99, P = 0.92 and P = 0.75, respectively. Moreover, in a receiver operating characteristic (ROC curve, the association between a negative CD4 count slope and virological failure was poor (area under the curve = 0.59; sensitivity = 53.0%; specificity = 63.6%; positive predictive value = 10.9%. Conclusion CD4 count changes correlated significantly with VL at group level but had very limited utility in identifying virological failure in individual patients. CD4 count is an inadequate alternative to VL measurement for early detection of virological failure.
Busari, Jamiu O; Duits, Ashley J
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. 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. 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.
Moyo, B; Masika, P J
A survey to document tick control methods used by resource-limited farmers in the control of cattle ticks in the Eastern Cape Province of South Africa was conducted by interviewing 59 cattle farmers using structured questionnaires and general conversation. Information collected was on external parasites of cattle, their effects and their control methods. Ticks were reported to be a major problem causing diseases like anaplasmosis (89.8%), babesiosis (55.9%) and ehrlichiosis (16.9%), as well as wounds that predispose to screwworm infestation, tick worry and teat damage to cows troubling farmers in their farming enterprises. The main tick control methods were; acaricides provided by government, however 94.9% of the farmers interviewed were of the opinion that the dip wash is not effective in killing the ticks. As a result, farmers complement the government dipping service with their own initiatives like spraying with conventional acaricides (22%), household disinfectants such as Jeyes fluid (18.6%), used engine oil (10.2%), chickens (5.1%), manual removal (5.1%), and pouricides (1.7%). In addition, some farmers also use plants (6.8%), mainly the leaf of Aloe ferox and the bark of Ptaeroxylon obliquum. The study revealed ticks to be a major problem in the study area.
Ondiek, Johnson; Namukaya, Zikulah; Mtapuri-Zinyowera, Sekesai; Balkan, Suna; Elbireer, Ali; Ushiro Lumb, Ines; Kiyaga, Charles; Goel, Neha; Ritchie, Allyson; Ncube, Patience; Omuomu, Kenneth; Ndiege, Kenneth; Kekitiinwa, Adeodata; Mangwanya, Douglas; Fowler, Mary G; Nadala, Lou; Lee, Helen
Early diagnosis of HIV-1 infection and the prompt initiation of antiretroviral therapy are critical to achieving a reduction in the morbidity and mortality of infected infants. The Simple AMplification-Based Assay (SAMBA) HIV-1 Qual Whole Blood Test was developed specifically for early infant diagnosis and prevention of mother-to-child transmission programs implemented at the point-of-care in resource-limited settings. We have evaluated the performance of this test run on the SAMBA I semiautomated platform with fresh whole blood specimens collected from 202 adults and 745 infants in Kenya, Uganda, and Zimbabwe. Results were compared with those obtained with the Roche COBAS AmpliPrep/COBAS TaqMan (CAP/CTM) HIV-1 assay as performed with fresh whole blood or dried blood spots of the same subjects, and discrepancies were resolved with alternative assays. The performance of the SAMBA and CAP/CTM assays evaluated at 5 laboratories in the 3 countries was similar for both adult and infant samples. The clinical sensitivity, specificity, positive predictive value, and negative predictive value for the SAMBA test were 100%, 99.2%, 98.7%, and 100%, respectively, with adult samples, and 98.5%, 99.8%, 99.7%, and 98.8%, respectively, with infant samples. Our data suggest that the SAMBA HIV-1 Qual Whole Blood Test would be effective for early diagnosis of HIV-1 infection in infants at point-of-care settings in sub-Saharan Africa.
Kibadi, K; Moutet, F
The authors describe their experience using silicone infusion tubing in place of Hunter rods for two-stage zone 2 flexor tendon reconstruction in a resource-limited surgical environment. This case report features a 47-year-old, right-handed man who had no active PIP and DIP joint flexion in four fingers of the right hand 5 months after an injury. During the first repair stage, the A2 and A4 pulleys were reconstructed using an extensor retinaculum graft. An infusion tube was inserted instead of Hunter rods. During the second stage, formation of a digital neo-canal around the infusion tubing was observed. The infusion tubing was removed and replaced with a palmaris longus tendon graft according to the conventional technique. Physiotherapy and rehabilitation followed surgery. At 6 months, very significant progress had been made with complete recovery of PIP and DIP flexion in the four fingers. Copyright © 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Chidambaram, Swathi; Vasudevan, Madabushi Chakravarthy; Nair, Mani Nathan; Joyce, Cara; Germanwala, Anand V
Postoperative central nervous system infections (PCNSIs) are serious complications following neurosurgical intervention. We previously investigated the incidence and causative pathogens of PCNSIs at a resource-limited, neurosurgical center in south Asia. This follow-up study was conducted to analyze differences in PCNSIs at the same institution following only one apparent change: the operating room air filtration system. This was a retrospective study of all neurosurgical cases performed between December 1, 2013, and March 31, 2016 at our center. Providers, patient demographic data, case types, perioperative care, rate of PCNSI, and rates of other complications were reviewed. These results were then compared with the findings of our previous study of neurosurgical cases between June 1, 2012, and June 30, 2013. All 623 neurosurgical operative cases over the study period were reviewed. Four patients (0.6%) had a PCNSI, and no patients had a positive cerebrospinal fluid (CSF) culture. In the previous study, among 363 cases, 71 patients (19.6%) had a PCNSI and 7 (1.9%) had a positive CSF culture (all Gram-negative organisms). The differences in both parameters are statistically significant (P system inside the neurosurgical operating rooms; this environmental change occurred during the 5 months between the 2 studies. This study demonstrates the impact of environmental factors in reducing infections. Copyright © 2017 Elsevier Inc. All rights reserved.
Eleje, George U; Adinma, Joseph I; Ghasi, Samuel; Ikechebelu, Joseph I; Igwegbe, Anthony O; Okonkwo, John E; Okafor, Charles I; Ezeama, Chukwuemeka O; Ezebialu, Ifeanyichukwu U; Ogbuagu, Chukwuanugo N
To identify microbes prevalent in the genital tract of pregnant women with preterm premature rupture of membranes (PPROM) and to assess the susceptibility of the microbial isolates to a range of antibiotics to determine appropriate antibiotics for treating cases of PPROM in resource-limited settings. A prospective cross-sectional study was undertaken involving women with (n=105) and without (n=105) a confirmed diagnosis of PPROM admitted to Nnamdi Azikiwe University Teaching Hospital, southeast Nigeria, between January 1, 2011, and April 30, 2013. Endocervical swabs were collected from all participants and examined microbiologically. Antibiotic sensitivity testing was performed using Kirby-Bauer disk diffusion. Streptococcus spp., Staphylococcus aureus, and Escherichia coli were significantly more prevalent among women with PPROM than among those without PPROM (P<0.01). Among the antibiotics considered safe to use during pregnancy, the bacteria were most sensitive to ampicillin-sulbactam, cefixime, cefuroxime, and erythromycin. For the first 48hours, women with PPROM should receive an intravenous dose combining ampicillin-sulbactam, cefixime, cefuroxime, or erythromycin with metronidazole followed by oral administration of the chosen antibiotic combination to complete a 7-day course. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Electronic resources access and usage among the postgraduates of a Nigerian University of Technology. ... by postgraduates in using e-resources include takes too much time to find, e-resources are not always accessible, lack of supporting structures (connection, downloading, printing limits) and too many resources.
... available information, including, but not limited to, information from the State Historic Preservation... 30 Mineral Resources 3 2010-07-01 2010-07-01 false General environmental resources information... INFORMATION ON ENVIRONMENTAL RESOURCES § 783.12 General environmental resources information. Each application...
Full Text Available Commercially available HIV-1 drug resistance (HIVDR genotyping assays are expensive and have limitations in detecting non-B subtypes and circulating recombinant forms that are co-circulating in resource-limited settings (RLS. This study aimed to optimize a low cost and broadly sensitive in-house assay in detecting HIVDR mutations in the protease (PR and reverse transcriptase (RT regions of pol gene. The overall plasma genotyping sensitivity was 95.8% (N = 96. Compared to the original in-house assay and two commercially available genotyping systems, TRUGENE® and ViroSeq®, the optimized in-house assay showed a nucleotide sequence concordance of 99.3%, 99.6% and 99.1%, respectively. The optimized in-house assay was more sensitive in detecting mixture bases than the original in-house (N = 87, P<0.001 and TRUGENE® and ViroSeq® assays. When the optimized in-house assay was applied to genotype samples collected for HIVDR surveys (N = 230, all 72 (100% plasma and 69 (95.8% of the matched dried blood spots (DBS in the Vietnam transmitted HIVDR survey were genotyped and nucleotide sequence concordance was 98.8%; Testing of treatment-experienced patient plasmas with viral load (VL ≥ and <3 log10 copies/ml from the Nigeria and Malawi surveys yielded 100% (N = 46 and 78.6% (N = 14 genotyping rates, respectively. Furthermore, all 18 matched DBS stored at room temperature from the Nigeria survey were genotyped. Phylogenetic analysis of the 236 sequences revealed that 43.6% were CRF01_AE, 25.9% subtype C, 13.1% CRF02_AG, 5.1% subtype G, 4.2% subtype B, 2.5% subtype A, 2.1% each subtype F and unclassifiable, 0.4% each CRF06_CPX, CRF07_BC and CRF09_CPX.The optimized in-house assay is broadly sensitive in genotyping HIV-1 group M viral strains and more sensitive than the original in-house, TRUGENE® and ViroSeq® in detecting mixed viral populations. The broad sensitivity and substantial reagent cost saving make this assay more accessible
Zhou, Zhiyong; Wagar, Nick; DeVos, Joshua R; Rottinghaus, Erin; Diallo, Karidia; Nguyen, Duc B; Bassey, Orji; Ugbena, Richard; Wadonda-Kabondo, Nellie; McConnell, Michelle S; Zulu, Isaac; Chilima, Benson; Nkengasong, John; Yang, Chunfu
Commercially available HIV-1 drug resistance (HIVDR) genotyping assays are expensive and have limitations in detecting non-B subtypes and circulating recombinant forms that are co-circulating in resource-limited settings (RLS). This study aimed to optimize a low cost and broadly sensitive in-house assay in detecting HIVDR mutations in the protease (PR) and reverse transcriptase (RT) regions of pol gene. The overall plasma genotyping sensitivity was 95.8% (N = 96). Compared to the original in-house assay and two commercially available genotyping systems, TRUGENE® and ViroSeq®, the optimized in-house assay showed a nucleotide sequence concordance of 99.3%, 99.6% and 99.1%, respectively. The optimized in-house assay was more sensitive in detecting mixture bases than the original in-house (N = 87, P<0.001) and TRUGENE® and ViroSeq® assays. When the optimized in-house assay was applied to genotype samples collected for HIVDR surveys (N = 230), all 72 (100%) plasma and 69 (95.8%) of the matched dried blood spots (DBS) in the Vietnam transmitted HIVDR survey were genotyped and nucleotide sequence concordance was 98.8%; Testing of treatment-experienced patient plasmas with viral load (VL) ≥ and <3 log10 copies/ml from the Nigeria and Malawi surveys yielded 100% (N = 46) and 78.6% (N = 14) genotyping rates, respectively. Furthermore, all 18 matched DBS stored at room temperature from the Nigeria survey were genotyped. Phylogenetic analysis of the 236 sequences revealed that 43.6% were CRF01_AE, 25.9% subtype C, 13.1% CRF02_AG, 5.1% subtype G, 4.2% subtype B, 2.5% subtype A, 2.1% each subtype F and unclassifiable, 0.4% each CRF06_CPX, CRF07_BC and CRF09_CPX. The optimized in-house assay is broadly sensitive in genotyping HIV-1 group M viral strains and more sensitive than the original in-house, TRUGENE® and ViroSeq® in detecting mixed viral populations. The broad sensitivity and substantial reagent cost saving make this assay more accessible for
Full Text Available Purpose: Pediatric medulloblastoma (MB treatment has evolved over the past few decades; however, treating children in countries with limited resources remains challenging. Until now, the literature regarding childhood MB in Malaysia has been nonexistent. Our objectives were to review the demographics and outcome of pediatric MB treated at the University Malaya Medical Center between January 1994 and December 2013 and describe the challenges encountered. Methods: Fifty-one patients with childhood MB were seen at University Malaya Medical Center. Data from 43 patients were analyzed; eight patients were excluded because their families refused treatment after surgery. Results: Headache and vomiting were the most common presenting symptoms, and the mean interval between symptom onset and diagnosis was 4 weeks. Fourteen patients presented with metastatic disease. Five-year progression-free survival (± SE for patients ≥ 3 years old was 41.7% ± 14.2% (95% CI, 21.3% to 81.4% in the high-risk group and 68.6% ± 18.6% (95% CI, 40.3% to 100% in the average-risk group, and 5-year overall survival (± SE in these two groups was 41.7% ± 14.2% (95% CI, 21.3% to 81.4% and 58.3% ± 18.6% (95% CI, 31.3% to 100%, respectively. Children younger than 3 years old had 5-year progression-free and overall survival rates (± SE of 47.6% ± 12.1% (95% CI, 28.9% to 78.4% and 45.6% ± 11.7% (95% CI, 27.6% to 75.5%, respectively. Time to relapse ranged from 4 to 132 months. Most patients who experienced relapse died within 1 year. Febrile neutropenia, hearing loss, and endocrinopathy were the most common treatment-related complications. Conclusion: The survival rate of childhood MB in Malaysia is inferior to that usually reported in the literature. We postulate that the following factors contribute to this difference: lack of a multidisciplinary neuro-oncology team, limited health care facilities, inconsistent risk assessment, insufficient data in the National Cancer
Rajagopal, Revathi; Abd-Ghafar, Sayyidatul; Ganesan, Dharmendra; Bustam Mainudin, Anita Zarina; Wong, Kum Thong; Ramli, Norlisah; Jawin, Vida; Lum, Su Han; Yap, Tsiao Yi; Bouffet, Eric; Qaddoumi, Ibrahim; Krishnan, Shekhar; Ariffin, Hany; Abdullah, Wan Ariffin
Pediatric medulloblastoma (MB) treatment has evolved over the past few decades; however, treating children in countries with limited resources remains challenging. Until now, the literature regarding childhood MB in Malaysia has been nonexistent. Our objectives were to review the demographics and outcome of pediatric MB treated at the University Malaya Medical Center between January 1994 and December 2013 and describe the challenges encountered. Fifty-one patients with childhood MB were seen at University Malaya Medical Center. Data from 43 patients were analyzed; eight patients were excluded because their families refused treatment after surgery. Headache and vomiting were the most common presenting symptoms, and the mean interval between symptom onset and diagnosis was 4 weeks. Fourteen patients presented with metastatic disease. Five-year progression-free survival (± SE) for patients ≥ 3 years old was 41.7% ± 14.2% (95% CI, 21.3% to 81.4%) in the high-risk group and 68.6% ± 18.6% (95% CI, 40.3% to 100%) in the average-risk group, and 5-year overall survival (± SE) in these two groups was 41.7% ± 14.2% (95% CI, 21.3% to 81.4%) and 58.3% ± 18.6% (95% CI, 31.3% to 100%), respectively. Children younger than 3 years old had 5-year progression-free and overall survival rates (± SE) of 47.6% ± 12.1% (95% CI, 28.9% to 78.4%) and 45.6% ± 11.7% (95% CI, 27.6% to 75.5%), respectively. Time to relapse ranged from 4 to 132 months. Most patients who experienced relapse died within 1 year. Febrile neutropenia, hearing loss, and endocrinopathy were the most common treatment-related complications. The survival rate of childhood MB in Malaysia is inferior to that usually reported in the literature. We postulate that the following factors contribute to this difference: lack of a multidisciplinary neuro-oncology team, limited health care facilities, inconsistent risk assessment, insufficient data in the National Cancer Registry and pathology reports, inadequate long
Rosati, Adolfo; Paoletti, Andrea; Al Hariri, Raeed; Morelli, Alessio; Famiani, Franco
It has long been debated whether tree growth is source limited, or whether photosynthesis is adjusted to the actual sink demand, directly regulated by internal and environmental factors. Many studies support both possibilities, but no studies have provided quantitative data at the whole-tree level, across different cultivars and fruit load treatments. This study investigated the effect of different levels of reproductive growth on whole-tree biomass growth across two olive cultivars with different growth rates (i.e., Arbequina, slow-growing and Frantoio, fast-growing), over 2 years. Young trees of both cultivars were completely deflowered either in 2014, 2015, both years or never, providing a range of levels of cumulated reproductive growth over the 2 years. Total vegetative dry matter growth over the 2 years was assessed by destructive sampling (whole tree). Vegetative growth increased significantly less in fruiting trees, however, the total of vegetative and reproductive growth did not differ significantly for any treatment or cultivar. Vegetative growth over the 2 years was closely (R2 = 0.89) and inversely related to reproductive growth across all treatments and cultivars. When using data from 2015 only, the regression improved further (i.e., R2 = 0.99). When biomass was converted into grams of glucose equivalents, based on the chemical composition of the different parts, the results indicated that for every gram of glucose equivalent invested in reproductive growth, vegetative growth was reduced by 0.73-0.78 g of glucose equivalent. This indicates that competition for resources played a major role in determining tree growth, but also that photosynthesis was probably also enhanced at increasing fruit load (or downregulated at decreasing fruit load). The leaf area per unit of trunk cross sectional area increased with deflowering (i.e., decreased with reproductive growth), suggesting that water relations might have limited photosynthesis in deflowered plants
Udupa, K S; Rajendranath, R; Sagar, T G; Sundersingh, S; Joseph, T
Tyrosine kinase inhibitors have revolutionized the treatment of metastatic lung cancer in patients with epidermal growth factor receptor (EGFR) mutations. Amplified refractory mutation system (ARMS)-reverse transcription-polymerase chain reaction (RT-PCR), the current standard for detecting EGFR mutation status is time-consuming and highly expensive. Consequently any surrogate test which are cheaper, faster and as accurate as the PCR method will help in early diagnosis and management of patients with lung cancer, especially in resource-limited settings. Eighty-five patients, all of South Indian origin, with adenocarcinoma of lung, registered between October 2009 and January 2013, were evaluated for EGFR mutation status by using scorpion probe based ARMS RT-PCR method. Immunohistochemical (IHC) was performed using the phosphorylated AKT (P-AKT) and thyroid transcription factor-1 (TTF-1) on above patient's sample, and the results were compared with EGFR mutation tests. EGFR mutation was positive in 34 of 85 patients (40%). P-AKT and TTF-1 were positive in 50 (58.8%) and 68 (80%) patients respectively. Both P-AKT and TTF-1 had statistically significant correlation with EGFR mutation status. Positive and negative predictive value of P-AKT in diagnosing EGFR mutation was 58% and 85.5% and that for TTF-1 was 48.5% and 94.1%, respectively. The problem of low positive predictive value can partly be overcome by testing P-AKT and TTF-1 simultaneously. P-AKT and TTF-1 using IHC had statistically significant correlation with EGFR mutation with high negative predictive value. In the case of urgency of starting treatment, EGFR mutation testing may be avoided in those patients who are negative for these IHC markers and can be started on chemotherapy.
Tagny, C. T.; Ndoumba, A.; Laperche, S.; Murphy, E.; Mbanya, D.
Background and Objectives Although interest in assessing risk of TTIs, very few trends in blood safety epidemiological data from resource-limited blood services are reported in the literature. This analysis aims at reporting trends in seroprevalences of TTIs in blood donations in the Yaoundé University Teaching Hospital (UTH) from 2011 to 2015 and to describe reasons for these changes. Materials and Methods All donations of 2015 were tested for HIV 1&2 antibodies and the P24 antigen, HBsAg, HCV antibody and the Treponema pallidum antibody. Screening for HIV uses a national algorithm based on the systematic use of two assays of different principles: a rapid determination testing assay and an EIA HIV 1 & 2 Ab-Ag. The tests used for HBsAg and HCVAb screening were all based on EIA techniques. Treponema pallidum antibody screening was based on Treponema Pallidum hemagglutination assay (TPHA) and rapid immunochromatographic test (RIT). Screening techniques and results from 2015 were compared to retrospective data from 2011, 2012, 2013 and 2014. Results In 2015, 13·4% (n = 214) of 1,596 blood donations were seropositive for at least one screened TTIs. The most frequent serological marker was HBsAg with 123 (7·7%) blood units contaminated. Nineteen (1·2%) and 18 (1·1%) blood units was positive for HIV and syphilis, respectively. There was a significant decrease in the total number of blood donations (P < 10−4) and HIV, HBsAg and syphilis seroprevalences and an increase in the proportion of voluntary non-remunerated blood donor (P < 0·05). HCVAb seroprevalence was 3·8% in 2015 and has not decreased significantly over the years (P = 0·09). Conclusion Significant progress is noted in reduction in seroprevalences of HIV, HBV, HCV and syphilis since the beginning of a regular registration of data in 1990. PMID:28484511
Abdu Kisekka Musubire
Full Text Available BackgroundNon-traumatic myelopathy is common in Africa and there are geographic differences in etiology. Clinical management is challenging due to the broad differential diagnosis and the lack of diagnostics. The objective of this systematic review is to determine the most common etiologies of non-traumatic myelopathy in sub-Saharan Africa to inform a regionally appropriate diagnostic algorithm.MethodsWe conducted a systemic review searching Medline and Embase databases using the following search terms: “Non traumatic spinal cord injury” or “myelopathy” with limitations to epidemiology or etiologies and Sub-Saharan Africa. We described the frequencies of the different etiologies and proposed a diagnostic algorithm based on the most common diagnoses.ResultsWe identified 19 studies all performed at tertiary institutions; 15 were retrospective and 13 were published in the era of the HIV epidemic. Compressive bone lesions accounted for more than 48% of the cases; a majority were Pott’s disease and metastatic disease. No diagnosis was identified in up to 30% of cases in most studies; in particular, definitive diagnoses of non-compressive lesions were rare and a majority were clinical diagnoses of transverse myelitis and HIV myelopathy. Age and HIV were major determinants of etiology.ConclusionCompressive myelopathies represent a majority of non-traumatic myelopathies in sub-Saharan Africa, and most were due to Pott’s disease. Non-compressive myelopathies have not been well defined and need further research in Africa. We recommend a standardized approach to management of non-traumatic myelopathy focused on identifying treatable conditions with tests widely available in low-resource settings.
Chalmers, Lauren; Cross, Jessica; Chu, Cindy S; Phyo, Aung Pyae; Trip, Margreet; Ling, Clare; Carrara, Verena; Watthanaworawit, Wanitda; Keereecharoen, Lily; Hanboonkunupakarn, Borimas; Nosten, François; McGready, Rose
Published literature from resource-limited settings is infrequent, although urinary tract infections (UTI) are a common cause of outpatient presentation and antibiotic use. Point-of-care test (POCT) interpretation relates to antibiotic use and antibiotic resistance. We aimed to assess the diagnostic accuracy of POCT and their role in UTI antibiotic stewardship. One-year retrospective analysis in three clinics on the Thailand-Myanmar border of non-pregnant adults presenting with urinary symptoms. POCT (urine dipstick and microscopy) were compared to culture with significant growth classified as pure growth of a single organism >10(5) CFU/ml. In 247 patients, 82.6% female, the most common symptoms were dysuria (81.2%), suprapubic pain (67.8%) and urinary frequency (53.7%). After excluding contaminated samples, UTI was diagnosed in 52.4% (97/185); 71.1% (69/97) had a significant growth on culture, and >80% of these were Escherichia coli (20.9% produced extended-spectrum β-lactamase (ESBL)). Positive urine dipstick (leucocyte esterase ≥1 and/or nitrate positive) compared against positive microscopy (white blood cell >10/HPF, bacteria ≥1/HPF, epithelial cells sensitivity (99% vs. 57%) but a lower specificity (47% vs. 89%), respectively. Combined POCT resulted in the best sensitivity (98%) and specificity (81%). Nearly one in ten patients received an antimicrobial to which the organism was not fully sensitive. One rapid, cost-effective POCT was too inaccurate to be used alone by healthcare workers, impeding antibiotic stewardship in a high ESBL setting. Appropriate prescribing is improved with concurrent use and concordant results of urine dipstick and microscopy. © 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
Intermittent detection of fetal heart rate abnormalities identify infants at greatest risk for fresh stillbirths, birth asphyxia, neonatal resuscitation, and early neonatal deaths in a limited-resource setting: a prospective descriptive observational study at Haydom Lutheran Hospital.
Langli Ersdal, Hege; Mduma, Estomih; Svensen, Erling; Sundby, Johanne; Perlman, Jeffrey
Intermittent fetal heart rate (FHR) monitoring during labor using an acoustic stethoscope is the most frequent method for fetal assessment of well-being in low- and middle-income countries. Evidence concerning reliability and efficacy of this technique is almost nonexistent. To determine the value of routine intermittent FHR monitoring during labor in the detection of FHR abnormalities, and the relationship of abnormalities to the subsequent fresh stillbirths (FSB), birth asphyxia (BA), need for neonatal face mask ventilation (FMV), and neonatal deaths within 24 h. This is a descriptive observational study in a delivery room from November 2009 through December 2011. Research assistants/observers (n = 14) prospectively observed every delivery and recorded labor information including FHR and interventions, neonatal information including responses in the delivery room, and fetal/neonatal outcomes (FSB, death within 24 h, admission neonatal area, or normal). 10,271 infants were born. FHR was abnormal (i.e. 160 beats/min) in 279 fetuses (2.7%) and absent in 200 (1.9%). Postnatal outcomes included FSB in 159 (1.5%), need for FMV in 695 (6.8%), BA (i.e. 5-min Apgar score neonatal resuscitation, BA, and neonatal death in a limited-resource setting. The likelihood of an abnormal FHR is magnified with labor complications. Copyright © 2012 S. Karger AG, Basel.
Evidence from Students’ Information Seeking Diaries Underscores the Importance of Including Librarians in Undergraduate Education. A Review of: Lee, J. Y., Paik, W., & Joo, S. (2012. Information resource selection of undergraduate students in academic search tasks. Information Research, 17(1, paper511. Retrieved 8 Aug., 2012 from http://informationr.net/ir/17-1/paper511.html
were broken down into six categories and the resources were rated on a five point scale. Librarians (4.50 were the most useful resource and lecture notes (5.0 were the most credible. Family (3.29 was the least useful, and social question and answer services, such as Yahoo! Answers, (2.62 were the least credible. Family was the most accessible and familiar resource (4.90 and 4.95 respectively. Experts (2.25 were least accessible and librarians (1.50 were the least familiar. Students were most satisfied with Google Scholar (4.33 and were most likely to use an online database (4.52 again. They were least satisfied with social question and answer services (3.05 and least likely to use a report sharing site (2.93 again. The usefulness and credibility of the resource contributed most to the undergraduates’ satisfaction with the resource, while accessibility and usefulness were the major contributing factors to users intended continued use of a resource.Conclusion – There are multiple reasons that support further information literacy education. Information literacy courses would encourage and teach students how to effectively use resources that they found credible and reliable, but considered inaccessible and unfamiliar. Information literacy education would also help educate students on how to best formulate their search strategies and how to select the best resource to use based on that strategy. Students also highlighted the importance of human interaction in resource selection and utilization. This is an opportunity for librarians and professors to play a more active role in assisting students in selecting and using the best resources to complete course assignments. Due to the limitations of this study, further research is needed to investigate the factors affecting the exclusion of resources, not only the inclusion. Future study designs should address the characteristics of the study participants themselves, such as the age and gender. The impact of the research topic
Background Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT). Methods This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods. Results The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. Conclusions District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to
Tesfaye, Brook; Atique, Suleman; Elias, Noah; Dibaba, Legesse; Shabbir, Syed-Abdul; Kebede, Mihiretu
, nearly accurate results were obtained by employing decision tree and rule induction techniques. Determinants are identified and a web-based child mortality prediction model in Ethiopian local language is developed. Thus, the result obtained could support child health intervention programs in Ethiopia where trained human resource for health is limited. Advanced classification algorithms need to be tested to come up with optimal models. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Chalya Phillipo L
Full Text Available Abstract Background Typhoid intestinal perforation is still prevalent in many developing countries. Despite the advances in the management, the outcome in these patients in resource limited countries is still very poor. This study was to review our experiences on the surgical management of typhoid intestinal perforation and to determine the prognostic factors for mortality in our local setting. Methods This was a combined retrospective and prospective study of patients who were operated for typhoid intestinal perforation at Bugando Medical Centre between August 2006 and September 2011. Data collected were analyzed using SPSS computer software version 15. Results A total of 104 patients were studied representing 8.7% of typhoid fever cases. Males were affected twice more than the females (2.6:1. Their ages ranged from 8 to 76 years with a median age of 18.5 years. The peak age incidence was in the 11-20 years age group. Fever and abdominal pain were the most common presenting symptoms and majority of the patients (80.8% perforated between within 14 days of illness. Chest and abdominal radiographs revealed pneumoperitonium in 74.7% of cases. Ultrasound showed free peritoneal collection in 85.7% of cases. Nine (10.2% patients were HIV positive with a median CD4+ count of 261 cells/μl. The perforation-surgery interval was more than 72 hours in 90(86.5% patients. The majority of patients (84.6% had single perforations and ileum was the most common part of the bowel affected occurring in 86.2% of cases. Simple closure of the perforations was the most commonly performed procedure accounting for 78.8% of cases. Postoperative complication rate was 39.4% and surgical site infection was the most frequent complication in 55.5% of cases. Mortality rate was 23.1% and it was statistically significantly associated with delayed presentation, inadequate antibiotic treatment prior to admission, shock on admission, HIV positivity, low CD4 count (P Conclusion
Amanda K Debes
Full Text Available Vibrio cholerae is endemic in South Asia and Africa where outbreaks of cholera occur widely and are particularly associated with poverty and poor sanitation. Knowledge of the genetic diversity of toxigenic V. cholerae isolates, particularly in Africa, remains scarce. The constraints in improving this understanding is not only the lack of regular cholera disease surveillance, but also the lack of laboratory capabilities in endemic countries to preserve, store and ship isolates in a timely manner. We evaluated the use of simplified sample preservation methods for molecular characterization using multi-locus variable-number tandem-repeat analysis (MLVA for differentiation of Vibrio cholerae genotypes.Forty-seven V. cholerae isolates and 18 enriched clinical specimens (e.g. stool specimens after enrichment in broth from cholera outbreaks in Cameroon were preserved on Whatman filter paper for DNA extraction. The samples were collected from two geographically distinct outbreaks in the Far North of Cameroon (FNC in June 2014 and October 2014. In addition, a convenience sample of 14 isolates from the Philippines and 8 from Mozambique were analyzed. All 87 DNAs were successfully analyzed including 16 paired samples, one a cultured isolate and the other the enriched specimen from which the isolate was collected. Genotypic results were identical between 15 enriched specimens and their culture isolates and the other pair differed at single locus. Two closely related, but distinct clonal complexes were identified among the Cameroonian specimens from 2014.Collecting V. cholerae using simplified laboratory methods in remote and low-resource settings allows for subsequent advanced molecular characterization of V. cholerae O1. These simplified DNA preservation methods identify V. cholerae and make possible timely information regarding the genetic diversity of V. cholerae; our results set the stage for continued molecular epidemiological research to better
A geometrically exact Cosserat shell-model including size effects, avoiding degeneracy in the thin shell limit. Part I: Formal dimensional reduction for elastic plates and existence of minimizers for positive Cosserat couple modulus
This contribution is concerned with a consistent formal dimensional reduction of a previously introduced finite-strain three-dimensional Cosserat micropolar elasticity model to the two-dimensional situation of thin plates and shells. Contrary to the direct modelling of a shell as a Cosserat surface with additional directors, we obtain the shell model from the Cosserat bulk model which already includes a triad of rigid directors. The reduction is achieved by assumed kinematics, quadratic through the thickness. The three-dimensional transverse boundary conditions can be evaluated analytically in terms of the assumed kinematics and determines exactly two appearing coefficients in the chosen ansatz. Further simplifications with subsequent analytical integration through the thickness determine the reduced model in a variational setting. The resulting membrane energy turns out to be a quadratic, elliptic, first order, non degenerate energy in contrast to classical approaches. The bending contribution is augmented by a curvature term representing an additional stiffness of the Cosserat model and the corresponding system of balance equations remains of second order. The lateral boundary conditions for simple support are non-standard. The model includes size-effects, transverse shear resistance, drilling degrees of freedom and accounts implicitly for thickness extension and asymmetric shift of the midsurface. The formal thin shell “membrane” limit without classical h 3-bending term is non-degenerate due to the additional Cosserat curvature stiffness and control of drill rotations. In our formulation, the drill-rotations are strictly related to the size-effects of the bulk model and not introduced artificially for numerical convenience. Upon linearization with zero Cosserat couple modulus μ_c = 0 we recover the well known infinitesimal-displacement Reissner-Mindlin model without size-effects and without drill-rotations. It is shown that the dimensionally reduced
Ngambi, Peslie G; Kalungia, Aubrey C; Law, Michael R; Kalemeera, Francis; Truter, IIse; Godman, Brian; Munkombwe, Derick
The 2016 World Health Organization (WHO) consolidated guideline recommends lifelong antiretroviral therapy (ART) for all HIV-infected pregnant and breastfeeding women for preventing mother-to-child HIV transmission (PMTCT). Ambiguity remains about the cost-effectiveness of this strategy in resource-limited developing countries. Areas covered: We reviewed model-based studies on the cost-effectiveness of lifelong ART (formerly Option B+) relative to previous WHO guidelines for PMTCT. Our search using PubMed, Medline and Google Scholar for articles on Option B+ resulted in the final inclusion of seven studies published between 2012 and 2016. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to assess the quality of reporting. Outcomes of interest, which included infant infections averted, maternal quality and length of life, and the Incremental Cost Effectiveness Ratio (ICER), were used in comparing cost-effectiveness. Expert commentary: Despite most model-based studies favouring lifelong ART (Option B+) in terms of its cost-effectiveness in comparison to Options A and B, inclusiveness of the evidence remains weak for generalization. This is largely because setting specificity for providing lifelong ART to all pregnant and breastfeeding women may differ significantly in each setting. Consequently, future cost-effectiveness studies should be robust, setting-specific, and endeavor to assess the willingness and ability to pay of each setting.
Discussion: In this urban, low-resource, academic EC in Ethiopia, POCUS provided clinically relevant information for patient management, particularly for polytrauma, undifferentiated shock and undifferentiated dyspnea. Results have subsequently been used to develop a locally relevant emergency department ultrasound curriculum for Ethiopia’s first emergency medicine residency program.
Byström, P.; Andersson, J.; Persson, L.; de Roos, A.M.
Variation in growth and habitat use is closely connected to individual responses to habitat specific resource levels and predation risk. In three mountain lakes which differed in the density of young-of-the-year (YOY) arctic char (Salvelinus alpinus), we studied the growth, diets and habitat use of
Bystrom, P.; Persson, L.; de Roos, A.M.; Andersson, J.A.
Variation in growth and habitat use is closely connected to individual responses to habitat specific resource levels and predation risk. In three mountain lakes which differed in the density of young-of-the-year (YOY) arctic char (Salvelinus alpinus), we studied the growth, diets and habitat use of
Pill, Shane; SueSee, Brendan
Many physical education curriculum frameworks include statements about the inclusion of critical inquiry processes and the development of creativity and problem-solving skills. The learning environment created by physical education can encourage or limit the application and development of the learners' cognitive resources for critical and creative…
Etheredge, Harriet; Paget, Graham
Resource constraints in developing countries compel policy makers to ration the provision of healthcare services. This article examines one such set of Guidelines: A patient dialysing in the state sector in South Africa may not refuse renal transplantation when a kidney becomes available. Refusal of transplantation can lead to exclusion from the state-funded dialysis programme. This Guideline is legally acceptable as related to Constitutional stipulations which allow for rationing healthcare resources in South Africa. Evaluating the ethical merit of the Guideline, and exploring the ethical dilemma it poses, proves a more complex task. We examine the actions of healthcare professionals as constrained by the Guideline. From a best interests framework, we argue that in these circumstances directing patient decision making (pressurising a patient to undergo renal transplantation) is not necessarily unethical or unacceptably paternalistic. We then scrutinise the guideline itself through several different ethical 'lenses'. Here, we argue that bioethics does not provide a definitive answer as to the moral merit of rationing dialysis under these circumstances, however it can be considered just in this context. We conclude by examining a potential pitfall of the Guideline: Unwilling transplant recipients may not comply with immunosuppressive medication, which raises questions for policies based on resource management and rationing. © 2014 John Wiley & Sons Ltd.
Impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach over 13 years in 51 cities of 19 limited-resource countries from Latin America, Asia, the Middle East, and Europe.
Rosenthal, Victor D; Pawar, Mandakini; Leblebicioglu, Hakan; Navoa-Ng, Josephine Anne; Villamil-Gómez, Wilmer; Armas-Ruiz, Alberto; Cuéllar, Luis E; Medeiros, Eduardo A; Mitrev, Zan; Gikas, Achilleas; Yang, Yun; Ahmed, Altaf; Kanj, Souha S; Dueñas, Lourdes; Gurskis, Vaidotas; Mapp, Trudell; Guanche-Garcell, Humberto; Fernández-Hidalgo, Rosalía; Kübler, Andrzej
To assess the feasibility and effectiveness of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene approach in 19 limited-resource countries and to analyze predictors of poor hand hygiene compliance. An observational, prospective, cohort, interventional, before-and-after study from April 1999 through December 2011. The study was divided into 2 periods: a 3-month baseline period and a 7-year follow-up period. Ninety-nine intensive care unit (ICU) members of the INICC in Argentina, Brazil, China, Colombia, Costa Rica, Cuba, El Salvador, Greece, India, Lebanon, Lithuania, Macedonia, Mexico, Pakistan, Panama, Peru, Philippines, Poland, and Turkey. Healthcare workers at 99 ICU members of the INICC. A multidimensional hand hygiene approach was used, including (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance, and (6) performance feedback. Observations were made for hand hygiene compliance in each ICU, during randomly selected 30-minute periods. A total of 149,727 opportunities for hand hygiene were observed. Overall hand hygiene compliance increased from 48.3% to 71.4% ([Formula: see text]). Univariate analysis indicated that several variables were significantly associated with poor hand hygiene compliance, including males versus females (63% vs 70%; [Formula: see text]), physicians versus nurses (62% vs 72%; [Formula: see text]), and adult versus neonatal ICUs (67% vs 81%; [Formula: see text]), among others. Adherence to hand hygiene increased by 48% with the INICC approach. Specific programs directed to improve hand hygiene for variables found to be predictors of poor hand hygiene compliance should be implemented.
Forest biomass is an abundant biomass feedstock that complements the conventional forest use of wood for paper and wood materials. It may be utilized for bioenergy production, such as heat and electricity, as well as for biofuels and a variety of bioproducts, such as industrial chemicals, textiles, and other renewable materials. The resources within the 2016 Billion-Ton Report include primary forest resources, which are taken directly from timberland-only forests, removed from the land, and taken to the roadside.
Full Text Available Background. Simulations are defined as situations where models are used for practice and to gain experience that will enhance students’ practical skills. The use of simulations in clinical skills training can stimulate deep learning and help students to bridge the gap between theory and practice in nursing. This has been revealed in many studies where simulations positively impacted on clinical decision-making and patient care, and there has been great interest in the use of simulation in nurse training. However, the introduction of technologically driven simulators, especially in resourceconstrained settings, has been met with mixed feelings. Objective. To explore the perceptions and experiences of nurse educators in using high-fidelity simulation (HFS in teaching. Methods. A qualitative case study design was utilised. Seven educators at a school of nursing, which has HFS, participated in a focus group discussion. Data were thematically analysed. Results. Four themes emerged from the educators’ experiences and perceptions. The use and benefits of HFS were generally accepted by educators. They valued its positive impact on learning outcomes in learners and the ability to simulate more complex scenarios during training. Lack of prior planning, inadequate training and lack of resources impacted negatively on the effective use and implementation of HFS. Conclusion. The results indicated that nurse educators perceived HFS as a learning pedagogy that can improve students’ learning outcomes if used effectively. They believed that to realise the potential of HFS, more support should be provided through training, the availability of necessary resources, and improved planning and organisation.
Van Hook, Daniel J.; Ljungberg, Magnus; Shaw, Robert; Ford, Mark; Aubin, Ethan; Konieczny, Eric; Lee, Daniel H.; Brown, Samuel T.
We address supporting unanticipated users and uses of limited information resources (sensors, databases, weapons - any resource intrinsically tied to digital information) in a timely and efficient fashion. Platform-centric systems often preclude users and uses not identified when the system was developed and deployed. Net-centric approaches, however, can address these problems by allowing services and information to be discovered and accessed at run-time. We have developed a resource brokering service that uses net-centric principles and semantic metadata to enable multi-domain information and resource sharing and support for unanticipated users and uses. The resource brokering service uses federated brokering agents and a modular software component framework for dynamically composing and tasking heterogeneous resources including sensors, data feeds, processors, archived data, networks, and even analysts into resilient, mission-oriented workflows. The resource brokering service is applicable to multiple sense-decide-act military domains including missile defense, space situation awareness, ISR, border protection, and cyber defense. In this paper we present a concept and architecture for resource brokering and describe current applications. Our architecture is aligned with the U.S. DoD's NCES (Net-Centric Enterprise Services).
Zhou, L.; Lemmen, K.D.; Zhang, Wei; Declerck, S.A.J.
One of the central tenets of ecological stoichiometry is that consumer growth rate is strongly determined by food phosphorus (P) content. In planktonic organisms population growth rates of zooplankton have repeatedly been shown to be reduced when fed with P-limited algal food sources. However,
Mobile Health Technology Can Objectively Capture Physical Activity (PA) Targets Among African-American Women Within Resource-Limited Communities-the Washington, D.C. Cardiovascular Health and Needs Assessment.
Thomas, S; Yingling, L; Adu-Brimpong, J; Mitchell, V; Ayers, C R; Wallen, G R; Peters-Lawrence, M; Brooks, A T; Sampson, D M; Wiley, K L; Saygbe, J; Henry, J; Johnson, A; Graham, A; Graham, L; Powell-Wiley, T M
Little is understood about using mobile health (mHealth) technology to improve cardiovascular (CV) health among African-American women in resource-limited communities. We conducted the Washington, D.C. CV Health and Needs Assessment in predominantly African-American churches in city wards 5, 7, and 8 with the lowest socioeconomic status based on community-based participatory research (CBPR) principles. The assessment measured CV health factors: body mass index (BMI), fasting blood glucose and cholesterol, blood pressure, fruit/vegetable (F/V) intake, physical activity (PA), and smoking. Participants were trained to use a PA monitoring wristband to measure 30 days of PA, wirelessly upload the PA data to hubs at the participating churches, and access their data from a church/home computer. CV health factors were compared across weight classes. Among females (N = 78; 99 % African-American; mean age = 59 years), 90 % had a BMI categorized as overweight/obese. Across weight classes, PA decreased and self-reported sedentary time (ST) increased (p ≤ 0.05). Diastolic blood pressure and glucose increased across weight classes (p ≤ 0.05); however, cholesterol, glucose, and BP were near intermediate CV health goals. Decreased PA and increased ST are potential community intervention targets for overweight and obese African-American women in resource-limited Washington D.C. areas. mHealth technology can assist in adapting CBPR intervention resources to improve PA for African-American women in resource-limited communities.
Full Text Available One of the central tenets of ecological stoichiometry is that consumer growth rate is strongly determined by food phosphorus (P content. In planktonic organisms population growth rates of zooplankton have repeatedly been shown to be reduced when fed with P-limited algal food sources. However, P-limitation may also affect other quality-related aspects of algae, such as biochemical composition or palatability. We studied the population growth, detailed life history and body elemental composition of the herbivorous rotifer, Brachionus calyciflorus, in response to three different food quality treatments: algae cultured in high phosphorus conditions (average algal molar C:P ≈ 112, ‘HP’, algae cultured in low P conditions (molar C:P ≈ 631, ‘LP’ and low-P cultured algae spiked with P just before feeding (molar C:P ≈ 113, ‘LP+P’. LP+P algae thus combined high P content with a history of growth under P-limited conditions. Total P content and the C:P ratio of rotifers in the LP+P treatment equaled those of rotifers in the HP treatment. Rotifer population growth rates were higher in HP than in LP and intermediate in the LP+P treatment. Similarly, many life history traits observed for animals in the LP+P treatment, such as somatic growth rate, age at maturity, and egg production rate were also intermediate to those observed in the LP and HP treatments. However, there were important deviations from this pattern: size at first reproduction and egg mortality in the LP+P treatment equaled the HP treatment, whereas size and development time of the first eggs equaled those of the LP treatment. Our results indicate that elemental limitation cannot fully explain reduced performance of consumers fed with P-limited algae and strongly suggest that indirect, non-stoichiometric effects of P-limitation, e.g., via changes in biochemical composition or morphology of the algae also play a major role. Furthermore, our study highlights that such indirect
Zhou, Libin; Lemmen, Kimberley D; Zhang, Wei; Declerck, Steven A J
One of the central tenets of ecological stoichiometry is that consumer growth rate is strongly determined by food phosphorus (P) content. In planktonic organisms population growth rates of zooplankton have repeatedly been shown to be reduced when fed with P-limited algal food sources. However, P-limitation may also affect other quality-related aspects of algae, such as biochemical composition or palatability. We studied the population growth, detailed life history and body elemental composition of the herbivorous rotifer, Brachionus calyciflorus , in response to three different food quality treatments: algae cultured in high phosphorus conditions (average algal molar C:P ≈ 112, 'HP'), algae cultured in low P conditions (molar C:P ≈ 631, 'LP') and low-P cultured algae spiked with P just before feeding (molar C:P ≈ 113, 'LP+P'). LP+P algae thus combined high P content with a history of growth under P-limited conditions. Total P content and the C:P ratio of rotifers in the LP+P treatment equaled those of rotifers in the HP treatment. Rotifer population growth rates were higher in HP than in LP and intermediate in the LP+P treatment. Similarly, many life history traits observed for animals in the LP+P treatment, such as somatic growth rate, age at maturity, and egg production rate were also intermediate to those observed in the LP and HP treatments. However, there were important deviations from this pattern: size at first reproduction and egg mortality in the LP+P treatment equaled the HP treatment, whereas size and development time of the first eggs equaled those of the LP treatment. Our results indicate that elemental limitation cannot fully explain reduced performance of consumers fed with P-limited algae and strongly suggest that indirect, non-stoichiometric effects of P-limitation, e.g., via changes in biochemical composition or morphology of the algae also play a major role. Furthermore, our study highlights that such indirect effects have a differential
Development of a Repeatable Protocol to Uniformly Coat Internal Complex Geometries of Fine Featured 3D Printed Objects with Ceramic Material, including Determination of Viscosity Limits to Properly Coat Certain Pore Sizes
Rogers, A. [Lawrence Livermore National Lab. (LLNL), Livermore, CA (United States)
HEPA filters are commonly used in air filtration systems ranging in application from simple home systems to the more advanced networks used in research and development. Currently, these filters are most often composed of glass fibers with diameter on the order of one micron with polymer binders. These fibers, as well as the polymers used, are known to be fragile and can degrade or become extremely brittle with heat, severely limiting their use in high temperature applications. Ceramics are one promising alternative and can enhance the filtration capabilities compared to the current technology. Because ceramic materials are more thermally resistant and chemically stable, there is great interest in developing a repeatable protocol to uniformly coat fine featured polymer objects with ceramic material for use as a filter. The purpose of this experiment is to determine viscosity limits that are able to properly coat certain pore sizes in 3D printed objects, and additionally to characterize the coatings themselves. Latex paint was used as a surrogate because it is specifically designed to produce uniform coatings.
Khan, Momna; Sultana, Syeda Seema; Jabeen, Nigar; Arain, Uzma; Khans, Salma
To determine the diagnostic accuracy of visual inspection of cervix using 3% acetic acid as a screening test for early detection of cervical cancer taking histopathology as the gold standard. The cross-sectional study was conducted at Civil Hospital Karachi from July 1 to December 31, 2012 and comprised all sexually active women aged 19-60 years. During speculum examination 3% acetic acid was applied over the cervix with the help of cotton swab. The observations were noted as positive or negative on visual inspection of the cervix after acetic acid application according to acetowhite changes. Colposcopy-guided cervical biopsy was done in patients with positive or abnormal looking cervix. Colposcopic-directed biopsy was taken as the gold standard to assess visual inspection readings. SPSS 17 was used for statistical analysis. There were 500 subjects with a mean age of 35.74 ± 9.64 years. Sensitivity, specifically, positive predicted value, negative predicted value of visual inspection of the cervix after acetic acid application was 93.5%, 95.8%, 76.3%, 99%, and the diagnostic accuracy was 95.6%. Visual inspection of the cervix after acetic acid application is an effective method of detecting pre-invasive phase of cervical cancer and a good alternative to cytological screening for cervical cancer in resource-poor setting like Pakistan and can reduce maternal morbidity and mortality.
Report of the Sixth Session of the CECAF Sub-Committee on Management of Resources Within the Limits of National Jurisdiction: Lomé, Togo, 2-5 December 1985 = Rapport de la Sixième Session du Sous-comité COPACE de l'aménagement des ressources à l'intérieur des limites de la juridiction nationale : Lomé, Togo, 2-5 décembre 1985
The final report of the Sixth Session of the CECAF Sub- Committee on Management of Resources within the Limits of National Jurisdiction held in Lome, Togo, from 2 to 5 December 1985 and adopted on 5...
Jaganath, Devan; Miranda, J Jaime; Gilman, Robert H; Wise, Robert A; Diette, Gregory B; Miele, Catherine H; Bernabe-Ortiz, Antonio; Checkley, William
It is unclear how geographic and social diversity affects the prevalence of chronic obstructive pulmonary disease (COPD). We sought to characterize the prevalence of COPD and identify risk factors across four settings in Peru with varying degrees of urbanization, altitude, and biomass fuel use. We collected sociodemographics, clinical history, and post-bronchodilator spirometry in a randomly selected, age-, sex- and site-stratified, population-based sample of 2,957 adults aged ≥35 years (median age was 54.8 years and 49.3% were men) from four resource-poor settings: Lima, Tumbes, urban and rural Puno. We defined COPD as a post-bronchodilator FEV1/FVC urban Tumbes, 6.1% in urban Puno, 6.2% in Lima, and 9.9% in rural Puno (p < 0.001). Population attributable risks (PARs) of COPD due to smoking ≥10 pack-years were less than 10% for all sites, consistent with a low prevalence of daily smoking (3.3%). Rather, we found that PARs of COPD varied by setting. In Lima, for example, the highest PARs were attributed to post-treatment tuberculosis (16% and 22% for men and women, respectively). In rural Puno, daily biomass fuel for cooking among women was associated with COPD (prevalence ratio 2.22, 95% CI 1.02-4.81) and the PAR of COPD due to daily exposure to biomass fuel smoke was 55%. The burden of COPD in Peru was not uniform and, unlike other settings, was not predominantly explained by tobacco smoking. This study emphasizes the role of biomass fuel use, and highlights pulmonary tuberculosis as an often neglected risk factor in endemic areas.
Stonbraker, Samantha; Befus, Montina; Nadal, Leonel Lerebours; Halpern, Mina; Larson, Elaine
Provider-reported summaries of clinical status may assist with clinical management of HIV in resource poor settings if they reflect underlying biological processes associated with HIV disease progression. However, their ability to do so is rarely evaluated. Therefore, we aimed to assess the relationship between a provider-recorded summary of clinical status and indicators of HIV progression. Data were abstracted from 201 randomly selected medical records at a large HIV clinic in the Dominican Republic. Multivariable logistic regressions were used to examine the relationship between provider-assigned clinical status and demographic (gender, age, nationality, education) and clinical factors (reported medication adherence, CD4 cell count, viral load). The mean age of patients was 41.2 (SD = ±10.9) years and most were female (n = 115, 57%). None of the examined characteristics were significantly associated with provider-recorded clinical status. Higher CD4 cell counts were more likely for females (OR = 2.2 CI: 1.12–4.31) and less likely for those with higher viral loads (OR = 0.33 CI: 0.15–0.72). Poorer adherence and lower CD4 cell counts were significantly associated with higher viral loads (OR = 4.46 CI: 1.11–20.29 and 6.84 CI: 1.47–37.23, respectively). Clinics using provider-reported summaries of clinical status should evaluate the performance of these assessments to ensure they are associated with biologic indicators of disease progression. PMID:27495146
Alemnji, George; Fonjungo, Peter; Van Der Pol, Barbara; Peter, Trevor; Kantor, Rami; Nkengasong, John
Strong laboratory services and systems are critical for delivering timely and quality health services that are vital to reduce patient attrition in the HIV treatment and prevention cascade. However, challenges exist in ensuring effective laboratory health systems strengthening and linkages. In particular, linkages and referrals between laboratory testing and other services need to be considered in the context of an integrated health system that includes prevention, treatment, and strategic information. Key components of laboratory health systems that are essential for effective linkages include an adequate workforce, appropriate point-of-care (POC) technology, available financing, supply chain management systems, and quality systems improvement, including accreditation. In this review, we highlight weaknesses of and gaps between laboratory testing and other program services. We propose a model for strengthening these systems to ensure effective linkages of laboratory services for improved access and retention in care of HIV/AIDS patients, particularly in low- and middle-income countries.
Pilakka-Kanthikeel, Sudheesh; Kris, Arheart; Selvaraj, Anbalagan; Swaminathan, Soumya; Pahwa, Savita
Gut damage resulting in microbial translocation (MT) is considered a major cause of immune activation (IA) in HIV infection, but data in children are limited, particularly in the absence of antiretroviral therapy. Sixty perinatally HIV-infected, antiretroviral therapy-naive children, aged 2-12 years, were evaluated for plasma levels of lipopolysaccharide, DNA sequences encoding bacterial 16 second ribosomal DNA (16S rDNA) and soluble CD14 concurrently with markers of CD4 and CD8 T-cell IA and immune exhaustion (IE), CD4 counts, and plasma viral load. At study entry, participants were classified into immune categories (ICs): IC1 (CD4% > 25), IC2 (CD4% 15-25), and IC3 (CD4% natural history cohort of HIV-infected children not on therapy, MT was more pronounced in the most severely immunocompromised patients and was associated with IA. Strategies to reduce MT may help to reduce IA and prevent CD4 depletion.
Priestley, Stacey C.; Wohling, Daniel L.; Keppel, Mark N.; Post, Vincent E. A.; Love, Andrew J.; Shand, Paul; Tyroller, Lina; Kipfer, Rolf
The investigation of regionally extensive groundwater systems in remote areas is hindered by a shortage of data due to a sparse observation network, which limits our understanding of the hydrogeological processes in arid regions. The study used a multidisciplinary approach to determine hydraulic connectivity between the Great Artesian Basin (GAB) and the underlying Arckaringa Basin in the desert region of Central Australia. In order to manage the impacts of groundwater abstraction from the Arckaringa Basin, it is vital to understand its connectivity with the GAB (upper aquifer), as the latter supports local pastoral stations and groundwater-dependent springs with unique endemic flora and fauna. The study is based on the collation of available geological information, a detailed analysis of hydraulic data, and data on environmental tracers. Enhanced inter-aquifer leakage in the centre of the study area was identified, as well as recharge to the GAB from ephemeral rivers and waterholes. Throughout the rest of the study area, inter-aquifer leakage is likely controlled by diffuse inter-aquifer leakage, but the coarse spatial resolution means that the presence of additional enhanced inter-aquifer leakage sites cannot be excluded. This study makes the case that a multi-tracer approach along with groundwater hydraulics and geology provides a tool-set to investigate enhanced inter-aquifer leakage even in a groundwater basin with a paucity of data. A particular problem encountered in this study was the ambiguous interpretation of different age tracers, which is attributed to diffusive transport across flow paths caused by low recharge rates.
Kumar, Janavi; Adhikari, Koushik; Li, Yijing; Lindshield, Erika; Muturi, Nancy; Kidd, Tandalayo
Purpose: The purpose of this paper is to enable community members to discuss their perceptions of eating habits and physical activity in relation to sixth, seventh, and eighth graders, and reveal facilitators and barriers to healthy eating behavior and physical activity engagement. Design/methodology/approach: Nine focus groups, which included six…
With over 1 billion population, China is adding some 15 million to that total each year. And in the 18 years from 1982 to 2000, the net increase of Chinese population is expected to exceed 200 million. Because of the gigantic pressure from population and some mistakes in policies, the levels of ecological destruction and environment pollution are both serious. This includes deforestation, grassland degradation, desert encroachment, water resources shortage, and waste of mineral resources. Natural disasters including floods and droughts caused by those problems happen more and more frequently. If development damages the resource base, it can only result in a false prosperity, the so-called hollow economy. A large number of environmental problems result directly or indirectly from the pressure of population growth. Studies show that the appropriate number of people that can be supported by China's 9.6 million sq. km is about 700 million. However, this limit is now exceeded by over 300 million people, and will be exceeded by 500 million by the end of this century. Therefore, the task is to implement a birth control policy. At present, in urban areas, the goal of family planning has been reached, but in rural areas hard work is needed. Population control in urban areas, especially in big and medium-sized cities, includes dealing with the inflow of migrants from the countryside. There are 13 cities with a population above 2 million, 37 cities above 1-2 million, and 75 cities above 0.5-1 million. A lot of cities are very crowded, exerting great pressure on the environment. The booming of rural enterprises could provide a good solution to control the flow of rural people into big and medium-sized cities. The relationship between population, resources, environment, and development should be managed properly.
Macaia, Damas; Lapão, Luís Velez
Angola is among sub-Saharan African countries dealing with a crisis of Human Resources for Health (HRH). The province of Cabinda, besides the efforts, still suffers from both HRH shortage and a badly distributed health workforce. In Cabinda, one can find urban concentration and rural shortages of healthcare professionals, many rural areas' healthcare facilities often secured only by basic or medium level HRH; and difficulties in developing HRH retention strategies in rural areas where most services are covered by foreign HRH. This study aims at analysing the situation of HRH in the province of Cabinda. It considers organizational issues, policies and practices resulting from the HRH strategy followed in the recent years, moreover the creation of a medical school. The context that affects the distribution of the health workforce is analysed to contribute to the development of evidence-based policies that promote a better HRH allocation in the poorest and distant villages in the province. A mixed-methods study was developed, combining a quantitative and qualitative approach to analyse HRH situation in the province of Cabinda. Data was collected from key informants, selected by intentional sampling from public and private health organizations, to respond to a questionnaire and a semi-structured interview. Quantitative and qualitative data was analysed with descriptive and inferential statistics and content analysis respectively. The study was complemented by a comprehensive desk review. Results show a clear change in HRH data from 2011 to 2015 with significant fluctuations due to variations in retirement, migration and lack of regular public HRH recruitment tenders. HRH density is apparently better in rural when compared with urban areas. However, one should bear in mind that often HRH allocated to rural areas do not stay there, which leads to real geographical imbalances. Factors like lack of proper incentives for HRH retention and social support goes against
Full Text Available Hepatitis B and C infections are prevalent among HIV-infected individuals with different epidemiologic profiles, modes of transmission, natural histories, and treatments. Southeast Asian countries are classified as “highly prevalent zones,” with a rate of hepatitis B and C coinfection in people living with HIV/AIDS of approximately 3.2–11%. Majority of hepatitis B coinfection is of genotype C. Most of the patients infected with hepatitis C in Thailand have genotype 3 which is significantly related to intravenous drug use whereas, in Vietnam, it is genotype 6. The options for antiretroviral drugs are limited and rely on global funds and research facilities. Only HBV treatment is available for free through the national health scheme. Screening tests for HBV and HCV prior to commencing antiretroviral treatment are low. Insufficient concern on hepatitis-virus-related liver malignancy and long-term hepatic morbidities is noted. Cost-effective HCV treatment can be incorporated into the national health program for those who need it by utilizing data obtained from clinical research studies. For example, patients infected with HCV genotype 2/3 with a certain IL-28B polymorphism can be treated with a shorter course of interferon and ribavirin which can also help reduce costs.
Jouego, Christelle Géneviève; Agbor, Valirie Ndip; Noeske, Juergen; Manuel, Ndo Akono; Ayuk, Leo Njock
Tuberculosis remains a major cause of morbidity and mortality worldwide, especially in developing countries. The diagnosis and treatment of multi-drug resistant tuberculosis (MDR-TB) in children remain a major limitation in this setting, largely due to difficulties in isolating Mycobacterium tuberculosis from pediatric specimens, management with toxic second line drugs, and practically the inexistence of contact tracing. In 2016, the World Health Organization (WHO) recommended a standardized 9-month regimen for adults and children in zones which are highly endemic for the human immunodeficiency virus (HIV). Herein, we present a case of pediatric MDR-TB/HIV co-infection highlighting the difficulties in treatment and the importance of contact tracing. A 6-year old male infant from the West Region of Cameroon infected with HIV who presented at a local health center with a 10 days history of productive cough associated with nocturnal fever and abdominal pains non responsive to broad spectrum antibiotics. A sputum sample analysis requested was smear positive for acid-fast bacilli, and he was initiated on quadritherapy for drug sensitive pulmonary tuberculosis. Since he was a household contact of the mother who was being managed in a referral hospital for MDR-TB at 1 month of treatment, and given his critical clinical situation, a gastric aspirate was repeated and sent for Xpert MTB/RIF to the Tuberculosis Reference Laboratory which was positive for a Rifampicin resistant strain of M. tuberculosis. The short 9 months regimen against MDR-TB was then initiated. During the course of his management, he developed minor side effects of the drugs which were managed symptomatically. Even though pediatric MDR-TB is difficult to confirm, it can be treated with favorable clinical outcomes using the short regimen recommended by the WHO. Experts involved in the control of tuberculosis over the national territory should consider adopting routine contact tracing for all cases of
Flavious B. Nkubli
Full Text Available Purpose: To survey structural designs of x-ray rooms and compliance to shielding design goals of three x-ray imaging facilities. Methods and Materials: The survey was conducted in three radiodiagnostic centers in South East Nigeria, labeled X, Y and Z for anonymity. A stretchable non-elastic meter rule was used to measure x-ray room dimensions. A Vernier caliper was used to measure lead thickness while a calibrated digital survey meter Radalert 100x was used for radiation survey of controlled and uncontrolled areas. Simple statistical tools such as mean and standard deviation were used for analysis with the aid of Microsoft Excel version 2007. Results: Center X had a room dimension of 2.4 m × 2.1 m, Center Y had an x-ray room dimension of 3.6 m × 3.3 m, and Center Z had two x-ray rooms with identical dimensions of 6.3 m × 3.6 m. Measured exit radiation doses for controlled areas in all the centers were: 0.00152 mSv/wk; 0.00496 mSv/wk; 0.00168 mSv/wk; 0.00224 mSv/wk respectively. Lead was the common shielding material used. Conclusion: Based on the parameters studied, Center Z had the ideal room size and layout. Relative distances from the x-ray tubes to the nearest walls were not optimized in all the centers except in Center Z. Measured exit doses were within recommended limits except in Center Y. The location of the control consoles and measured doses were appropriate and within recommended design goals.
Natural gas and electricity commodities are among the most volatile commodities in the world. Spurred on by the recent significant increases in the price of natural gas, the BC Utilities Commission initiated an investigation into factors impacting on natural gas prices, and the validity of the Sumas index (a market trading point, or interchange where multiple pipelines interconnect, allowing the purchase and sale of gas among market participants) as a price setting mechanism. The Commission also sought the opinions and perspectives of the the province's natural gas industry regarding the high volatility of the Sumas gas prices, and as to what could be done to alleviate the wild fluctuations. Following review of the responses from stakeholders, the Commission issued a directive to BC Gas to undertake discussions on regional resource planning with full representation from all stakeholders. This study is the result of the Commission's directive, and is intended to address the issues contained in the directives. Accordingly, the study examined gas demand in the region, demand growth, including power generation, natural gas resource balance in the region, the California impacts on demand and on supply to the region, supply shortfalls on a peak day, and on a seasonal and annual basis, near term remedies, possible resource additions in the longer term, the economic justification for adding major resources and proposed actions to develop needed resource additions. The study confirmed the existence of a growing capacity deficit, which limits the supply of natural gas to the region. Near term options to alleviate the regional capacity deficit were found to be limited to discouraging power generation from serving export markets, demand side management efforts, and expansion of the WEI's systems by 105 mmcf/d. Longer term solutions would involve larger scale expansion of WEI's T-South capacity, the BC Gas' Inland Pacific Connector Project and the Washington Lateral proposed by
Tomita, Andrew; Vandormael, Alain M; Cuadros, Diego; Di Minin, Enrico; Heikinheimo, Vuokko; Tanser, Frank; Slotow, Rob; Burns, Jonathan K
Unprecedented levels of habitat transformation and rapid urbanisation are changing the way individuals interrelate with the natural environment in developing countries with high economic disparities. Although the potential benefit of green environments for mental health has been recognised, population-level evidence to this effect is scarce. We investigated the effect of green living environment in potentially countering incident depression in a nationally representative survey in South Africa. We used panel data from the South African National Income Dynamics Study (SA-NIDS). Our study used SA-NIDS data from three waves: wave 1 (2008), wave 2 (2010), and wave 3 (2012). Households were sampled on the basis of a stratified two-stage cluster design. In the first stage, 400 primary sampling units were selected for inclusion. In the second stage, two clusters of 12 dwelling units each were drawn from within each primary sampling unit (or 24 dwelling units per unit). Household and individual adult questionnaires were administered to participants. The main outcome, incident depression (ie, incident cohort of 11 156 study participants without significant depression symptoms at their first entry into SA-NIDS), was assessed in the adult survey via a ten item version of the Center for Epidemiologic Studies Depression Scale; a total score of ten or higher was used as a cutoff to indicate significant depressive symptoms. Each participant was assigned a value for green living space via a satellite-derived normalised difference vegetation index (NDVI) based on the GPS coordinates of their household location. Overall, we found uneven benefit of NDVI on incident depression among our study participants. Although the green living environment showed limited benefit across the study population as a whole, our final analysis based on logistic regression models showed that higher NDVI was a predictor of lower incident depression among middle-income compared with low-income participants
Cowing, Keith L.
Centrifuges will continue to serve as a valuable research tool in gaining an understanding of the biological significance of the inertial acceleration due to gravity. Space- and possibly lunar-based centrifuges will play a significant and enabling role with regard to the human component of future lunar and martian exploration, both as a means of accessing potential health and performance risks and as a means of alleviating these risks. Lunar-based centrifuges could be particularly useful as part of a program of physiologic countermeasures designed to alleviate the physical deconditioning that may result from prolonged exposure to a 1/6-g environment. Centrifuges on the lunar surface could also be used as part of a high-fidelity simulation of a trip to Mars. Other uses could include crew readaptation to 1 g, waste separation, materials processing, optical mirror production in situ on the Moon, and laboratory specimen separation.
Terris-Prestholt, Fern; Windmeijer, Frank
Despite condoms being cheap and effective in preventing HIV, there remains an 8billion shortfall in condom use in risky sex-acts. Social marketing organisations apply private sector marketing approaches to sell public health products. This paper investigates the impact of marketing tools, including promotion and pricing, on demand for male and female condoms in 52 countries between 1997 and 2009. A static model differentiates drivers of demand between products, while a dynamic panel data estimator estimates their short- and long-run impacts. Products are not equally affected: female condoms are not affected by advertising, but highly affected by interpersonal communication and HIV prevalence. Price and promotion have significant short- and long-run effects, with female condoms far more sensitive to price than male condoms. The design of optimal distribution strategies for new and existing HIV prevention technologies must consider both product and target population characteristics. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.
Protecting nuclear materials is a challenging problem for facility managers. To counter the broad spectrum of potential threats, facility managers rely on diverse safeguards measures, including elements of physical protection, material control and accountability, and human reliability programs. Deciding how to upgrade safeguards systems involves difficult tradeoffs between increased protection and the costs and operational impact of protection measures. Effective allocation of safeguards and security resources requires a prioritization of systems upgrades based on a relative measure of upgrade benefits to upgrade costs. Analytical tools are needed to help safeguards managers measure the relative benefits and cost and allocate their limited resources to achieve balanced, cost-effective protection against the full spectrum of threats. This paper presents a conceptual approach and quantitative model that have been developed by Lawrence Livermore National Laboratory to aid safeguards managers
Genital herpes - resources; Resources - genital herpes ... following organizations are good resources for information on genital herpes : March of Dimes -- www.marchofdimes.com/pregnancy/complications- ...
Dittrich, Sabine; Tadesse, Birkneh Tilahun; Moussy, Francis; Chua, Arlene; Zorzet, Anna; Tängdén, Thomas; Dolinger, David L; Page, Anne-Laure; Crump, John A; D'Acremont, Valerie; Bassat, Quique; Lubell, Yoel; Newton, Paul N; Heinrich, Norbert; Rodwell, Timothy J; González, Iveth J
Acute fever is one of the most common presenting symptoms globally. In order to reduce the empiric use of antimicrobial drugs and improve outcomes, it is essential to improve diagnostic capabilities. In the absence of microbiology facilities in low-income settings, an assay to distinguish bacterial from non-bacterial causes would be a critical first step. To ensure that patient and market needs are met, the requirements of such a test should be specified in a target product profile (TPP). To identify minimal/optimal characteristics for a bacterial vs. non-bacterial fever test, experts from academia and international organizations with expertise in infectious diseases, diagnostic test development, laboratory medicine, global health, and health economics were convened. Proposed TPPs were reviewed by this working group, and consensus characteristics were defined. The working group defined non-severely ill, non-malaria infected children as the target population for the desired assay. To provide access to the most patients, the test should be deployable to community health centers and informal health settings, and staff should require 90% and >80% for sensitivity and specificity, respectively. Other key characteristics, to account for the challenging environment at which the test is targeted, included: i) time-to-result targeted and timely efforts by industry partners and academic institutions.
..., DEPARTMENT OF HOMELAND SECURITY DISASTER ASSISTANCE FEDERAL DISASTER ASSISTANCE Coastal Barrier Resources Act... within the Coastal Barrier Resources System, including but not limited to: (a) Construction... any project to prevent the erosion of, or to otherwise stabilize, any inlet, shoreline, or inshore...
Eleje, George Uchenna; Ezugwu, Euzebus Chinonye; Ogunyemi, Dotun; Eleje, Lydia Ijeoma; Ikechebelu, Joseph Ifeanyichukwu; Igwegbe, Anthony Osita; Okonkwo, John E; Ikpeze, Okechukwu Christian; Udigwe, Gerald Okanandu; Onah, Hyacinth Eze; Nwosu, Betrand Obi; Ezeama, Chukwuemeka Okwudili; Ezenkwele, Eziamaka Pauline
To determine accuracy and costs of placental α-microglobulin-1 (PAMG-1) test compared to standard clinical assessment (SCA) for diagnosing rupture of membranes (ROM). A multicenter double-blind study of consecutive women with symptoms and signs of ROM in Nnamdi Azikiwe University Teaching Hospital, Nnewi and University of Nigeria Teaching Hospital, Enugu, both in south-east Nigeria using SCA for ROM and the PAMG-1 test was done. ROM was diagnosed if two out of three methods from SCA (pooling, positive nitrazine test or ferning) were present and confirmed post-delivery based on presence of any two of these clinical criteria: delivery in 48 h to 7 days, evidence of chorioamnionitis, membranes overtly ruptured at delivery and adverse perinatal outcomes strongly correlated with prolonged PROM. A cost-analysis was also done. The outcome measures included sensitivity, specificity, accuracy and costs for the two tests. Accuracy, sensitivity and specificity for the PAMG-1 test were 97.2%, 97.4% and 96.7%, higher than for SCA which were 83.7%, 87.9% and 70.5%, respectively (P < 0.001). Accuracy of SCA was higher at less than 34 weeks than 34 weeks or more (88.3% vs 81.4%) while the PAMG-1 test performed equally at both gestational age categories (96.1% vs 97.7%). In women without pooling, accuracy of the PAMG-1 test was 96.7%, while it was 40.0% with SCA. Analysis showed that the overall cost of SCA was 45% higher than the PAMG-1 test. This study confirms that the PAMG-1 test has a consistently high diagnostic accuracy at all gestational ages and with equivocal cases of ROM. The PAMG-1 test appears less costly than SCA. © 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.
Full Text Available Acute fever is one of the most common presenting symptoms globally. In order to reduce the empiric use of antimicrobial drugs and improve outcomes, it is essential to improve diagnostic capabilities. In the absence of microbiology facilities in low-income settings, an assay to distinguish bacterial from non-bacterial causes would be a critical first step. To ensure that patient and market needs are met, the requirements of such a test should be specified in a target product profile (TPP. To identify minimal/optimal characteristics for a bacterial vs. non-bacterial fever test, experts from academia and international organizations with expertise in infectious diseases, diagnostic test development, laboratory medicine, global health, and health economics were convened. Proposed TPPs were reviewed by this working group, and consensus characteristics were defined. The working group defined non-severely ill, non-malaria infected children as the target population for the desired assay. To provide access to the most patients, the test should be deployable to community health centers and informal health settings, and staff should require 90% and >80% for sensitivity and specificity, respectively. Other key characteristics, to account for the challenging environment at which the test is targeted, included: i time-to-result <10 min (but maximally <2 hrs; ii storage conditions at 0-40°C, ≤90% non-condensing humidity with a minimal shelf life of 12 months; iii operational conditions of 5-40°C, ≤90% non-condensing humidity; and iv minimal sample collection needs (50-100μL, capillary blood. This expert approach to define assay requirements for a bacterial vs. non-bacterial assay should guide product development, and enable targeted and timely efforts by industry partners and academic institutions.
Shah, Adil Aijaz; Rehman, Abdul; Sayyed, Raza Hasnain; Haider, Adil Hussain; Bawa, Amber; Zafar, Syed Nabeel; Zia-Ur-Rehman; Ali, Kamran; Zafar, Hasnain
Pre-hospital triage is an intricate part of any mass casualty response system. However, in settings where no such system exists, it is not known if hospital-based disaster response efforts are beneficial. This study describes in-hospital disaster response management and patient outcomes following a mass casualty event (MCE) involving 200 victims in a lower-middle income country in South Asia. We performed a single-center, retrospective review of bombing victims presenting to a trauma center in the spring of 2013, after a high energy car bomb leveled a residential building. Descriptive analysis was utilized to present demographic variables and physical injuries. A disaster plan was devised based on the canons of North-American trauma care; some adaptations to the local environment were incorporated. Relevant medical and surgical specialties were mobilized to the ED awaiting a massive influx of patients. ED waiting room served as the triage area. Operating rooms, ICU and blood bank were alerted. Seventy patients presented to the ED. Most victims (88%) were brought directly without prehospital triage or resuscitation. Four were pronounced dead on arrival. The mean age of victims was 27 (±14) years with a male preponderance (78%). Penetrating shrapnel injury was the most common mechanism of injury (71%). Most had a systolic blood pressure (SBP) >90 with a mean of 120.3 (±14.8). Mean pulse was 90.2 (±21.6) and most patients had full GCS. Extremities were the most common body region involved (64%) with orthopedics service being consulted most frequently. Surgery was performed on 36 patients, including 4 damage control surgeries. All patients survived. This overwhelming single mass-casualty incident was met with a swift multidisciplinary response. In countries with no prehospital triage system, implementing a pre-existing disaster plan with pre-defined interdisciplinary responsibilities can streamline in-hospital management of casualties. Copyright © 2014 Elsevier Ltd
abortions, 65% had tried to avoid the current pregnancy, and 12% of women were ART naïve. Several predictors such as education, abortion rate, unplanned pregnancies, and partners’ decision were associated with the nonuse of effective contraceptive methods. Moreover, barriers including sex inequity, lack of partner support, ART shortages, and lack of HIV viral load monitoring were prevalent among the participants (P=0.001. However FPS use, ART compliance, and safe options to PMTCT significantly increased after the educational counseling interventions (P=0.001.Conclusion: Scaling up the FPS by incorporating routine PMTCT services into reproductive health care should contribute to preventing both horizontal and vertical transmission of HIV. Keywords: contraception, HIV infected women, transmission, interventions, education
Massarrat, Sadegh; Kolahdoozan, Shadi
Scientific progress is an important indicator for the social and economic developments of any country. According to various reports, worldwide, Iran has the most growth in the field of science due to a high increase in the numbers of publications during the past decade. The aim of this study is to assess not only the quantity, but also the quality of publications of indexed Iranian journals and compare them to Turkey, as an Islamic neighboring country, in addition to the contributions of these two countries to our knowledge. A number of international journals with high impact factors were selected to assess the contributions of scientists from Iran and Turkey to the medical sciences. English medical journals from Iran and Turkey indexed by the ISI Web of Sciences with known impact factors (IF) announced at the beginning of 2010 were included for evaluation. We calculated the number of all articles published from the beginning of 2007 until the October 2010, the number of total citations, and citations from authors outside both countries for each journal. In addition, we selected all articles cited at least six times by authors outside of both countries and discussed their content with regard to originality and novelty, as well as their contributions to current knowledge. Furthermore, 60 international journals in basic or clinical research with IF greater than 6 were selected for the magnitude of contributions of both countries to our scientific knowledge. In 2010, out of a total of 21 Iranian journals indexed in ISI since 2007, only 12 have a known IF with a mean of 0.39 (range: 0.07-0.97), whereas out of 28 Turkish medical journals indexed in ISI, 15 have a known IF (mean: 0.35, range: 0.05-0.82). The total number of articles published since 2007 from Iran, total citations and total citations by authors from outside Iran were 2080, 1218, and 463, respectively. The same data related to Turkish journals were 4876, 2036, and 1331, respectively. Indeed, the mean
NSGIC Education | GIS Inventory — A Water Resource is a DEP primary facility type related to the Water Use Planning Program. The sub-facility types related to Water Resources that are included are:...
This paper reports that to prevent the concentration of control over federal oil and gas resources in a few companies or individuals, Congress has limited the number of acres of oil and gas leases that one party may control in a single state. An exception to this limitation involves lease acreage within the boundaries of development contracts. These contracts permit oil and gas lease operators and pipeline companies to contract with enough lessees to economically justify large-scale drilling operations for the production and transportation of oil and gas, subject to approval by the Secretary of the Interior, who must find that such contracts are in the public interest. Since 1986 Interior has entered into or approved 10 contracts with 12 lease operators for exploration of largely unleased federal lands-ranging from about 180,000 to 3.5 million acres in four western states-and has designated them as developmental contracts. GAO believes that the 10 contracts do not satisfy the legal requirements for development contracts because they are for oil and gas exploration on largely unleased federal lands, rather than for developing existing leases. By designating the 10 contracts as development contracts, Interior has enabled nine of the 12 contract parties to accumulate lease acreage that vastly exceeds the statutory acreage limitation. All nine of the contract parties were major or large independent oil companies. As a result, other parties who wish to participate in developing federal oil and gas resources within the four states may be adversely affected because the parties to Interior's contracts have been able to compete for and obtain lease acreage beyond the statutory acreage limitation. Although Interior believes that the Secretary has the discretion under law to use development contracts in the current manner, in April 1989 it ceased issuing these contracts pending completion of GAO's review
Oluoch, Tom; Muturi, David; Kiriinya, Rose; Waruru, Anthony; Lanyo, Kevin; Nguni, Robert; Ojwang, James; Waters, Keith P; Richards, Janise
Sub-Saharan Africa (SSA) bears the heaviest burden of the HIV epidemic. Health workers play a critical role in the scale-up of HIV programs. SSA also has the weakest information and communication technology (ICT) infrastructure globally. Implementing interoperable national health information systems (HIS) is a challenge, even in developed countries. Countries in resource-limited settings have yet to demonstrate that interoperable systems can be achieved, and can improve quality of healthcare through enhanced data availability and use in the deployment of the health workforce. We established interoperable HIS integrating a Master Facility List (MFL), District Health Information Software (DHIS2), and Human Resources Information Systems (HRIS) through application programmers interfaces (API). We abstracted data on HIV care, health workers deployment, and health facilities geo-coordinates. Over 95% of data elements were exchanged between the MFL-DHIS and HRIS-DHIS. The correlation between the number of HIV-positive clients and nurses and clinical officers in 2013 was R2=0.251 and R2=0.261 respectively. Wrong MFL codes, data type mis-match and hyphens in legacy data were key causes of data transmission errors. Lack of information exchange standards for aggregate data made programming time-consuming.
Inzaule, Seth; Yang, Chunfu; Kasembeli, Alex; Nafisa, Lillian; Okonji, Jully; Oyaro, Boaz; Lando, Richard; Mills, Lisa A; Laserson, Kayla; Thomas, Timothy; Nkengasong, John; Zeh, Clement
HIV-1 drug resistance (HIVDR) assays are important tools in clinical management of HIV-infected patients on antiretroviral therapy (ART) and surveillance of drug-resistant variants at population levels. The high cost associated with commercial assays hinders their use in resource-limited settings. We adopted and validated a low-cost in-house assay using 68 matched plasma and dried blood spot (DBS) samples with a median viral load (VL) of 58,187 copies/ml, ranging from 253 to 3,264,850 against the commercial assay ViroSeq. Results indicated that the in-house assay not only had a higher plasma genotyping rate than did ViroSeq (94% versus 78%) but also was able to genotype 89.5% (51/57) of the matched DBS samples with VLs of ≥ 1,000 copies/ml. The sensitivity in detecting DR mutations by the in-house assay was 98.29% (95% confidence interval [CI], 97.86 to 98.72) on plasma and 96.54 (95% CI, 95.93 to 97.15) on DBS, and the specificity was 99.97% (95% CI, 99.91 to 100.00) for both sample types compared to ViroSeq. The minor DR mutation differences detected by