Science.gov

Sample records for limited resource setting

  1. Strengthening laboratory systems in resource-limited settings.

    PubMed

    Olmsted, Stuart S; Moore, Melinda; Meili, Robin C; Duber, Herbert C; Wasserman, Jeffrey; Sama, Preethi; Mundell, Ben; Hilborne, Lee H

    2010-09-01

    Considerable resources have been invested in recent years to improve laboratory systems in resource-limited settings. We reviewed published reports, interviewed major donor organizations, and conducted case studies of laboratory systems in 3 countries to assess how countries and donors have worked together to improve laboratory services. While infrastructure and the provision of services have seen improvement, important opportunities remain for further advancement. Implementation of national laboratory plans is inconsistent, human resources are limited, and quality laboratory services rarely extend to lower tier laboratories (eg, health clinics, district hospitals). Coordination within, between, and among governments and donor organizations is also frequently problematic. Laboratory standardization and quality control are improving but remain challenging, making accreditation a difficult goal. Host country governments and their external funding partners should coordinate their efforts effectively around a host country's own national laboratory plan to advance sustainable capacity development throughout a country's laboratory system.

  2. Diagnostics in Ebola Virus Disease in Resource-Rich and Resource-Limited Settings

    PubMed Central

    Shorten, Robert J; Brown, Colin S; Jacobs, Michael; Rattenbury, Simon; Simpson, Andrew J.; Mepham, Stephen

    2016-01-01

    The Ebola virus disease (EVD) outbreak in West Africa was unprecedented in scale and location. Limited access to both diagnostic and supportive pathology assays in both resource-rich and resource-limited settings had a detrimental effect on the identification and isolation of cases as well as individual patient management. Limited access to such assays in resource-rich settings resulted in delays in differentiating EVD from other illnesses in returning travellers, in turn utilising valuable resources until a diagnosis could be made. This had a much greater impact in West Africa, where it contributed to the initial failure to contain the outbreak. This review explores diagnostic assays of use in EVD in both resource-rich and resource-limited settings, including their respective limitations, and some novel assays and approaches that may be of use in future outbreaks. PMID:27788135

  3. Transmission of Tuberculosis in Resource-Limited Settings

    PubMed Central

    Kompala, Tejaswi; Shenoi, Sheela V.; Friedland, Gerald

    2013-01-01

    Unrecognized transmission is a major contributor to ongoing TB epidemics in high-burden, resource-constrained settings. Limitations in diagnosis, treatment, and infection control in health-care and community settings allow for continued transmission of drug-sensitive and drug-resistant TB, particularly in regions of high HIV prevalence. Health-care facilities are common sites of TB transmission. Improved implementation of infection control practices appropriate for the local setting and in combination, has been associated with reduced transmission. Community settings account for the majority of TB transmission and deserve increased focus. Strengthening and intensifying existing high-yield strategies, including household contact tracing, can reduce onward TB transmission. Recent studies documenting high transmission risk community sites and strategies for community-based intensive case finding hold promise for feasible, effective transmission reduction. Infection control in community settings has been neglected and requires urgent attention. Developing and implementing improved strategies for decreasing transmission to children, within prisons and of drug-resistant TB are needed. PMID:23824469

  4. Caring for the injured child in settings of limited resource.

    PubMed

    Stephenson, Jacob

    2016-02-01

    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. PMID:26831134

  5. Promotion and Reporting of Research from Resource-Limited Settings

    PubMed Central

    Siriwardhana, Chesmal

    2015-01-01

    Driven by global burden of disease and inequalities in health care, research activities in resource-poor settings have radically increased. However, a corresponding increase in reporting of research from these settings has not been observed. This article critically explores the importance of promoting and reporting of health research from resource-poor settings, current trends, and practices, and discusses the key challenges faced by researchers from such settings. These challenges include changing face of open-access (OA) and online publishing, the threat of predatory OA journals, authorship and international partnership ethics, attitudinal problems hindering research reporting, and a lack of alternative publishing spaces. A combined, decisive effort is needed to bridge the gap between research activity and reporting in resource-poor settings. PMID:26396528

  6. Molecular oncology testing in resource-limited settings.

    PubMed

    Gulley, Margaret L; Morgan, Douglas R

    2014-11-01

    Cancer prevalence and mortality are high in developing nations, where resources for cancer control are inadequate. Nearly one-quarter of cancers in resource-limited nations are infection related, and molecular assays can capitalize on this relationship by detecting pertinent pathogen genomes and human gene variants to identify those at highest risk for progression to cancer, to classify lesions, to predict effective therapy, and to monitor tumor burden over time. Prime examples are human papillomavirus in cervical neoplasia, Helicobacter pylori and Epstein-Barr virus in gastric adenocarcinoma and lymphoma, and hepatitis B or C virus in hepatocellular cancer. Research is underway to engineer devices that overcome social, economic, and technical barriers limiting effective laboratory support. Additional challenges include an educated workforce, infrastructure for quality metrics and record keeping, and funds to sustain molecular test services. The combination of well-designed interfaces, novel and robust electrochemical technology, and telemedicine tools will promote adoption by frontline providers. Fast turnaround is crucial for surmounting loss to follow-up, although increased use of cell phones, even in rural areas, enhances options for patient education and engagement. Links to a broadband network facilitate consultation and centralized storage of medical data. Molecular technology shows promise to address gaps in health care through rapid, user-friendly, and cost-effective devices reflecting clinical priorities in resource-poor areas. PMID:25242061

  7. Molecular Oncology Testing in Resource-Limited Settings

    PubMed Central

    Gulley, Margaret L.; Morgan, Douglas R.

    2015-01-01

    Cancer prevalence and mortality are high in developing nations, where resources for cancer control are inadequate. Nearly one-quarter of cancers in resource-limited nations are infection related, and molecular assays can capitalize on this relationship by detecting pertinent pathogen genomes and human gene variants to identify those at highest risk for progression to cancer, to classify lesions, to predict effective therapy, and to monitor tumor burden over time. Prime examples are human papillomavirus in cervical neoplasia, Helicobacter pylori and Epstein-Barr virus in gastric adenocarcinoma and lymphoma, and hepatitis B or C virus in hepatocellular cancer. Research is underway to engineer devices that overcome social, economic, and technical barriers limiting effective laboratory support. Additional challenges include an educated workforce, infrastructure for quality metrics and record keeping, and funds to sustain molecular test services. The combination of well-designed interfaces, novel and robust electrochemical technology, and telemedicine tools will promote adoption by frontline providers. Fast turnaround is crucial for surmounting loss to follow-up, although increased use of cell phones, even in rural areas, enhances options for patient education and engagement. Links to a broadband network facilitate consultation and centralized storage of medical data. Molecular technology shows promise to address gaps in health care through rapid, user-friendly, and cost-effective devices reflecting clinical priorities in resource-poor areas. PMID:25242061

  8. Rethinking breast cancer screening strategies in resource-limited settings.

    PubMed

    Galukande, M; Kiguli-Malwadde, E

    2010-03-01

    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 Malaria). These factors and more make the future of breast cancer care including screening in Sub Saharan African grim.Although mass breast cancer screening by mammography has been proved to be efficacious in the developed nations of the world, this has not been replicated in the developing nations because mass screening is not yet possible for the reasons stated. This paper proposes an alternative to mammography mass screening.Breast health programs for the most part are adhoc or non-existent in Uganda. The challenge of mass screening is not only limited to less readily available mammogram machines and trained human resources but also to the fact that the targeted population is of relatively young women in their 30s, implying that screening should commence earlier than it is practiced in nations where breast cancer peaks among women in their 50s. Mammography is not efficacious in young women with dense breast tissue. Ultra sound scans are not only up to 10 fold more available than mammography machines but are half the cost per examination.Although using ultra sound Scan for screening for non-palpable lumps is not up to par with standard breast cancer care mammography. It may be better than nothing, may be beneficial in aiding early cancer diagnosis. This concept is akin to the 'task shifting' advocated by WHO. It is worth investigating use of ultra sound scan for mass screening for breast cancer in resource-limited environments. This is not in any way lowering standards of oncologic diagnosis but filling the otherwise unattended to gap, the unmet need.

  9. Rethinking breast cancer screening strategies in resource-limited settings.

    PubMed

    Galukande, M; Kiguli-Malwadde, E

    2010-03-01

    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 Malaria). These factors and more make the future of breast cancer care including screening in Sub Saharan African grim.Although mass breast cancer screening by mammography has been proved to be efficacious in the developed nations of the world, this has not been replicated in the developing nations because mass screening is not yet possible for the reasons stated. This paper proposes an alternative to mammography mass screening.Breast health programs for the most part are adhoc or non-existent in Uganda. The challenge of mass screening is not only limited to less readily available mammogram machines and trained human resources but also to the fact that the targeted population is of relatively young women in their 30s, implying that screening should commence earlier than it is practiced in nations where breast cancer peaks among women in their 50s. Mammography is not efficacious in young women with dense breast tissue. Ultra sound scans are not only up to 10 fold more available than mammography machines but are half the cost per examination.Although using ultra sound Scan for screening for non-palpable lumps is not up to par with standard breast cancer care mammography. It may be better than nothing, may be beneficial in aiding early cancer diagnosis. This concept is akin to the 'task shifting' advocated by WHO. It is worth investigating use of ultra sound scan for mass screening for breast cancer in resource-limited environments. This is not in any way lowering standards of oncologic diagnosis but filling the otherwise unattended to gap, the unmet need. PMID:20811531

  10. A Diagnostic Scoring Model for Leptospirosis in Resource Limited Settings

    PubMed Central

    Rajapakse, Senaka; Weeratunga, Praveen; Niloofa, Roshan; Fernando, Narmada; de Silva, Nipun Lakshitha; Rodrigo, Chaturaka; Maduranga, Sachith; Nandasiri, Nuwanthi; Premawansa, Sunil; Karunanayake, Lilani; de Silva, H. Janaka; Handunnetti, Shiroma

    2016-01-01

    Background Leptospirosis is a zoonotic infection with significant morbidity and mortality. The clinical presentation of leptospirosis is known to mimic the clinical profile of other prevalent tropical fevers. Laboratory confirmation of leptospirosis is based on the reference standard microscopic agglutination test (MAT), direct demonstration of the organism, and isolation by culture and DNA detection by polymerase chain reaction (PCR) amplification. However these methods of confirmation are not widely available in resource limited settings where the infection is prevalent, and reliance is placed on clinical features for provisional diagnosis. In this prospective study, we attempted to develop a model for diagnosis of leptospirosis, based on clinical features and standard laboratory test results. Methods The diagnostic score was developed based on data from a prospective multicentre study in two hospitals in the Western Province of Sri Lanka. All patients presenting to these hospitals with a suspected diagnosis of leptospirosis, based on the WHO surveillance criteria, were recruited. Confirmed disease was defined as positive genus specific MAT (Leptospira biflexa). A derivation cohort and a validation cohort were randomly selected from available data. Clinical and laboratory manifestations associated with confirmed leptospirosis in the derivation cohort were selected for construction of a multivariate regression model with correlation matrices, and adjusted odds ratios were extracted for significant variables. The odds ratios thus derived were subsequently utilized in the criteria model, and sensitivity and specificity examined with ROC curves. Results A total of 592 patients were included in the final analysis with 450 (180 confirmed leptospirosis) in the derivation cohort and 142 (52 confirmed leptospirosis) in the validation cohort. The variables in the final model were: history of exposure to a possible source of leptospirosis (adjusted OR = 2.827; 95% CI = 1

  11. The burden of pulmonary hypertension in resource-limited settings.

    PubMed

    Gidwani, Suman; Nair, Ajith

    2014-09-01

    Pulmonary vascular disease (PVD) is a significant global health problem and accounts for a substantial portion of cardiovascular disease in the developing world. Although there have been considerable advances in therapeutics for pulmonary arterial hypertension, over 97% of the disease burden lies within the developing world where there is limited access to health care and pharmaceuticals. The causes of pulmonary arterial hypertension differ between industrialized and developing nations. Infectious diseases-including schistosomiasis human immunodeficiency virus, and rheumatic fever-are common causes of PVD, as are hemoglobinopathies, and untreated congenital heart disease. High altitude and exposure to household air pollutants also contribute to a significant portion of PVD cases. Although diagnosis of pulmonary arterial hypertension requires the use of imaging and invasive hemodynamics, access to equipment may be limited. PVD therapies may be prohibitively expensive and limited to a select few. Prevention is therefore important in limiting the global PVD burden. PMID:25667181

  12. When to Start Antiretroviral Therapy in Resource-limited Settings

    PubMed Central

    Walensky, Rochelle P.; Wolf, Lindsey L.; Wood, Robin; Fofana, Mariam O.; Freedberg, Kenneth A.; Martinson, Neil A.; Paltiel, A. David; Anglaret, Xavier; Weinstein, Milton C.; Losina, Elena

    2011-01-01

    Background Results of international clinical trials assessing when to initiate antiretroviral therapy (ART) will not be available for several years. Objective To inform HIV treatment decisions over the short- and long-term regarding the optimal CD4 threshold at which to initiate ART in South Africa, while awaiting “when to start” trial results. Design Cost-effectiveness analysis using a computer simulation model of HIV disease. Data Sources Published data from randomized trials and observational cohorts in South Africa. Target Population HIV-infected patients in South Africa. Time Horizon Five-year and lifetime. Perspective Modified societal. Interventions No treatment, initiate ART at CD4<250/μl, and initiate ART at CD4<350/μl. Outcome Measures Morbidity, mortality, life expectancy, medical costs, and cost-effectiveness. Results of Base-Case Analysis If 10-100% of HIV-infected patients are diagnosed and linked to care, initiating ART at CD4<350/μl would reduce severe opportunistic diseases by 22,000-221,000 and deaths by 25,000-253,000 during the next 5 years, compared to initiating ART at CD4<250/μl; cost increases would range from $142 million (10%) to $1.4 billion (100%). Either ART strategy increased long-term survival by at least 7.9 years, with a mean per person life expectancy of 3.8 years for no ART and 12.5 years for ART at <350/μl. Compared to initiating ART at <250/μl, initiating ART at <350/μl had an incremental cost-effectiveness ratio of $1,200/year of life saved. Results of Sensitivity Analysis Initiating ART at CD4<350/μl remained cost-effective over the next 5 years even if the probability that the trial would demonstrate superiority to earlier therapy is as low as 17%. Limitations This model does not consider the possible benefits of ART initiation at CD4>350/μl nor reduced HIV transmission. Conclusions Earlier ART initiation in South Africa will likely reduce morbidity and mortality, improve long-term survival, and be very cost

  13. Developments in CD4 and viral load monitoring in resource-limited settings.

    PubMed

    Rowley, Christopher F

    2014-02-01

    CD4 counts and human immunodeficiency virus (HIV) load testing are essential components of HIV care, and making these tests available in resource-limited settings is critical to the roll-out of HIV treatment globally. Until recently, the evidence supporting the importance of laboratory monitoring in resource-limited settings was lacking, but there is now a consensus emerging that testing should become routine to ensure the longevity of treatment programs. Low-cost, point-of-care testing offers the potential to fill this role as it potentially improves all aspects of HIV care, ranging from the diagnosis and staging of HIV infection in both infants and adults to monitoring for treatment failure once antiretroviral therapy has been initiated. It is imperative for low-cost solutions to become a reality, but it is equally imperative that close scrutiny be given to each new device that hits the market to ensure they perform optimally in all settings.

  14. Cholestatic hepatic injury due to a thyroid storm: a case report from a resource limited setting

    PubMed Central

    2012-01-01

    Introduction Thyroid storm is an endocrinological emergency caused by an exacerbation of the hyperthyroid state and is characterized by multi organ dysfunction. Liver dysfunction or injury predominantly of a cholestatic type is one of the atypical manifestations of thyroid storm and has been previously described in literature. However, there have been few published case reports among African patients and from resource limited settings. Case report We report a case of a 21 year old Ugandan female patient who presented with a thyroid storm due to untreated Graves’ disease complicated by cholestatic hepatic injury, congestive heart failure and acute kidney injury. Conclusion This case highlights the varied multi organ dysfunctions seen in a patient with thyroid storm with emphasis on liver injury mainly to increase awareness among clinicians in resource limited settings. Mechanisms of liver injury due to thyroid storm or hyperthyroidism are discussed in the literature review. PMID:22839423

  15. Diagnostic challenges of sexually transmitted infections in resource-limited settings.

    PubMed

    Peeling, Rosanna W; Ronald, Allan

    2009-12-01

    The global burden of sexually transmitted infections (STIs) is highest in the developing world where access to laboratory services is limited. Sophisticated laboratory diagnostic tests using noninvasive specimens have enabled developed countries to screen and diagnose curable STIs in a variety of settings, but control programs in resource-limited settings continue to struggle to find simple rapid tests that can provide adequate performance in the absence of laboratory services. While recent technological advances and investments in research and development may soon yield improved STI tests that can make an impact, these tests will need to be deployed within a health system that includes: regulatory oversight, quality assurance, good supply-chain management, effective training, information systems and a sound surveillance system to monitor disease trends, inform policy decisions and assess the impact of interventions. PMID:19995188

  16. Obstacles and proposed solutions to effective antiretroviral therapy in resource-limited settings.

    PubMed

    Bartlett, John A; Hornberger, John; Shewade, Ashwini; Bhor, Menaka; Rajagopalan, Rukmini

    2009-01-01

    More than 3 million people were receiving antiretroviral therapy (ART) at the end of 2007, but this number represents only 31% of people clinically eligible for ART in resource-limited settings. The primary objective of this study is to summarize the key obstacles that impede the goal of universal access prevention, care, and treatment. We performed a systematic literature search to review studies that reported barriers to diagnosis and access to treatment of HIV/AIDS in resource-limited countries. Persons living with HIV/ AIDS commonly face economic, sociocultural, and behavioral obstacles to access treatment and care for HIV. A variety of programs to overcome these barriers have been implemented, including efforts to destigmatize HIV/AIDS, enhance treatment literacy, provide income-generation skills, decentralize HIV services, promote gender equality, and adopt a multisectoral approach to optimize limited resources. An understanding of these obstacles and suggested methods to overcome them must be addressed by global policy makers before universal ART access can be achieved.

  17. Natural Conception May Be an Acceptable Option in HIV-Serodiscordant Couples in Resource Limited Settings.

    PubMed

    Sun, Lijun; Wang, Fang; Liu, An; Xin, Ruolei; Zhu, Yunxia; Li, Jianwei; Shao, Ying; Ye, Jiangzhu; Chen, Danqing; Li, Zaicun

    2015-01-01

    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.

  18. Natural Conception May Be an Acceptable Option in HIV-Serodiscordant Couples in Resource Limited Settings

    PubMed Central

    Xin, Ruolei; Zhu, Yunxia; Li, Jianwei; Shao, Ying; Ye, Jiangzhu; Chen, Danqing; Li, Zaicun

    2015-01-01

    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. PMID:26540103

  19. HIV/AIDS and lipodystrophy: Implications for clinical management in resource-limited settings

    PubMed Central

    Finkelstein, Julia L; Gala, Pooja; Rochford, Rosemary; Glesby, Marshall J; Mehta, Saurabh

    2015-01-01

    Introduction Lipodystrophy is a term used to describe a metabolic complication of fat loss, fat gain, or a combination of fat loss and gain, which is associated with some antiretroviral (ARV) therapies given to HIV-infected individuals. There is limited research on lipodystrophy in low- and middle-income countries, despite accounting for more than 95% of the burden of HIV/AIDS. The objective of this review was to evaluate the prevalence, pathogenesis and prognosis of HIV-related lipoatrophy, lipohypertrophy and mixed syndrome, to inform clinical management in resource-limited settings. Methods We conducted a structured literature search using MEDLINE electronic databases. Relevant MeSH terms were used to identify published human studies on HIV and lipoatrophy, lipohypertrophy, or mixed syndrome in low-, low-middle- and upper-middle-income countries through 31 March 2014. The search resulted in 5296 articles; after 1599 studies were excluded (958 reviews, 641 non-human), 3697 studies were extracted for further review. After excluding studies conducted in high-income settings (n=2808), and studies that did not meet inclusion criteria (n=799), 90 studies were included in this review. Results and Discussion Of the 90 studies included in this review, only six were from low-income countries and eight were from lower middle-income economies. These studies focused on lipodystrophy prevalence, risk factors and side effects of antiretroviral therapy (ART). In most studies, lipodystrophy developed after the first six months of therapy, particularly with the use of stavudine. Lipodystrophy is associated with increased risk of cardiometabolic complications. This is disconcerting and anticipated to increase, given the rapid scale-up of ART worldwide, the increasing number and lifespan of HIV-infected patients on long-term therapy, and the emergence of obesity and non-communicable diseases in settings with extensive HIV burden. Conclusions Lipodystrophy is common in resource-limited

  20. Evaluating Diagnostic Point-of-Care Tests in Resource-Limited Settings

    PubMed Central

    Drain, Paul K; Hyle, Emily P; Noubary, Farzad; Freedberg, Kenneth A; Wilson, Douglas; Bishai, William; Rodriguez, William; Bassett, Ingrid V

    2014-01-01

    Diagnostic point-of-care (POC) testing is intended to minimize the time to obtain a test result, thereby allowing clinicians and patients to make an expeditious clinical decision. As POC tests expand into resource-limited settings (RLS), the benefits must outweigh the costs. To optimize POC testing in RLS, diagnostic POC tests need rigorous evaluations focused on relevant clinical outcomes and operational costs, which differ from evaluations of conventional diagnostic tests. Here, we reviewed published studies on POC testing in RLS, and found no clearly defined metric for the clinical utility of POC testing. Therefore, we propose a framework for evaluating POC tests, and suggest and define the term “test efficacy” to describe a diagnostic test’s capacity to support a clinical decision within its operational context. We also proposed revised criteria for an ideal diagnostic POC test in resource-limited settings. Through systematic evaluations, comparisons between centralized diagnostic testing and novel POC technologies can be more formalized, and health officials can better determine which POC technologies represent valuable additions to their clinical programs. PMID:24332389

  1. Advances in addressing technical challenges of point-of-care diagnostics in resource-limited settings

    PubMed Central

    Wang, ShuQi; Lifson, Mark A.; Inci, Fatih; Liang, Li-Guo; Sheng, Ye-Feng; Demirci, Utkan

    2016-01-01

    The striking prevalence of HIV, TB and malaria, as well as outbreaks of emerging infectious diseases, such as influenza A (H7N9), Ebola and MERS, poses great challenges for patient care in resource-limited settings (RLS). However, advanced diagnostic technologies cannot be implemented in RLS largely due to economic constraints. Simple and inexpensive point-of-care (POC) diagnostics, which rely less on environmental context and operator training, have thus been extensively studied to achieve early diagnosis and treatment monitoring in non-laboratory settings. Despite great input from material science, biomedical engineering and nanotechnology for developing POC diagnostics, significant technical challenges are yet to be overcome. Summarized here are the technical challenges associated with POC diagnostics from a RLS perspective and the latest advances in addressing these challenges are reviewed. PMID:26777725

  2. Flow-through, viral co-infection assay for resource-limited settings.

    PubMed

    Cretich, Marina; Torrisi, Marcello; Daminelli, Serena; Gagni, Paola; Plavisch, Lauren; Chiari, Marcella

    2015-01-01

    Here we present a new and rapid immunofiltration assay for simultaneous detection of HIV p24 and hepatitis B virus antigens. The assay platform is composed of a 13 mm nitrocellulose filter spotted with capturing bioprobes and inserted in a Swinnex(®) syringe filter holder. Samples and reagents are flown through the nitrocellulose filter by manual pressure on the syringe. A colorimetric detection allows for naked eye results interpretation. The assay provides sensitivity in the picomolar range in just 5 min, even using low volumes of sample in complex matrix. Probe deposition by spotting allows for flexible combinations of different capturing agents and multiple diagnoses; furthermore, the very simple and inexpensive set-up makes the syringe-based immunoassay on paper microarray a suitable diagnostic system for resource-limited settings.

  3. Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings

    PubMed Central

    Scanlon, Michael L; Vreeman, Rachel C

    2013-01-01

    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 compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings. PMID:23326204

  4. The Cost-Effectiveness of Repeat HIV Testing During Pregnancy in a Resource-Limited Setting

    PubMed Central

    Kim, Lena H.; Cohan, Deborah L.; Sparks, Teresa N.; Pilliod, Rachel A.; Arinaitwe, Emmanuel; Caughey, Aaron B.

    2013-01-01

    OBJECTIVE To estimate the cost-effectiveness of HIV screening strategies for the prevention of perinatal transmission in Uganda, a resource-limited country with high HIV prevalence and incidence. STUDY DESIGN We designed a decision-analytic model from a health care system perspective to assess the vertical transmission rates and cost-effectiveness of four different HIV screening strategies in pregnancy: 1) Rapid HIV antibody (Ab) test at initial visit (current standard of care); 2) Strategy 1 + HIV RNA at initial visit (adds detection of acute HIV); 3) Strategy 1 + repeat HIV Ab at delivery (adds detection of incident HIV); 4) Strategy 3 + HIV RNA at delivery (adds detection of acute HIV at delivery). Model estimates were derived from the literature and local sources, and life years saved were discounted at a rate of 3% per year. Based on World Health Organization guidelines, we defined our cost-effectiveness threshold as ≤3 times the gross domestic product per capita, which for Uganda was US$3300 in 2008. RESULTS Using base case estimates of 10% HIV prevalence among women entering prenatal care and 3% incidence during pregnancy, strategy 3 was incrementally the cost-effective option that led to the greatest total life years. CONCLUSION Repeat rapid HIV Ab testing at the time of labor is a cost-effective strategy even in a resource-limited setting such as Uganda. PMID:23392461

  5. Supporting research sites in resource-limited settings: challenges in implementing information technology infrastructure.

    PubMed

    Whalen, Christopher J; Donnell, Deborah; Tartakovsky, Michael

    2014-01-01

    As information and communication technology infrastructure becomes more reliable, new methods of electronic data capture, data marts/data warehouses, and mobile computing provide platforms for rapid coordination of international research projects and multisite studies. However, despite the increasing availability of Internet connectivity and communication systems in remote regions of the world, there are still significant obstacles. Sites with poor infrastructure face serious challenges participating in modern clinical and basic research, particularly that relying on electronic data capture and Internet communication technologies. This report discusses our experiences in supporting research in resource-limited settings. We describe examples of the practical and ethical/regulatory challenges raised by the use of these newer technologies for data collection in multisite clinical studies.

  6. Supporting research sites in resource-limited settings: Challenges in implementing IT infrastructure

    PubMed Central

    Whalen, Christopher; Donnell, Deborah; Tartakovsky, Michael

    2014-01-01

    As Information and Communication Technology infrastructure becomes more reliable, new methods of Electronic Data Capture (EDC), datamarts/Data warehouses, and mobile computing provide platforms for rapid coordination of international research projects and multisite studies. However, despite the increasing availability of internet connectivity and communication systems in remote regions of the world, there are still significant obstacles. Sites with poor infrastructure face serious challenges participating in modern clinical and basic research, particularly that relying on EDC and internet communication technologies. This report discusses our experiences in supporting research in resource-limited settings (RLS). We describe examples of the practical and ethical/regulatory challenges raised by use of these newer technologies for data collection in multisite clinical studies. PMID:24321986

  7. Comparative effectiveness of efavirenz-based antiretroviral regimens in resource-limited settings

    PubMed Central

    Castillo-Mancilla, Jose R; Campbell, Thomas B

    2012-01-01

    Efavirenz (EFV) is a non-nucleoside widely used as first-line therapy for HIV-1 infection. Most of the research available on EFV comes from trials performed in industrialized countries and only a few studies have evaluated EFV in resource-limited settings (RLSs). In this article, we present a systematic review of the available randomized-controlled trials performed in RLSs that have compared EFV with other antiretrovirals, such as nevirapine and protease inhibitors. The data derived from these studies show that both EFV and nevirapine are adequate first-line therapy options for HIV-1 infection in RLSs, even in patients with concomitant tuberculosis. However, EFV may show a slight benefit in terms of toxicity and adverse events. By contrast, the data comparing EFV versus protease inhibitors is contradictory and further studies may be required to elucidate these discrepancies. PMID:22707879

  8. Standard measures are inadequate to monitor pediatric adherence in a resource-limited setting.

    PubMed

    Müller, Alexandra D; Jaspan, Heather B; Myer, Landon; Hunter, Ashley Lewis; Harling, Guy; Bekker, Linda-Gail; Orrell, Catherine

    2011-02-01

    This study aims to compare the use and cost of objective and subjective measures of adherence to pediatric antiretroviral treatment in a primary care facility in South Africa. In a 1-month longitudinal study of 53 caregiver-child dyads, pharmacy refill (PR), measurement of returned syrups (RS), caregiver self-report (3DR) and Visual Analogue Scale (VAS) were compared to Medication Event Monitoring System (MEMS). Adherence was 100% for both VAS and 3DR; by PR and RS 100% and 103%, respectively. MEMS showed that 92% of prescribed doses were administered, but only 66% of these within the correct 12-hourly interval. None of the four measures correlated significantly with MEMS. MEMS data suggest that timing of doses is often more deviant from prescribed than expected and should be better addressed when monitoring adherence. Of all, MEMS was by far the most expensive measure. Alternative, cheaper electronic devices need to be more accessible in resource-limited settings. PMID:20953692

  9. Challenges in diagnosis and management of Cryptococcal immune reconstitution inflammatory syndrome (IRIS) in resource limited settings.

    PubMed

    Musubire, A K; Meya, B D; Mayanja-Kizza, H; Lukande, R; Wiesner, L D; Bohjanen, P; R Boulware, R D

    2012-06-01

    In many resource-limited settings, cryptococcal meningitis (CM) contributes up to 20% of all deaths with further complications due to Immune Reconstitution Inflammatory Syndrome (IRIS). We present a case report on a patient who developed CM-IRIS and then subsequent CM-relapse with a fluconazole-resistant organism and then later CM-IRIS once again, manifesting as cystic cryptococcomas, hydrocephalus, and sterile CSF. In this case we, demonstrate that CM-IRIS and persistent low level cryptococcal infection are not mutually exclusive phenomena. The management of IRIS with corticosteroids may increase the risk of culture positive CM-relapse which may further increase the risk of recurrent IRIS and resulting complications including death. We also highlight the role of imaging and fluconazole resistance testing in patients with recurrent meningitis and the importance of CSF cultures in guiding treatment decisions.

  10. Monitoring HIV Viral Load in Resource Limited Settings: Still a Matter of Debate?

    PubMed Central

    Arnedo, Mireia; Alonso, Elena; Eisenberg, Nell; Ibáñez, Laura; Ferreyra, Cecilia; Jaén, Angels; Flevaud, Laurence; Khamadi, Samuel; Roddy, Paul; Gatell, Jose Maria; Dalmau, David

    2012-01-01

    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. PMID:23236346

  11. Feasibility of HIV point-of-care tests for resource-limited settings: challenges and solutions.

    PubMed

    Stevens, Wendy; Gous, Natasha; Ford, Nathan; Scott, Lesley E

    2014-01-01

    Improved access to anti-retroviral therapy increases the need for affordable monitoring using assays such as CD4 and/or viral load in resource-limited settings. Barriers to accessing treatment, high rates of loss to initiation and poor retention in care are prompting the need to find alternatives to conventional centralized laboratory testing in certain countries. Strong advocacy has led to a rapidly expanding repertoire of point-of-care tests for HIV. point-of-care testing is not without its challenges: poor regulatory control, lack of guidelines, absence of quality monitoring and lack of industry standards for connectivity, to name a few. The management of HIV increasingly requires a multidisciplinary testing approach involving hematology, chemistry, and tests associated with the management of non-communicable diseases, thus added expertise is needed. This is further complicated by additional human resource requirements and the need for continuous training, a sustainable supply chain, and reimbursement strategies. It is clear that to ensure appropriate national implementation either in a tiered laboratory model or a total decentralized model, clear country-specific assessments need to be conducted. PMID:25197773

  12. Weight Estimation Tool for Children Aged 6 to 59 Months in Limited-Resource Settings

    PubMed Central

    2016-01-01

    Importance 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. Objective 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. Design 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. Setting Locations with high prevalence of acute and chronic malnutrition. Participants 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). Exposures Weight was estimated using Broselow Tape, Hong Kong formula, and database MUAC alone, height alone, and height and MUAC combined. Main Outcomes and Measures 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. Results 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

  13. Protocol for a drugs exposure pregnancy registry for implementation in resource-limited settings

    PubMed Central

    2012-01-01

    Background The absence of robust evidence of safety of medicines in pregnancy, particularly those for major diseases provided by public health programmes in developing countries, has resulted in cautious recommendations on their use. We describe a protocol for a Pregnancy Registry adapted to resource-limited settings aimed at providing evidence on the safety of medicines in pregnancy. Methods/Design Sentinel health facilities are chosen where women come for prenatal care and are likely to come for delivery. Staff capacity is improved to provide better care during the pregnancy, to identify visible birth defects at delivery and refer infants with major anomalies for surgical or clinical evaluation and treatment. Consenting women are enrolled at their first antenatal visit and careful medical, obstetric and drug-exposure histories taken; medical record linkage is encouraged. Enrolled women are followed up prospectively and their histories are updated at each subsequent visit. The enrolled woman is encouraged to deliver at the facility, where she and her baby can be assessed. Discussion In addition to data pooling into a common WHO database, the WHO Pregnancy Registry has three important features: First is the inclusion of pregnant women coming for antenatal care, enabling comparison of birth outcomes of women who have been exposed to a medicine with those who have not. Second is its applicability to resource-poor settings regardless of drug or disease. Third is improvement of reproductive health care during pregnancies and at delivery. Facility delivery enables better health outcomes, timely evaluation and management of the newborn, and the collection of reliable clinical data. The Registry aims to improves maternal and neonatal care and also provide much needed information on the safety of medicines in pregnancy. PMID:22943425

  14. Turning off the spigot: reducing drug-resistant tuberculosis transmission in resource-limited settings

    PubMed Central

    Nardell, E.; Dharmadhikari, A.

    2013-01-01

    SUMMARY Ongoing transmission and re-infection, primarily in congregate settings, is a key factor fueling the global multidrug-resistant/extensively drug-resistant tuberculosis (MDR/XDR-TB) epidemic, especially in association with the human immunodeficiency virus. Even as efforts to broadly implement conventional TB transmission control measures begin, current strategies may be incompletely effective under the overcrowded conditions extant in high-burden, resource-limited settings. Longstanding evidence suggesting that TB patients on effective therapy rapidly become non-infectious and that unsuspected, untreated TB cases account for the most transmission makes a strong case for the implementation of rapid point-of-care diagnostics coupled with fully supervised effective treatment. Among the most important decisions affecting transmission, the choice of an MDR-TB treatment model that includes community-based treatment may offer important advantages over hospital or clinic-based care, not only in cost and effectiveness, but also in transmission control. In the community, too, rapid identification of infectious cases, especially drug-resistant cases, followed by effective, fully supervised treatment, is critical to stopping transmission. Among the conventional interventions available, we present a simple triage and separation strategy, point out that separation is intimately linked to the design and engineering of clinical space and call attention to the pros and cons of natural ventilation, simple mechanical ventilation systems, germicidal ultraviolet air disinfection, fit-tested respirators on health care workers and short-term use of masks on patients before treatment is initiated. PMID:20843413

  15. Advances in developing HIV-1 viral load assays for resource-limited settings.

    PubMed

    Wang, ShuQi; Xu, Feng; Demirci, Utkan

    2010-01-01

    Commercial HIV-1 RNA viral load assays have been routinely used in developed countries to monitor antiretroviral treatment (ART). However, these assays require expensive equipment and reagents, well-trained operators, and established laboratory infrastructure. These requirements restrict their use in resource-limited settings where people are most afflicted with the HIV-1 epidemic. Inexpensive alternatives such as the Ultrasensitive p24 assay, the reverse transcriptase (RT) assay and in-house reverse transcription quantitative polymerase chain reaction (RT-qPCR) have been developed. However, they are still time-consuming, technologically complex and inappropriate for decentralized laboratories as point-of-care (POC) tests. Recent advances in microfluidics and nanotechnology offer new strategies to develop low-cost, rapid, robust and simple HIV-1 viral load monitoring systems. We review state-of-the-art technologies used for HIV-1 viral load monitoring in both developed and developing settings. Emerging approaches based on microfluidics and nanotechnology, which have potential to be integrated into POC HIV-1 viral load assays, are also discussed.

  16. An innovative system for 3D clinical photography in the resource-limited settings

    PubMed Central

    2014-01-01

    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

  17. Mobile learning for HIV/AIDS healthcare worker training in resource-limited settings

    PubMed Central

    2010-01-01

    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. PMID:20825677

  18. Implementation of HIV Prevention Interventions in Resource Limited Settings: the Partner Project

    PubMed Central

    Jones, Deborah; Weiss, Stephen M.; Arheart, Kris; Cook, Ryan; Chitalu, Ndashi

    2013-01-01

    Introduction Evidence-based HIV prevention interventions have been translated to a variety of contexts across sub-Saharan Africa. Non-specialized community health center (CHC) staff members have been successfully engaged to deliver the interventions, which can be integrated into pre-existing HIV service programs in community-based health care delivery sites. This manuscript describes the process of implementing the Partner Project, a couples HIV risk reduction intervention, and examines the ability of CHC staff to achieve risk reduction outcomes comparable to those of the highly-trained research staff. Methods The Partner Project was implemented within the HIV Counseling and Testing program in 6 urban community health clinics in Lusaka, Zambia. One hundred ninety seven HIV-seroconcordant and –discordant couples were sequentially enrolled to the control group or to receive the intervention from Partner research or CHC staff members. Couple members completed assessments on condom use, alcohol use, and intimate partner violence (IPV) at baseline, 6, and 12 months follow-up. Results Sexual barrier use outcomes achieved by the CHC staff were comparable to or better than those achieved by the Partner Project research staff, and both were superior to the control group. A reduction in IPV was observed for the entire sample, although no change in alcohol use was observed. Conclusions Implementation of HIV prevention interventions at the community level should take advantage of existing resources available within the CHC staff. This is especially relevant in resource limited settings as consideration of the financial and clinical requirements of intervention programs is essential to the achievement of successful program implementation. PMID:23963855

  19. Challenges and opportunities for the implementation of virological testing in resource-limited settings

    PubMed Central

    Roberts, Teri; Bygrave, Helen; Fajardo, Emmanuel; Ford, Nathan

    2012-01-01

    Though the advantages of routine virological monitoring for patients on anti-retroviral therapy have been established, cost and complexity limit its full implementation. Monitoring is important for diagnosing virological failure early on, before the development of drug resistance mutations, and to trigger early adherence interventions. Simple and cost-effective viral load tests that facilitate simplification and decentralization of testing and strategies, such as the use of dried blood spots and pooled sample testing, which further aid simplification, are becoming available. In addition, replacing immunological monitoring with virological monitoring in non-viremic patients in a phased manner will reduce the costs associated with dual immuno-virological monitoring. Going forward, the simplification of testing paired with price reducing strategies that will allow for healthy competition between multiple manufacturers will enable the implementation of viral load testing in resource-poor settings. It is important that future HIV and AIDS treatment guidelines provide clear recommendations for routine virological monitoring and that governments and donors fund the implementation of accurate and operationally proven testing platforms in a comprehensive manner. PMID:23078767

  20. Forgotten, not neglected: viral hepatitis in resource-limited settings, recall for action.

    PubMed

    Lemoine, Maud; Thursz, Mark; Njie, Ramou; Dusheiko, Geoffrey

    2014-01-01

    In 2010, the World Health Assembly adopted a resolution calling for interventions for the prevention and control of chronic viral hepatitis. These infectious diseases mostly affect resource-limited countries accounting for 80% of the world's population and facing numerous obstacles to contain the epidemic. At a time when morbidity and mortality of chronic liver disease have been considerably improved in wealthy countries by new innovative strategies and new potent antiviral drugs, it is now urgent to recall for concrete actions from stakeholders of global health policy to reduce the burden in resource-limited countries.

  1. A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions

    PubMed Central

    Turner, Erin L.; Nielsen, Katie R.; Jamal, Shelina M.; von Saint André-von Arnim, Amelie; Musa, Ndidiamaka L.

    2016-01-01

    Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings. PMID:26925393

  2. How to improve the clinical diagnosis of acute appendicitis in resource limited settings.

    PubMed

    Alvarado, Alfredo

    2016-01-01

    This article is a general review of the diagnostic tools that the clinician can use for the early diagnosis of acute appendicitis with emphasis on the Alvarado Score, and it is aimed principally to the medical practitioners in different parts of the world where the diagnostic facilities and technological resources are limited.

  3. EXPANDING ANTIRETROVIRAL OPTIONS IN RESOURCE-LIMITED SETTINGS – A COSTEFFECTIVENESS ANALYSIS

    PubMed Central

    Bendavid, Eran; Wood, Robin; Katzenstein, David A.; Bayoumi, Ahmed M.; Owens, Douglas K.

    2009-01-01

    Background Current World Health Organization (WHO) guidelines for treatment of HIV in resource-limited settings call for two antiretroviral regimens. The effectiveness and cost-effectiveness of increasing the number of antiretroviral regimens is unknown. Methods Using a simulation model, we compared the survival and costs of current WHO regimens with two 3-regimen strategies: an initial regimen of three nucleoside reverse transcriptase inhibitors followed by the WHO regimens; and the WHO regimens followed by a regimen with a second-generation boosted protease inhibitor (2bPI). We evaluated monitoring with CD4 counts only and with both CD4 counts and viral load. We used cost and effectiveness data from Cape Town, and tested all assumptions in sensitivity analyses. Results Over the lifetime of the cohort, 25.6% of individuals failed both WHO regimens by virologic criteria. However, when patients were monitored using CD4 counts alone, only 6.5% were prescribed additional HAART, due to missed and delayed detection of failure. The life expectancy gain for individuals who took a 2bPI was 6.7–8.9 months, depending on the monitoring strategy. When CD4 alone was available, adding a regimen with a 2bPI was associated with an incremental cost-effectiveness ratio of $2,581 per year-of-life gained, and when viral load was available, the ratio was $6,519 per year-of-life gained. Strategies with triple-NRTI regimens in initial therapy were dominated. Results were sensitive to the price of 2bPIs. Conclusions About 1 in 4 individuals who start HAART in sub-Saharan Africa will fail currently recommended regimens. At current prices, adding a regimen with a 2bPI is cost-effective for South Africa and other middle-income countries by WHO standards. PMID:19448557

  4. Solar-thermal complex sample processing for nucleic acid based diagnostics in limited resource settings

    PubMed Central

    Gumus, Abdurrahman; Ahsan, Syed; Dogan, Belgin; Jiang, Li; Snodgrass, Ryan; Gardner, Andrea; Lu, Zhengda; Simpson, Kenneth; Erickson, David

    2016-01-01

    The use of point-of-care (POC) devices in limited resource settings where access to commonly used infrastructure, such as water and electricity, can be restricted represents simultaneously one of the best application fits for POC systems as well as one of the most challenging places to deploy them. Of the many challenges involved in these systems, the preparation and processing of complex samples like stool, vomit, and biopsies are particularly difficult due to the high number and varied nature of mechanical and chemical interferents present in the sample. Previously we have demonstrated the ability to use solar-thermal energy to perform PCR based nucleic acid amplifications. In this work demonstrate how the technique, using similar infrastructure, can also be used to perform solar-thermal based sample processing system for extracting and isolating Vibrio Cholerae nucleic acids from fecal samples. The use of opto-thermal energy enables the use of sunlight to drive thermal lysing reactions in large volumes without the need for external electrical power. Using the system demonstrate the ability to reach a 95°C threshold in less than 5 minutes and maintain a stable sample temperature of +/− 2°C following the ramp up. The system is demonstrated to provide linear results between 104 and 108 CFU/mL when the released nucleic acids were quantified via traditional means. Additionally, we couple the sample processing unit with our previously demonstrated solar-thermal PCR and tablet based detection system to demonstrate very low power sample-in-answer-out detection. PMID:27231636

  5. Solar-thermal complex sample processing for nucleic acid based diagnostics in limited resource settings.

    PubMed

    Gumus, Abdurrahman; Ahsan, Syed; Dogan, Belgin; Jiang, Li; Snodgrass, Ryan; Gardner, Andrea; Lu, Zhengda; Simpson, Kenneth; Erickson, David

    2016-05-01

    The use of point-of-care (POC) devices in limited resource settings where access to commonly used infrastructure, such as water and electricity, can be restricted represents simultaneously one of the best application fits for POC systems as well as one of the most challenging places to deploy them. Of the many challenges involved in these systems, the preparation and processing of complex samples like stool, vomit, and biopsies are particularly difficult due to the high number and varied nature of mechanical and chemical interferents present in the sample. Previously we have demonstrated the ability to use solar-thermal energy to perform PCR based nucleic acid amplifications. In this work demonstrate how the technique, using similar infrastructure, can also be used to perform solar-thermal based sample processing system for extracting and isolating Vibrio Cholerae nucleic acids from fecal samples. The use of opto-thermal energy enables the use of sunlight to drive thermal lysing reactions in large volumes without the need for external electrical power. Using the system demonstrate the ability to reach a 95°C threshold in less than 5 minutes and maintain a stable sample temperature of +/- 2°C following the ramp up. The system is demonstrated to provide linear results between 10(4) and 10(8) CFU/mL when the released nucleic acids were quantified via traditional means. Additionally, we couple the sample processing unit with our previously demonstrated solar-thermal PCR and tablet based detection system to demonstrate very low power sample-in-answer-out detection.

  6. Solar-thermal complex sample processing for nucleic acid based diagnostics in limited resource settings.

    PubMed

    Gumus, Abdurrahman; Ahsan, Syed; Dogan, Belgin; Jiang, Li; Snodgrass, Ryan; Gardner, Andrea; Lu, Zhengda; Simpson, Kenneth; Erickson, David

    2016-05-01

    The use of point-of-care (POC) devices in limited resource settings where access to commonly used infrastructure, such as water and electricity, can be restricted represents simultaneously one of the best application fits for POC systems as well as one of the most challenging places to deploy them. Of the many challenges involved in these systems, the preparation and processing of complex samples like stool, vomit, and biopsies are particularly difficult due to the high number and varied nature of mechanical and chemical interferents present in the sample. Previously we have demonstrated the ability to use solar-thermal energy to perform PCR based nucleic acid amplifications. In this work demonstrate how the technique, using similar infrastructure, can also be used to perform solar-thermal based sample processing system for extracting and isolating Vibrio Cholerae nucleic acids from fecal samples. The use of opto-thermal energy enables the use of sunlight to drive thermal lysing reactions in large volumes without the need for external electrical power. Using the system demonstrate the ability to reach a 95°C threshold in less than 5 minutes and maintain a stable sample temperature of +/- 2°C following the ramp up. The system is demonstrated to provide linear results between 10(4) and 10(8) CFU/mL when the released nucleic acids were quantified via traditional means. Additionally, we couple the sample processing unit with our previously demonstrated solar-thermal PCR and tablet based detection system to demonstrate very low power sample-in-answer-out detection. PMID:27231636

  7. Lung cancer management in limited resource settings: guidelines for appropriate good care.

    PubMed

    Macbeth, Fergus R; Abratt, Raymond P; Cho, Kwan H; Stephens, Richard J; Jeremic, Branislav

    2007-02-01

    Lung cancer is a major cause of cancer death worldwide and is becoming an increasing problem in developing countries. It is important that, in countries where health care resources are limited, these resources are used most effectively and cost-effectively. The authors, with the support of the International Atomic Energy Agency, drew on existing evidence-based clinical guidelines, published systematic reviews and meta-analyses, as well as recent research publications, to summarise the current evidence and to make broad recommendations on the non-surgical treatment of patients with lung cancer. Tables were constructed which summarise the different treatment options for specific groups of patients, the increase in resource use for and the likely additional clinical benefit from each option. These tables can be used to assess the cost-effectiveness and appropriateness of different interventions in a particular health care system and to develop local clinical guidelines.

  8. Neonatal hearing screening and intervention in resource-limited settings: an overview.

    PubMed

    Olusanya, Bolajoko O

    2012-07-01

    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.

  9. SAGES: a suite of freely-available software tools for electronic disease surveillance in resource-limited settings.

    PubMed

    Lewis, Sheri L; Feighner, Brian H; Loschen, Wayne A; Wojcik, Richard A; Skora, Joseph F; Coberly, Jacqueline S; Blazes, David L

    2011-05-10

    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.

  10. Universal antiretroviral therapy for HIV infection: should US treatment guidelines be applied to resource-limited settings?

    PubMed

    Gallant, Joel E; Mehta, Shruti H; Sugarman, Jeremy

    2013-09-01

    US treatment guidelines now recommend antiretroviral therapy (ART) for all persons infected with human immunodeficiency virus (HIV), regardless of CD4 count, both for the benefit of infected individuals and to prevent HIV transmission. In an effort to meet the critical goal of treating all HIV-infected persons worldwide, there is movement toward extrapolating these guidelines and the data supporting them to resource-limited settings. While economic and practical barriers to universal ART are widely recognized, there has been little discussion of the ethical considerations resulting from global disparities in the safety and efficacy of universal ART in these settings. We argue that the risk-benefit considerations for initiating ART are not the same worldwide due to limitations in the ART regimens used, laboratory monitoring, and consistent availability of ART, which raises ethical questions about universally applying US guidelines in resource-limited settings at the present time.

  11. The plateau in mnemonic resolution across large set sizes indicates discrete resource limits in visual working memory.

    PubMed

    Anderson, David E; Awh, Edward

    2012-07-01

    The precision of visual working memory (WM) representations declines monotonically with increasing storage load. Two distinct models of WM capacity predict different shapes for this precision-by-set-size function. Flexible-resource models, which assert a continuous allocation of resources across an unlimited number of items, predict a monotonic decline in precision across a large range of set sizes. Conversely, discrete-resource models, which assert a relatively small item limit for WM storage, predict that precision will plateau once this item limit is exceeded. Recent work has demonstrated such a plateau in mnemonic precision. Moreover, the set size at which mnemonic precision reached asymptote has been strongly predicted by estimated item limits in WM. In the present work, we extend this evidence in three ways. First, we show that this empirical pattern generalizes beyond orientation memory to color memory. Second, we rule out encoding limits as the source of discrete limits by demonstrating equivalent performance across simultaneous and sequential presentations of the memoranda. Finally, we demonstrate that the analytic approach commonly used to estimate precision yields flawed parameter estimates when the range of stimulus space is narrowed (e.g., a 180º rather than a 360º orientation space) and typical numbers of observations are collected. Such errors in parameter estimation reconcile an apparent conflict between our findings and others based on different stimuli. These findings provide further support for discrete-resource models of WM capacity.

  12. Developing open source, self-contained disease surveillance software applications for use in resource-limited settings

    PubMed Central

    2012-01-01

    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. PMID:22950686

  13. Transumbilical SILC Using Conventional Laparoscopic Instruments-Initial Experience in a Resource-Limited Setting.

    PubMed

    Wani, Mumtaz; Shahdhar, Muddassir; Sheikh, Umar

    2015-12-01

    In the era of minimal access, single-incision laparoscopic surgery is gaining popularity. Expensive ports, disposable hand instruments and flexible endoscopes have been utilised, but they increase the cost of operation. We report our initial experience of two-trocar single-incision laparoscopic cholecystectomy (SILC) in 70 patients using conventional instruments that can be adapted as a novel technique in achieving minimal trauma and aesthetic results in resource-limited hospitals. Between September 2011 and September 2012, 70 consecutive patients underwent an attempted SILC in a single centre. The mean age of the patients was 42 years (range 18-65 years). There were 12 males and 58 females with a male-to-female ratio of 1:4.8. Transumbilical incision was used to access the abdomen, and two 10-mm ports/trocars were placed through the single incision side by side, maintaining a facial bridge of 5-8 mm in between. Gall bladder was manipulated through two strategically placed traction sutures to expose the Callot's triangle. Mean operation time in our series was 42.12 min (range 22-90 min). There was no need of additional sutures. Bleeding was minimal in nearly all cases. The mean hospital stay was 1.06 days (range 1-4 days). The post-operative analgesic requirement was one dose in 60.4 % patients. Additional port was required in two of our patients. Two patients needed conversion to open surgery. There was no major complication or mortality in our series. This technique of two-trocar SILC using conventional instruments can be adapted as a less invasive surgical procedure in resource-limited hospitals in selected group of patients. Cosmetic result, reduced pain, short hospital stay and the degree of satisfaction appear to be significant with this technique. PMID:26730076

  14. The Costs of Delivering Integrated HIV and Sexual Reproductive Health Services in Limited Resource Settings

    PubMed Central

    Obure, Carol Dayo; Sweeney, Sedona; Darsamo, Vanessa; Michaels-Igbokwe, Christine; Guinness, Lorna; Terris-Prestholt, Fern; Muketo, Esther; Nhlabatsi, Zelda; Warren, Charlotte E.; Mayhew, Susannah; Watts, Charlotte; Vassall, Anna

    2015-01-01

    Objective To present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services. Design A retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland. Methods Economic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider’s perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars. Results The mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to $Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity. Conclusion For all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements. PMID:25933414

  15. Delivering pediatric HIV care in resource-limited settings: cost considerations in an expanded response.

    PubMed

    Tolle, Michael A; Phelps, B Ryan; Desmond, Chris; Sugandhi, Nandita; Omeogu, Chinyere; Jamieson, David; Ahmed, Saeed; Reuben, Elan; Muhe, Lulu; Kellerman, Scott E

    2013-11-01

    If children are to be protected from HIV, the expansion of PMTCT programs must be complemented by increased provision of paediatric treatment. This is expensive, yet there are humanitarian, equity and children's rights arguments to justify the prioritization of treating HIV-infected children. In the context of limited budgets, inefficiencies cost lives, either through lower coverage or less effective services. With the goal of informing the design and expansion of efficient paediatric treatment programs able to utilize to greatest effect the available resources allocated to the treatment of HIV-infected children, this article reviews what is known about cost drivers in paediatric HIV interventions, and makes suggestions for improving efficiency in paediatric HIV programming. High-impact interventions known to deliver disproportional returns on investment are highlighted and targeted for immediate scale-up. Progress will carry a cost - increased funding, as well as additional data on intervention costs and outcomes, will be required if universal access of HIV-infected children to treatment is to be achieved and sustained. PMID:24361627

  16. Delivering pediatric HIV care in resource-limited settings: cost considerations in an expanded response.

    PubMed

    Tolle, Michael A; Phelps, B Ryan; Desmond, Chris; Sugandhi, Nandita; Omeogu, Chinyere; Jamieson, David; Ahmed, Saeed; Reuben, Elan; Muhe, Lulu; Kellerman, Scott E

    2013-11-01

    If children are to be protected from HIV, the expansion of PMTCT programs must be complemented by increased provision of paediatric treatment. This is expensive, yet there are humanitarian, equity and children's rights arguments to justify the prioritization of treating HIV-infected children. In the context of limited budgets, inefficiencies cost lives, either through lower coverage or less effective services. With the goal of informing the design and expansion of efficient paediatric treatment programs able to utilize to greatest effect the available resources allocated to the treatment of HIV-infected children, this article reviews what is known about cost drivers in paediatric HIV interventions, and makes suggestions for improving efficiency in paediatric HIV programming. High-impact interventions known to deliver disproportional returns on investment are highlighted and targeted for immediate scale-up. Progress will carry a cost - increased funding, as well as additional data on intervention costs and outcomes, will be required if universal access of HIV-infected children to treatment is to be achieved and sustained.

  17. Challenges in using mobile phones for collection of antiretroviral therapy adherence data in a resource-limited setting

    PubMed Central

    Haberer, Jessica E.; Kiwanuka, Julius; Nansera, Denis; Wilson, Ira B.; Bangsberg, David R

    2010-01-01

    Frequent antiretroviral therapy adherence monitoring could detect incomplete adherence before viral rebound develops and thus potentially prevent treatment failure. Mobile phone technologies make frequent, brief adherence interviews possible in resource-limited settings; however, feasibility and acceptability are unknown. Interactive voice response (IVR) and short message service (SMS) text messaging were used to collect adherence data from 19 caregivers of HIV-infected children in Uganda. IVR calls or SMS quantifying missed doses were sent in the local language once weekly for three to four weeks. Qualitative interviews were conducted to assess participant impressions of the technologies. Participant interest and participation rates were high; however, weekly completion rates for adherence queries were low (0-33%), most commonly due to misunderstanding of personal identification numbers. Despite near ubiquity of mobile phone technology in resource-limited settings, individual level collection of healthcare data presents challenges. Further research is needed for effective training and incentive methods. PMID:20532605

  18. Proposing evidence-based strategies to strengthen implementation of healthcare reform in resource-limited settings: a summative analysis

    PubMed Central

    Manyazewal, Tsegahun; Oosthuizen, Martha J; Matlakala, Mokgadi C

    2016-01-01

    Objectives Many resource-limited countries have adopted and implemented healthcare reform to improve the quality of healthcare, but few have had much impact and strategies in support of these efforts remain limited. We aimed to explore and propose evidence-based strategies to strengthen implementation of healthcare reform in resource-limited settings. Design Descriptive and exploratory designs in two phases. Phase I involved assessing the effectiveness of the healthcare reform implemented in Ethiopia in the form of business process reengineering, with evidence compiled from healthcare professionals through a self-administered questionnaire; and phase II involved proposing strategies and seeking consensus from experts using Delphi method. Setting Public hospitals in central Ethiopia. Participants 406 healthcare professionals and 10 senior health policy experts. Findings The healthcare reform that we evaluated was able to restructure hospital departments into case teams, with the goal of adopting a ‘one-stop shopping’ approach. However, shortages of critical infrastructure, furniture and supplies and job dissatisfaction continued to hamper the system. The most important predictors that influenced implementation of the reform were financial resources, top management commitment and support, collaborative working environment and information technology (IT). Five strategies with 14 operational objectives and 67 potential interventions that could strengthen the reform are proposed based on their strategic priority, which are as follows: reinforce patient-centred quality of care services; foster a healthy and respectful workforce environment; efficient and accountable leadership and governance; efficient use of hospital financing and maximise innovations and the use of health technologies. Conclusions Effective implementation of healthcare reform remained a challenge for governments in resource-limited settings. Resilient operational, clinical and governance functions

  19. An accurate and inexpensive color-based assay for detecting severe anemia in a limited-resource setting.

    PubMed

    McGann, Patrick T; Tyburski, Erika A; de Oliveira, Vysolela; Santos, Brigida; Ware, Russell E; Lam, Wilbur A

    2015-12-01

    Severe anemia is an important cause of morbidity and mortality among children in resource-poor settings, but laboratory diagnostics are often limited in these locations. To address this need, we developed a simple, inexpensive, and color-based point-of-care (POC) assay to detect severe anemia. The purpose of this study was to evaluate the accuracy of this novel POC assay to detect moderate and severe anemia in a limited-resource setting. The study was a cross-sectional study conducted on children with sickle cell anemia in Luanda, Angola. The hemoglobin concentrations obtained by the POC assay were compared to reference values measured by a calibrated automated hematology analyzer. A total of 86 samples were analyzed (mean hemoglobin concentration 6.6 g/dL). There was a strong correlation between the hemoglobin concentrations obtained by the POC assay and reference values obtained from an automated hematology analyzer (r=0.88, P<0.0001). The POC assay demonstrated excellent reproducibility (r=0.93, P<0.0001) and the reagents appeared to be durable in a tropical setting (r=0.93, P<0.0001). For the detection of severe anemia that may require blood transfusion (hemoglobin <5 g/dL), the POC assay had sensitivity of 88.9% and specificity of 98.7%. These data demonstrate that an inexpensive (<$0.25 USD) POC assay accurately estimates low hemoglobin concentrations and has the potential to become a transformational diagnostic tool for severe anemia in limited-resource settings.

  20. Evaluation of generic medical information accessed via mobile phones at the point of care in resource-limited settings

    PubMed Central

    Goldbach, Hayley; Chang, Aileen Y; Kyer, Andrea; Ketshogileng, Dineo; Taylor, Lynne; Chandra, Amit; Dacso, Matthew; Kung, Shiang-Ju; Rijken, Taatske; Fontelo, Paul; Littman-Quinn, Ryan; Seymour, Anne K; Kovarik, Carrie L

    2014-01-01

    Objective Many mobile phone resources have been developed to increase access to health education in the developing world, yet few studies have compared these resources or quantified their performance in a resource-limited setting. This study aims to compare the performance of resident physicians in answering clinical scenarios using PubMed abstracts accessed via the PubMed for Handhelds (PubMed4Hh) website versus medical/drug reference applications (Medical Apps) accessed via software on the mobile phone. Methods A two-arm comparative study with crossover design was conducted. Subjects, who were resident physicians at the University of Botswana, completed eight scenarios, each with multi-part questions. The primary outcome was a grade for each question. The primary independent variable was the intervention arm and other independent variables included residency and question. Results Within each question type there were significant differences in ‘percentage correct’ between Medical Apps and PubMed4Hh for three of the six types of questions: drug-related, diagnosis/definitions, and treatment/management. Within each of these question types, Medical Apps had a higher percentage of fully correct responses than PubMed4Hh (63% vs 13%, 33% vs 12%, and 41% vs 13%, respectively). PubMed4Hh performed better for epidemiologic questions. Conclusions While mobile access to primary literature remains important and serves an information niche, mobile applications with condensed content may be more appropriate for point-of-care information needs. Further research is required to examine the specific information needs of clinicians in resource-limited settings and to evaluate the appropriateness of current resources in bridging location- and context-specific information gaps. PMID:23535665

  1. Sankofa pediatric HIV disclosure intervention cyber data management: building capacity in a resource-limited setting and ensuring data quality

    PubMed Central

    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

    2015-01-01

    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

  2. Sankofa pediatric HIV disclosure intervention cyber data management: building capacity in a resource-limited setting and ensuring data quality.

    PubMed

    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

    2015-01-01

    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

  3. Emergency and urgent care capacity in a resource-limited setting: an assessment of health facilities in western Kenya

    PubMed Central

    Burke, Thomas F; Hines, Rosemary; Ahn, Roy; Walters, Michelle; Young, David; Anderson, Rachel Eleanor; Tom, Sabrina M; Clark, Rachel; Obita, Walter; Nelson, Brett D

    2014-01-01

    Objective Injuries, trauma and non-communicable diseases are responsible for a rising proportion of death and disability in low-income and middle-income countries. Delivering effective emergency and urgent healthcare for these and other conditions in resource-limited settings is challenging. In this study, we sought to examine and characterise emergency and urgent care capacity in a resource-limited setting. Methods We conducted an assessment within all 30 primary and secondary hospitals and within a stratified random sampling of 30 dispensaries and health centres in western Kenya. The key informants were the most senior facility healthcare provider and manager available. Emergency physician researchers utilised a semistructured assessment tool, and data were analysed using descriptive statistics and thematic coding. Results No lower level facilities and 30% of higher level facilities reported having a defined, organised approach to trauma. 43% of higher level facilities had access to an anaesthetist. The majority of lower level facilities had suture and wound care supplies and gloves but typically lacked other basic trauma supplies. For cardiac care, 50% of higher level facilities had morphine, but a minority had functioning ECG, sublingual nitroglycerine or a defibrillator. Only 20% of lower level facilities had glucometers, and only 33% of higher level facilities could care for diabetic emergencies. No facilities had sepsis clinical guidelines. Conclusions Large gaps in essential emergency care capabilities were identified at all facility levels in western Kenya. There are great opportunities for a universally deployed basic emergency care package, an advanced emergency care package and facility designation scheme, and a reliable prehospital care transportation and communications system in resource-limited settings. PMID:25260371

  4. Modelling the Medication Management System for Resource Limited Settings: A Formal Representation of the Prescribing and Dispensing Phases.

    PubMed

    Ogallo, William; Kanter, Andrew S

    2015-01-01

    We propose a conceptual data model for relational databases targeting the prescribing and dispensing phases of the medication management system. The model was developed using recommendations from existing standards and guidelines, with necessary modifications made to suit adoption in resource-limited settings. We present the model as an entity-relationship diagram with 10 entities, 12 relationships and 48 attributes. It is our hope that this work will help mitigate barriers in the implementation of electronic prescribing and dispensing standards in the developing world.

  5. Mobile device for disease diagnosis and data tracking in resource-limited settings.

    PubMed

    Guo, Tiffany W; Laksanasopin, Tassaneewan; Sridhara, Archana A; Nayak, Samiksha; Sia, Samuel K

    2015-01-01

    Here we describe a low-cost mobile device that combines cell-phone and satellite communication technologies with fluid miniaturization techniques for performing all essential functions of enzyme-linked immunosorbent assay (ELISA). Disease-specific antigens are immobilized on the microfluidic surface, and disease specific antibodies are captured on the surface and visualized with silver-gold amplification. The diagnostic result is automatically determined by the device by measuring the absorbance through the silver-gold amplification in the microchannel. The results are displayed for the user and are synchronized to a remote patient record. The overall system aims to be portable, robust, low-power, and fully utilize the ability of mobile devices for bringing better health care to resource poor areas. PMID:25626528

  6. Mobile device for disease diagnosis and data tracking in resource-limited settings.

    PubMed

    Guo, Tiffany W; Laksanasopin, Tassaneewan; Sridhara, Archana A; Nayak, Samiksha; Sia, Samuel K

    2015-01-01

    Here we describe a low-cost mobile device that combines cell-phone and satellite communication technologies with fluid miniaturization techniques for performing all essential functions of enzyme-linked immunosorbent assay (ELISA). Disease-specific antigens are immobilized on the microfluidic surface, and disease specific antibodies are captured on the surface and visualized with silver-gold amplification. The diagnostic result is automatically determined by the device by measuring the absorbance through the silver-gold amplification in the microchannel. The results are displayed for the user and are synchronized to a remote patient record. The overall system aims to be portable, robust, low-power, and fully utilize the ability of mobile devices for bringing better health care to resource poor areas.

  7. The development and implementation of a newborn medicine program in a resource-limited setting.

    PubMed

    Hansen, A; Magge, H; Labrecque, M; Munyaneza, R B M; Nahimana, E; Nyishime, M; Mwali, A

    2015-03-21

    The reduction in global neonatal mortality rates remains a challenge. Internationally recognized protocols for hospital care of sick and small newborns are limited, although this specialized area lends itself to standardization. An interdisciplinary team including international and local clinical experts worked with the Rwandan Ministry of Health and Rwandan professional associations to develop and implement a neonatal care program in a rural Rwandan district hospital that was ultimately accepted as the national standard for newborn medicine. Successful features and challenges are discussed. It is realistic to develop, implement and disseminate neonatal protocols for sick newborns.

  8. Facility-based constraints to exchange transfusions for neonatal hyperbilirubinemia in resource-limited settings

    PubMed Central

    Mabogunje, Cecilia A; Olaifa, Sarah M; Olusanya, Bolajoko O

    2016-01-01

    Several clinical guidelines for the management of infants with severe neonatal hyperbilirubinemia recommend immediate exchange transfusion (ET) when the risk or presence of acute bilirubin encephalopathy is established in order to prevent chronic bilirubin encephalopathy or kernicterus. However, the literature is sparse concerning the interval between the time the decision for ET is made and the actual initiation of ET, especially in low- and middle-income countries (LMICs) with significant resource constraints but high rates of ET. This paper explores the various stages and potential delays during this interval in complying with the requirement for immediate ET for the affected infants, based on the available evidence from LMICs. The vital role of intensive phototherapy, efficient laboratory and logistical support, and clinical expertise for ET are highlighted. The challenges in securing informed parental consent, especially on religious grounds, and meeting the financial burden of this emergency procedure to facilitate timely ET are examined. Secondary delays arising from post-treatment bilirubin rebound with intensive phototherapy or ET are also discussed. These potential delays can compromise the effectiveness of ET and should provide additional impetus to curtail avoidable ET in LMICs. PMID:27170928

  9. The impact of antiretroviral therapy in resource-limited settings and current HIV therapeutics.

    PubMed

    Kumarasamy, N

    2016-04-01

    Four million people of the global total of 35 million with HIV infection are from South-East Asia. ART is currently utilized by 15 million people and has led to a dramatic decline in the mortality rate, including those in low- and middle-income countries. A reduction in sexually transmitted HIV and in comorbidities including tuberculosis has also followed. Current recommendations for the initiation of antiretroviral therapy in people who are HIV+ are essentially to initiate ART irrespective of CD4 cell count and clinical stage. The frequency of HIV testing should be culturally specific and based on the HIV incidence in different key populations but phasing in viral load technology in LMIC is an urgent priority and this needs resources and capacity. With the availability of simplified potent ART regimens, persons with HIV now live longer. The recent WHO treatment guidelines recommending routine HIV testing and earlier initiation of treatment should be the stepping stone for ending the AIDS epidemic and to meet the UNAIDS mission of 90*90*90.

  10. Developmental monitoring using caregiver reports in a resource-limited setting: the case of Kilifi, Kenya

    PubMed Central

    Abubakar, A; Holding, P; Van de Vijver, F; Bomu, G; Van Baar, A

    2010-01-01

    Aim: The main aim of the current study was to evaluate the reliability, validity and acceptability of developmental monitoring using caregiver reports among mothers in a rural African setting. Methods: A structured interview for parents of children aged 24 months and less was developed through both participant consultation and a review of literature. The reliability and validity of the schedule was evaluated through a 10-month monitoring programme of 95 children, aged 2–10 months. The acceptability of the process was evaluated by studying retention rates and by organizing focus group discussions with participating mothers. Results: The structured interview ‘Developmental Milestones Checklist’ consisted of 66 items covering three broad domains of child functioning: motor, language and personal–social development. The interview yielded scores of developmental achievements that showed high internal consistency and excellent test–retest reliability. The results were sensitive to maturational changes and nutritional deficiencies. In addition, acceptable retention rates of approximately 80% were found. Participating mothers reported that they found the procedures both acceptable and beneficial. Conclusion: Developmental monitoring using caregiver report is a viable method to identify and monitor at-risk children in Sub-Saharan Africa. PMID:20353499

  11. Challenges in the management of iliofemoral deep vein thrombosis in a resource limited setting: a case series.

    PubMed

    Kesieme, Emeka Blessius; Okokhere, Peter; Eluehike, Sylvester; Isabu, Peter

    2014-01-01

    Iliofemoral deep vein thrombosis is a medical emergency associated with pulmonary embolism, severe postthrombotic morbidity and increased rates of recurrence. We present 3 cases of iliofemoral deep vein thrombosis managed in a setting of limited resources. Results of 2-D Ultrasound scan which suggested proximal DVT was confirmed by Doppler ultrasound scan. Patients were all managed by systemic anticoagulation alone. In experienced hands, it is possible to diagnose iliofemoral DVT with 2-D Ultrasound scan and treatment with systemic anticoagulation alone still has a role. However recent studies have proved clearly the superiority of thrombectomy over systemic anticoagulation alone. There is a need to improve the infrastructure and expertise of clinicians managing these conditions in underdeveloped settings to enable them offer the best to their patients.

  12. Acceptability of donated breast milk in a resource limited South African setting

    PubMed Central

    2011-01-01

    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 processes around donor breast

  13. Decentralization of CD4 testing in resource-limited settings: 7 years of experience in six African countries.

    PubMed

    Marinucci, F; Medina-Moreno, S; Paterniti, A D; Wattleworth, M; Redfield, R R

    2011-05-01

    Improving access to CD4 testing in resource-limited settings can be achieved through both centralized and decentralized testing networks. Decentralized testing models are more suitable for countries where the HIV epidemic affects a large portion of rural populations. Timely access to accurate CD4 results is crucial at the primary level of the health system. For the past 7 years, the Institute of Human Virology of the University of Maryland School of Medicine has implemented a flexible and sustainable three-phase model: (1) site assessment and improvement, (2) appropriate technology selection with capacity building through practical training and laboratory mentoring, and (3) quality management system strengthening and monitoring, to support accessibility to reliable CD4 counting at the point of service. CD4 testing capacity was established in 122 of 229 (53%) laboratories supported in Nigeria, Uganda, Kenya, Zambia, Tanzania, and Rwanda. Among those in rural settings, 46% (69/151) had CD4 testing available at site level, with a functioning flow cytometer installed at 28% (8/29) and 50% (61/122) of level 1 and level 2 sites, respectively. To strengthen local capacity, a total of 1,152 laboratory technicians were trained through 188 training sessions provided both on-site and at central locations. The overall quality of CD4 total testing procedure was assessed at 76% (92/121) of the laboratories, with 25% (23/92), 34% (31/92), and 33% (30/92) of them reporting excellent, good, and satisfactory performance. Balancing country-specific factors with the location of the clinic, number of patients, and the expected workload, was crucial in adapting this flexible model for decentralizing CD4 testing. The close collaboration with local governments and private vendors was key to successfully expanding access to CD4 testing within the framework of HIV care and treatment programs and for the sustainability of medical laboratories in resource-limited settings. PMID:21495181

  14. Best practices in developing a national palliative care policy in resource limited settings: lessons from five African countries.

    PubMed

    Luyirika, Emmanuel Bk; Namisango, Eve; Garanganga, Eunice; Monjane, Lidia; Ginindza, Ntombi; Madonsela, Gugulethu; Kiyange, Fatia

    2016-01-01

    Given the high unmet need for palliative care in Africa and other resource limited settings, it is important that countries embrace the public health approach to increasing access through its integration within existing healthcare systems. To give this approach a strong foundation that would ensure sustainability, the World Health Organisation urges member states to ensure that policy environments are suitable for this intervention. The development, strengthening, and implementation of national palliative care policies is a priority. Given the lack of a critical mass of palliative care professionals in the region and deficiency in documenting and sharing best practices as part of information critical for regional development, policy development becomes a complex process. This article shares experiences with regard to best practices when advocating the national palliative care policies. It also tells about policy development process, the important considerations, and cites examples of policy content outlines in Africa. PMID:27563347

  15. Best practices in developing a national palliative care policy in resource limited settings: lessons from five African countries.

    PubMed

    Luyirika, Emmanuel Bk; Namisango, Eve; Garanganga, Eunice; Monjane, Lidia; Ginindza, Ntombi; Madonsela, Gugulethu; Kiyange, Fatia

    2016-01-01

    Given the high unmet need for palliative care in Africa and other resource limited settings, it is important that countries embrace the public health approach to increasing access through its integration within existing healthcare systems. To give this approach a strong foundation that would ensure sustainability, the World Health Organisation urges member states to ensure that policy environments are suitable for this intervention. The development, strengthening, and implementation of national palliative care policies is a priority. Given the lack of a critical mass of palliative care professionals in the region and deficiency in documenting and sharing best practices as part of information critical for regional development, policy development becomes a complex process. This article shares experiences with regard to best practices when advocating the national palliative care policies. It also tells about policy development process, the important considerations, and cites examples of policy content outlines in Africa.

  16. Best practices in developing a national palliative care policy in resource limited settings: lessons from five African countries

    PubMed Central

    Luyirika, Emmanuel BK; Namisango, Eve; Garanganga, Eunice; Monjane, Lidia; Ginindza, Ntombi; Madonsela, Gugulethu; Kiyange, Fatia

    2016-01-01

    Given the high unmet need for palliative care in Africa and other resource limited settings, it is important that countries embrace the public health approach to increasing access through its integration within existing healthcare systems. To give this approach a strong foundation that would ensure sustainability, the World Health Organisation urges member states to ensure that policy environments are suitable for this intervention. The development, strengthening, and implementation of national palliative care policies is a priority. Given the lack of a critical mass of palliative care professionals in the region and deficiency in documenting and sharing best practices as part of information critical for regional development, policy development becomes a complex process. This article shares experiences with regard to best practices when advocating the national palliative care policies. It also tells about policy development process, the important considerations, and cites examples of policy content outlines in Africa. PMID:27563347

  17. Sickle cell disease and HIV: a case highlighting management challenges for children in a resource-limited setting.

    PubMed

    Odera, Esther Brenda; Kwobah, Charles; Stone, Geren; Some, Faraj; Vreeman, Rachel Christine

    2014-01-01

    Sickle cell disease (SCD) is a genetic disorder resulting from a mutation in the hemoglobin (Hb) gene. Sickle cell disease results in chronic anemia and a variety of acute and chronic complications that can lead to early mortality. A child with both SCD and HIV presents a management challenge, particularly in a resource-limited setting. In this case report, we describe the case of an 18-month-old Kenyan girl with SCD and HIV who developed a severe hypersensitivity reaction to first-line antiretroviral therapy (ART). Selecting an appropriate drug substitute for a child with SCD and HIV presents a management dilemma when the available options have problematic side effect profiles or are inaccessible or inappropriate according to national guidelines. The challenges in choosing an appropriate ART regimen for a child with SCD and HIV highlight the lack of data and scarcity of treatment options for pediatric patients.

  18. Low cost HIV-1 quantitative RT-PCR assay in resource-limited settings: improvement and implementation.

    PubMed

    Fibriani, Azzania; Farah, Nadya; Kusumadewi, Inri; Pas, Suzan D; van Crevel, Reinout; van der Ven, Andre; Boucher, Charles A B; Schutten, Martin

    2012-10-01

    Monitoring of HIV viral load in low and middle income settings is limited by high cost of the commercial assays. Therefore, we developed a novel RT-PCR quantitative assay was developed. This assay targets the HIV-1 pol integrase gene (INT). Subsequently, the performance of the INT assay, described previously as a Long Terminal Repeat (LTR) assay and a combined INT/LTR dual target RT-PCR assay was compared. The LTR-assay was found to be sensitive and cost-effective (50-70% cheaper than commercial assays) with the lowest coefficient of variation (%CV). Introduction of an internal standard further improved assay reliability. Therefore, this LTR assay was implemented in West Java, Indonesia. Linearity and precision of the LTR assay were good: %CV ranged from 1.0% to 10.4%. The limit of quantitation was 616 copies/ml. Performance was comparable with the commercial assay (Abbott assay) (r(2)=0.01), although on average the viral loads were 0.39 log(10)copies/ml lower. In clinical practice, it had excellent capability for monitoring treatment failure, the positive predictive value was 99% and the negative predictive value was 93%. In conclusion, the implementation of the improved HIV-1 viral load LTR-assay for routine diagnosis in resource poor settings can be a good alternative when commercial assays are unaffordable.

  19. International neurocognitive normative study: neurocognitive comparison data in diverse resource-limited settings: AIDS Clinical Trials Group A5271.

    PubMed

    Robertson, K; Jiang, H; Evans, S R; Marra, C M; Berzins, B; Hakim, J; Sacktor, N; Silva, M Tulius; Campbell, T B; 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

    2016-08-01

    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 impedes 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 ten 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 6 months. Participants were enrolled in eight strata, gender (female and male), education (<10 and ≥10 years), and age (<35 and ≥35 years). Of 2400 enrolled, 770 completed the 6-month follow-up. As expected, significant between-country differences were evident in all the neurocognitive test scores (p < 0.0001). 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 necessary neurocognitive normative data needed to build infrastructure for future neurological and neurocognitive studies in diverse RLS. These normative data are a much-needed resource for both clinicians and researchers. PMID:26733457

  20. Demonstrating the Efficacy of the FoneAstra Pasteurization Monitor for Human Milk Pasteurization in Resource-Limited Settings

    PubMed Central

    Coutsoudis, Anna; Israel-Ballard, Kiersten; Chaudhri, Rohit; Perin, Noah; Mlisana, Koleka

    2015-01-01

    Abstract Human milk provides crucial nutrition and immunologic protection for infants. When a mother's own milk is unavailable, donated human milk, pasteurized to destroy bacteria and viruses, is a lifesaving replacement. Flash-heat pasteurization is a simple, low-cost, and commonly used method to make milk safe, but currently there is no system to monitor milk temperature, which challenges quality control. FoneAstra, a smartphone-based mobile pasteurization monitor, removes this barrier by guiding users through pasteurization and documenting consistent and safe practice. This study evaluated FoneAstra's efficacy as a quality control system, particularly in resource-limited settings, by comparing bacterial growth in donor milk flash-heated with and without the device at a neonatal intensive care unit in Durban, South Africa. Materials and Methods: For 100 samples of donor milk, one aliquot each of prepasteurized milk, milk flash-heated without FoneAstra, and milk pasteurized with FoneAstra was cultured on routine agar for bacterial growth. Isolated bacteria were identified and enumerated. Results: In total, 300 samples (three from each donor sample) were analyzed. Bacterial growth was found in 86 of the 100 samples before any pasteurization and one of the 100 postpasteurized samples without FoneAstra. None of the samples pasteurized using FoneAstra showed bacterial growth. Conclusions: Both pasteurization methods were safe and effective. FoneAstra, however, provides the additional benefits of user-guided temperature monitoring and data tracking. By improving quality assurance and standardizing the pasteurization process, FoneAstra can support wide-scale implementation of human milk banks in resource-limited settings, increasing access and saving lives. PMID:25668396

  1. International neurocognitive normative study: neurocognitive comparison data in diverse resource-limited settings: AIDS Clinical Trials Group A5271.

    PubMed

    Robertson, K; Jiang, H; Evans, S R; Marra, C M; Berzins, B; Hakim, J; Sacktor, N; Silva, M Tulius; Campbell, T B; 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

    2016-08-01

    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 impedes 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 ten 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 6 months. Participants were enrolled in eight strata, gender (female and male), education (<10 and ≥10 years), and age (<35 and ≥35 years). Of 2400 enrolled, 770 completed the 6-month follow-up. As expected, significant between-country differences were evident in all the neurocognitive test scores (p < 0.0001). 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 necessary neurocognitive normative data needed to build infrastructure for future neurological and neurocognitive studies in diverse RLS. These normative data are a much-needed resource for both clinicians and researchers.

  2. Integrating sepsis management recommendations into clinical care guidelines for district hospitals in resource-limited settings: the necessity to augment new guidelines with future research.

    PubMed

    Jacob, Shevin T; Lim, Matthew; Banura, Patrick; Bhagwanjee, Satish; Bion, Julian; Cheng, Allen C; Cohen, Hillary; Farrar, Jeremy; Gove, Sandy; Hopewell, Philip; Moore, Christopher C; Roth, Cathy; West, T Eoin

    2013-04-18

    Several factors contribute to the high mortality attributed to severe infections in resource-limited settings. While improvements in survival and processes of care have been made in high-income settings among patients with severe conditions, such as sepsis, guidelines necessary for achieving these improvements may lack applicability or have not been tested in resource-limited settings. The World Health Organization's recent publication of the Integrated Management of Adolescent and Adult Illness District Clinician Manual provides details on how to optimize management of severely ill, hospitalized patients in such settings, including specific guidance on the management of patients with septic shock and respiratory failure without shock. This manuscript provides the context, process and underpinnings of these sepsis guidelines. In light of the current deficits in care and the limitations associated with these guidelines, the authors propose implementing these standardized best practice guidelines while using them as a foundation for sepsis research undertaken in, and directly relevant to, resource-limited settings.

  3. Challenges and priorities in the management of HIV/HBV and HIV/HCV coinfection in resource-limited settings.

    PubMed

    Easterbrook, Philippa; Sands, Anita; Harmanci, Hande

    2012-05-01

    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.

  4. Design of a Novel Low Cost Point of Care Tampon (POCkeT) Colposcope for Use in Resource Limited Settings

    PubMed Central

    Lam, Christopher T.; Krieger, Marlee S.; Gallagher, Jennifer E.; Asma, Betsy; Muasher, Lisa C.; Schmitt, John W.; Ramanujam, Nimmi

    2015-01-01

    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

  5. SAMBA HIV semiquantitative test, a new point-of-care viral-load-monitoring assay for resource-limited settings.

    PubMed

    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

    2014-09-01

    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 <1,000 copies/ml (SAMBA cutoff) or <5,000 copies/ml (WHO 2010 criterion; WHO, Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach, 2010). This study suggests that the 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.

  6. SAMBA HIV Semiquantitative Test, a New Point-of-Care Viral-Load-Monitoring Assay for Resource-Limited Settings

    PubMed Central

    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

    2014-01-01

    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 <1,000 copies/ml (SAMBA cutoff) or <5,000 copies/ml (WHO 2010 criterion; WHO, Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach, 2010). This study suggests that the 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. PMID:25031444

  7. Use of CHROMagar Candida for the presumptive identification of Candida species directly from clinical specimens in resource-limited settings

    PubMed Central

    Nadeem, Sayyada Ghufrana; Hakim, Shazia Tabassum; Kazmi, Shahana Urooj

    2010-01-01

    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

  8. Cell Phone-Based and Adherence Device Technologies for HIV Care and Treatment in Resource-Limited Settings: Recent Advances.

    PubMed

    Campbell, Jeffrey I; Haberer, Jessica E

    2015-12-01

    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.

  9. Management of HIV-associated tuberculosis in resource-limited settings: a state-of-the-art review

    PubMed Central

    2013-01-01

    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. PMID:24295487

  10. Evaluation and Acceptability of a Simplified Test of Visual Function at Birth in a Limited-Resource Setting.

    PubMed

    Carrara, Verena I; Darakomon, Mue Chae; Thin, Nant War War; Paw, Naw Ta Kaw; Wah, Naw; Wah, Hser Gay; Helen, Naw; Keereecharoen, Suporn; Paw, Naw Ta Mlar; Jittamala, Podjanee; Nosten, François H; Ricci, Daniela; McGready, Rose

    2016-01-01

    Neurological examination, including visual fixation and tracking of a target, is routinely performed in the Shoklo Malaria Research Unit postnatal care units on the Thailand-Myanmar border. We aimed to evaluate a simple visual newborn test developed in Italy and performed by non-specialized personnel working in neonatal care units. An intensive training of local health staff in Thailand was conducted prior to performing assessments at 24, 48 and 72 hours of life in healthy, low-risk term singletons. The 48 and 72 hours results were then compared to values obtained to those from Italy. Parents and staff administering the test reported on acceptability. One hundred and seventy nine newborns, between June 2011 and October 2012, participated in the study. The test was rapidly completed if the infant remained in an optimal behavioral stage (7 ± 2 minutes) but the test duration increased significantly (12 ± 4 minutes, p < 0.001) if its behavior changed. Infants were able to fix a target and to discriminate a colored face at 24 hours of life. Horizontal tracking of a target was achieved by 96% (152/159) of the infants at 48 hours. Circular tracking, stripe discrimination and attention to distance significantly improved between each 24-hour test period. The test was easily performed by non-specialized local staff and well accepted by the parents. Healthy term singletons in this limited-resource setting have a visual response similar to that obtained to gestational age matched newborns in Italy. It is possible to use these results as a reference set of values for the visual assessment in Karen and Burmese infants in the first 72 hours of life. The utility of the 24 hours test should be pursued. PMID:27300137

  11. Evaluation and Acceptability of a Simplified Test of Visual Function at Birth in a Limited-Resource Setting

    PubMed Central

    Carrara, Verena I.; Darakomon, Mue Chae; Thin, Nant War War; Paw, Naw Ta Kaw; Wah, Naw; Wah, Hser Gay; Helen, Naw; Keereecharoen, Suporn; Paw, Naw Ta Mlar; Jittamala, Podjanee; Nosten, François H.; Ricci, Daniela; McGready, Rose

    2016-01-01

    Neurological examination, including visual fixation and tracking of a target, is routinely performed in the Shoklo Malaria Research Unit postnatal care units on the Thailand-Myanmar border. We aimed to evaluate a simple visual newborn test developed in Italy and performed by non-specialized personnel working in neonatal care units. An intensive training of local health staff in Thailand was conducted prior to performing assessments at 24, 48 and 72 hours of life in healthy, low-risk term singletons. The 48 and 72 hours results were then compared to values obtained to those from Italy. Parents and staff administering the test reported on acceptability. One hundred and seventy nine newborns, between June 2011 and October 2012, participated in the study. The test was rapidly completed if the infant remained in an optimal behavioral stage (7 ± 2 minutes) but the test duration increased significantly (12 ± 4 minutes, p < 0.001) if its behavior changed. Infants were able to fix a target and to discriminate a colored face at 24 hours of life. Horizontal tracking of a target was achieved by 96% (152/159) of the infants at 48 hours. Circular tracking, stripe discrimination and attention to distance significantly improved between each 24-hour test period. The test was easily performed by non-specialized local staff and well accepted by the parents. Healthy term singletons in this limited-resource setting have a visual response similar to that obtained to gestational age matched newborns in Italy. It is possible to use these results as a reference set of values for the visual assessment in Karen and Burmese infants in the first 72 hours of life. The utility of the 24 hours test should be pursued. PMID:27300137

  12. Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings

    PubMed Central

    Modi, Payal; Glavis-Bloom, Justin; Nasrin, Sabiha; Guy, Allysia; Rege, Soham; Noble, Vicki E.; Alam, Nur H.; Levine, Adam C.

    2016-01-01

    Introduction 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. Objective To assess the accuracy of point-of-care ultrasound measurement of the aorta-to-IVC ratio as a predictor of dehydration in children. Methods 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. Results 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. Conclusions 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. PMID:26766306

  13. The Use of Pill Counts as a Facilitator of Adherence with Antiretroviral Therapy in Resource Limited Settings

    PubMed Central

    Achieng, Loice; Musangi, Helen; Billingsley, Katherine; Onguit, Sharon; Ombegoh, Edwin; Bryant, LeeAnn; Mwiindi, Jonathan; Smith, Nathaniel; Keiser, Philip

    2013-01-01

    Background Pill counts are often used to measure adherence to ART, but there is little data on how they affect adherence. We previously showed a bivariate relationship between clinicians counting pills and adherence in patients receiving HIV care in Kenya. We present a secondary analysis of the relationship between numbers of pill counts and clinical outcomes in resource limited settings Methods Patients initiating ART at Kijabe Hospital were monitored for the number of discretionary pill counts performed by their clinician in the first 6 months of ART. Subjects were followed for at least 1 year after enrollment. The number of clinician pill counts was correlated to ART adherence. The primary endpoints were time to treatment failure, defined as a detectable HIV-1 viral load, death; or loss to follow-up. Results Clinician pill counts were done at 68% of clinic visits for 304 subjects. There was a positive correlation between the number of clinician pill counts and ART adherence (r = 0.21, p <0.001). Patients were divided into 3 groups (0 counts, 1 to 3 counts, 4 to 7 counts) and exhibited adherence of 76%, 84%, and 92%, respectively (p = 0.004). Time to treatment failure for these groups was 220 days, 438 days, and 497 days (P<0.01), respectively. Time to virologic failure in living patients remaining in the cohort was longer in those with more pill count (P =0.02). Multi-variate analysis adjusting for co-variates affecting time to treatment failure found that that clinician pill counts were associated with a decreased risk of treatment failure (HR = 0.69, p =0.04). Conclusions The number of clinician pill count performed was independently associated with better adherence and a decreased risk of treatment failure. The use of clinician pill counts should be further studied as an adherence promoter through a randomized clinical trial. PMID:24339861

  14. Scaling Up the 2010 World Health Organization HIV Treatment Guidelines in Resource-Limited Settings: A Model-Based Analysis

    PubMed Central

    Walensky, Rochelle P.; Wood, Robin; Ciaranello, Andrea L.; Paltiel, A. David; Lorenzana, Sarah B.; Anglaret, Xavier; Stoler, Adam W.; Freedberg, Kenneth A.

    2010-01-01

    Background 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. Methods and Findings 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). Conclusions In settings where immediate implementation of all of the new WHO treatment guidelines is not feasible, ART initiation at CD4<350 cells

  15. Evaluation of atypical squamous cells on conventional cytology smears: An experience from a screening program practiced in limited resource settings

    PubMed Central

    Rekhi, Bharat; Ajit, Dulhan; Joseph, Santhosh K; Gawas, Sonali; Deodhar, Kedar K

    2010-01-01

    Background: The Bethesda system (TBS) 2001 has subdivided the category of atypical squamous cells (ASC) into: ASC-US (undetermined significance) and ASC-H (cannot exclude high-grade squamous intraepithelial lesion (HSIL)). The present study is an analysis of ASC-US and ASC-H cases diagnosed in a screening program practiced in limited resource settings. Methods: During the period January 2005 to December 2008, a total of 9190 smears were received, of which 568 were unsatisfactory. Cases initially diagnosed as ASC-US (n=74) and ASC-H (n=29) on conventional cytology smears were reviewed. Biopsy and human papilloma virus (HPV) results were available in limited cases. Results: On review, diagnosis of ASC-US was retained in 49 (66.2%) of the 74 initially diagnosed ASC-US cases. Remaining 12 cases were re-labeled as negative for intraepithelial lesion or malignancy (NILM), nine as low-grade squamous intraepithelial lesion (LSIL), three as ASC-H and one case as squamous carcinoma (SCC). Similarly, on review, diagnosis of ASC-H cases was retained in 17 of the 29 initially diagnosed ASC-H cases. Seven cases were re-labeled as NILM, three as HSIL and one case each as ASC-US and SCC. Overall, 8622 cases (96.6%) were diagnosed as NILM, 72 (0.83%) as LSIL, 121 (1.40%) as HSIL, 23 (0.26%) as SCC, 50 (0.57%) as ASC-US cases, 20 (0.23%) as ASC-H, five (0.05%) as atypical glandular cells (AGC) and two cases as adenocarcinomas. Out of 50 ASC-US cases, biopsy in 23 cases showed presence of CIN 1 in 16 cases (69.5%) and CIN 2 in one case (4.34%), while the remaining six cases were negative for CIN/malignancy. The remaining 20 cases with unavailable biopsy results were HPV-positive. Out of 20 ASC-H cases, biopsy in 15 revealed CIN 2 and above in 11 cases (73.3%). Three cases (20%) revealed CIN 1. Conclusions: Critical review is helpful in further reducing the number of ASC cases. The percentage of cases with CIN 2 and above is higher with ASC-H cases. The reason for relative increase in

  16. Allocating limited resources in a time of fiscal constraints: a priority setting case study from Dalhousie University Faculty of Medicine.

    PubMed

    Mitton, Craig; Levy, Adrian; Gorsky, Diane; MacNeil, Christina; Dionne, Francois; Marrie, Tom

    2013-07-01

    Facing a projected $1.4M deficit on a $35M operating budget for fiscal year 2011/2012, members of the Dalhousie University Faculty of Medicine developed and implemented an explicit, transparent, criteria-based priority setting process for resource reallocation. A task group that included representatives from across the Faculty of Medicine used a program budgeting and marginal analysis (PBMA) framework, which provided an alternative to the typical public-sector approaches to addressing a budget deficit of across-the-board spending cuts and political negotiation. Key steps to the PBMA process included training staff members and department heads on priority setting and resource reallocation, establishing process guidelines to meet immediate and longer-term fiscal needs, developing a reporting structure and forming key working groups, creating assessment criteria to guide resource reallocation decisions, assessing disinvestment proposals from all departments, and providing proposal implementation recommendations to the dean. All departments were required to submit proposals for consideration. The task group approved 27 service reduction proposals and 28 efficiency gains proposals, totaling approximately $2.7M in savings across two years. During this process, the task group faced a number of challenges, including a tight timeline for development and implementation (January to April 2011), a culture that historically supported decentralized planning, at times competing interests (e.g., research versus teaching objectives), and reductions in overall health care and postsecondary education government funding. Overall, faculty and staff preferred the PBMA approach to previous practices. Other institutions should use this example to set priorities in times of fiscal constraints.

  17. Allocating limited resources in a time of fiscal constraints: a priority setting case study from Dalhousie University Faculty of Medicine.

    PubMed

    Mitton, Craig; Levy, Adrian; Gorsky, Diane; MacNeil, Christina; Dionne, Francois; Marrie, Tom

    2013-07-01

    Facing a projected $1.4M deficit on a $35M operating budget for fiscal year 2011/2012, members of the Dalhousie University Faculty of Medicine developed and implemented an explicit, transparent, criteria-based priority setting process for resource reallocation. A task group that included representatives from across the Faculty of Medicine used a program budgeting and marginal analysis (PBMA) framework, which provided an alternative to the typical public-sector approaches to addressing a budget deficit of across-the-board spending cuts and political negotiation. Key steps to the PBMA process included training staff members and department heads on priority setting and resource reallocation, establishing process guidelines to meet immediate and longer-term fiscal needs, developing a reporting structure and forming key working groups, creating assessment criteria to guide resource reallocation decisions, assessing disinvestment proposals from all departments, and providing proposal implementation recommendations to the dean. All departments were required to submit proposals for consideration. The task group approved 27 service reduction proposals and 28 efficiency gains proposals, totaling approximately $2.7M in savings across two years. During this process, the task group faced a number of challenges, including a tight timeline for development and implementation (January to April 2011), a culture that historically supported decentralized planning, at times competing interests (e.g., research versus teaching objectives), and reductions in overall health care and postsecondary education government funding. Overall, faculty and staff preferred the PBMA approach to previous practices. Other institutions should use this example to set priorities in times of fiscal constraints. PMID:23702521

  18. Setting up home-based palliative care in countries with limited resources: a model from Sarawak, Malaysia

    PubMed Central

    Devi, B. C. R.; Corbex, M.

    2008-01-01

    Background: The provision of palliative care (PC) and opioids is difficult to ensure in remote areas in low- and middle-income countries. We describe here the set up of a home-care program in Sarawak (the Malaysian part of the Borneo Island), where half the population lives in villages that are difficult to access. Methods: The establishment of this program, initiated in 1994 by the Department of Radiotherapy of Sarawak General Hospital, consisted of training, empowering nurses, simplifying referral, facilitating access to medication, and increasing awareness among public and health professionals about PC. Results: The program has been sustainable and cost efficient, serving 936 patients in 2006. The total morphine usage in the program increased from <200 g in 1993 to >1400 g in 2006. The results show that pain medication can be provided even in remote areas with effective organization and empowerment of nurses, who were the most important determinants for the set up of this program. Education of family was also a key aspect. Conclusion: The authors believe that the experience gained in Sarawak may help other regions with low or middle resources in the set up of their PC program especially for their remote rural population. PMID:18641007

  19. The use of Minilabs to improve the testing capacity of regulatory authorities in resource limited settings: Tanzanian experience.

    PubMed

    Risha, Peter Gasper; Msuya, Zera; Clark, Malcolm; Johnson, Keith; Ndomondo-Sigonda, Margareth; Layloff, Thomas

    2008-08-01

    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. PMID:18282632

  20. A partnership model for implementing electronic health records in resource-limited primary care settings: experiences from two nurse-managed health centers

    PubMed Central

    Dennehy, Patricia; White, Mary P; Hamilton, Andrew; Pohl, Joanne M; Tanner, Clare; Onifade, Tiffiani J

    2011-01-01

    Objective 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. Materials and Methods 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. Results 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. Discussion 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. Conclusion 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. PMID:21828225

  1. Usability and Navigability of an HIV/AIDS Internet Intervention for Adolescents in a Resource Limited Setting

    PubMed Central

    Ybarra, Michele; Biringi, Ruth; Prescott, Tonya; Bull, Sheana S.

    2012-01-01

    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

  2. Simplification of antiretroviral therapy: a necessary step in the public health response to HIV/AIDS in resource-limited settings.

    PubMed

    Vitoria, Marco; Ford, Nathan; Doherty, Meg; Flexner, Charles

    2014-01-01

    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. PMID:25310534

  3. Simplification of antiretroviral therapy: a necessary step in the public health response to HIV/AIDS in resource-limited settings.

    PubMed

    Vitoria, Marco; Ford, Nathan; Doherty, Meg; Flexner, Charles

    2014-01-01

    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.

  4. The design and evaluation of a system for improved surveillance and prevention programmes in resource-limited settings using a hospital-based burn injury questionnaire

    PubMed Central

    Peck, Michael; Falk, Henry; Meddings, David; Sugerman, David; Mehta, Sumi; Sage, Michael

    2016-01-01

    Background Limited and fragmented data collection systems exist for burn injury. A global registry may lead to better injury estimates and identify risk factors. A collaborative effort involving the WHO, the Global Alliance for Clean Cookstoves, the CDC and the International Society for Burn Injuries was undertaken to simplify and standardise inpatient burn data collection. An expert panel of epidemiologists and burn care practitioners advised on the development of a new Global Burn Registry (GBR) form and online data entry system that can be expected to be used in resource-abundant or resource-limited settings. Methods International burn organisations, the CDC and the WHO solicited burn centre participation to pilot test the GBR system. The WHO and the CDC led a webinar tutorial for system implementation. Results During an 8-month period, 52 hospitals in 30 countries enrolled in the pilot and were provided the GBR instrument, guidance and a data visualisation tool. Evaluations were received from 29 hospitals (56%). Key findings Median time to upload completed forms was <10 min; physicians most commonly entered data (64%), followed by nurses (25%); layout, clarity, accuracy and relevance were all rated high; and a vast majority (85%) considered the GBR ‘highly valuable’ for prioritising, developing and monitoring burn prevention programmes. Conclusions The GBR was shown to be simple, flexible and acceptable to users. Enhanced regional and global understanding of burn epidemiology may help prioritise the selection, development and testing of primary prevention interventions for burns in resource-limited settings. PMID:27044496

  5. A capacity-based approach for addressing ancillary care needs: implications for research in resource limited settings.

    PubMed

    Bright, Patricia L; Nelson, Robert M

    2012-11-01

    A paediatric clinical trial conducted in a developing country is likely to encounter conditions or illnesses in participants unrelated to the study. Since local healthcare resources may be inadequate to meet these needs, research clinicians may face the dilemma of deciding when to provide ancillary care and to what extent. The authors propose a model for identifying ancillary care obligations that draws on assessments of urgency, the capacity of the local healthcare infrastructure and the capacity of the research infrastructure. The model lends itself to a decision tree that can be adapted to the local context and resources so as to provide procedural guidance. This approach can help in planning and establishing organisational policies that govern the provision of ancillary care.

  6. Potential Impact of a Free Online HIV Treatment Response Prediction System for Reducing Virological Failures and Drug Costs after Antiretroviral Therapy Failure in a Resource-Limited Setting

    PubMed Central

    Revell, Andrew D.; Wang, Dechao; Pozniak, Anton; Montaner, Julio S.; Lane, H. Clifford; Larder, Brendan A.

    2013-01-01

    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. PMID:24175292

  7. Quantification of print, radio and television exposure among previous blood donors in Kenya: an opportunity for encouraging repeat donation in a resource-limited setting?

    PubMed

    Basavaraju, S V; Mwangi, J; Kellogg, T A; Odawo, L; Marum, L H

    2010-10-01

    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.

  8. Quantification of print, radio and television exposure among previous blood donors in Kenya: an opportunity for encouraging repeat donation in a resource-limited setting?

    PubMed

    Basavaraju, S V; Mwangi, J; Kellogg, T A; Odawo, L; Marum, L H

    2010-10-01

    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. PMID:20598106

  9. Contribution of modifiable risk factors for hypertension and type-2 diabetes in Peruvian resource-limited settings

    PubMed Central

    Carrillo-Larco, Rodrigo M; Gilman, Robert H; Checkley, William; Smeeth, Liam

    2016-01-01

    Background It is important to understand the local burden of non-communicable diseases including within-country heterogeneity. The aim of this study was to characterise hypertension and type-2 diabetes profiles across different Peruvian geographical settings emphasising the assessment of modifiable risk factors. Methods Analysis of the CRONICAS Cohort Study baseline assessment was conducted. Cardiometabolic outcomes were blood pressure categories (hypertension, prehypertension, normal) and glucose metabolism disorder status (diabetes, prediabetes, normal). Exposures were study setting and six modifiable factors (smoking, alcohol drinking, leisure time and transport-related physical activity levels, TV watching, fruit/vegetables intake and obesity). Poisson regression models were used to report prevalence ratios (PR). Population attributable risks (PAR) were also estimated. Results Data from 3238 participants, 48.3% male, mean age 45.3 years, were analysed. Age-standardised (WHO population) prevalence of prehypertension and hypertension was 24% and 16%, whereas for prediabetes and type-2 diabetes it was 18% and 6%, respectively. Outcomes varied according to study setting (p<0.001). In multivariable model, hypertension was higher among daily smokers (PR 1.76), heavy alcohol drinkers (PR 1.61) and the obese (PR 2.06); whereas only obesity (PR 2.26) increased the prevalence of diabetes. PAR showed that obesity was an important determinant for hypertension (15.7%) and type-2 diabetes (23.9%). Conclusions There is an evident heterogeneity in the prevalence of and risk factors for hypertension and diabetes within Peru. Prehypertension and prediabetes are highly prevalent across settings. Our results emphasise the need of understanding the epidemiology of cardiometabolic conditions to appropriately implement interventions to tackle the burden of non-communicable diseases. PMID:26248550

  10. Reconciling surveillance systems with limited resources: an evaluation of passive surveillance for rabies in an endemic setting.

    PubMed

    Craighead, Laura; Gilbert, William; Subasinghe, Dynatra; Häsler, Barbara

    2015-10-01

    Surveillance systems for rabies in endemic regions are often subject to severe constraints in terms of resources. The World Organisation for Animal Health (OIE) and the World Health Organisation (WHO) propose the use of an active surveillance system to substantiate claims of disease freedom, including rabies. However, many countries do not have the resources to establish active surveillance systems for rabies and the testing of dead dogs poses logistical challenges. This paper explores the potential of using a scenario tree model parameterised with data collected via questionnaires and interviews to estimate the sensitivity of passive surveillance, assessing its potential as a viable low-cost alternative to active surveillance systems. The results of this explorative study illustrated that given a large enough sample size, in this case the entire population of Colombo City, the sensitivity of passive surveillance can be 100% even at a low disease prevalence (0.1%), despite the low sensitivity of individual surveillance components (mean values in the range 4.077×10(-5)-1.834×10(-3) at 1% prevalence). In addition, logistic regression was used to identify factors associated with increased recognition of rabies in dogs and reporting of rabies suspect dogs. Increased recognition was observed amongst dog owners (OR 3.8 (CI, 1.3-10.8)), people previously bitten by dogs (OR 5.9 (CI, 2.2-15.9)) and people who believed they had seen suspect dogs in the past (OR 4.7 (CI, 1.8-12.9)). Increased likelihood of reporting suspect dogs was observed amongst dog owners (OR 5.3 (CI, 1.1-25)). Further work is required to validate the data collection tool and the assumptions made in the model with respect to sample size in order to develop a robust methodology for evaluating passive rabies surveillance.

  11. Setting Time Limits on Tests

    ERIC Educational Resources Information Center

    van der Linden, Wim J.

    2011-01-01

    It is shown how the time limit on a test can be set to control the probability of a test taker running out of time before completing it. The probability is derived from the item parameters in the lognormal model for response times. Examples of curves representing the probability of running out of time on a test with given parameters as a function…

  12. Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions

    PubMed Central

    2011-01-01

    Early infant diagnosis (EID) of HIV-1 infection confers substantial benefits to HIV-infected and HIV-uninfected infants, to their families, and to programs providing prevention of mother-to-child transmission (PMTCT) services, but has been challenging to implement in resource-limited settings. In order to correctly inform parents/caregivers of infant infection status and link HIV-infected infants to care and treatment, a 'cascade' of events must successfully occur. A frequently cited barrier to expansion of EID programs is the cost of the required laboratory assays. However, substantial implementation barriers, as well as personnel and infrastructure requirements, exist at each step in the cascade. In this update, we review challenges to uptake at each step in the EID cascade, highlighting that even with the highest reported levels of uptake, nearly half of HIV-infected infants may not complete the cascade successfully. We next synthesize the available literature about the costs and cost effectiveness of EID programs; identify areas for future research; and place these findings within the context of the benefits and challenges to EID implementation in resource-limited settings. PMID:21599888

  13. Severe malnutrition and metabolic complications of HIV-infected children in the antiretroviral era: clinical care and management in resource-limited settings.

    PubMed

    Musoke, Philippa M; Fergusson, Pamela

    2011-12-01

    More than 2 million children globally are living with HIV infection and >90% of these reside in sub-Saharan Africa. Severe acute malnutrition (SAM) remains a major problem for HIV-infected children who live in resource-limited settings (RLS), and SAM is an important risk factor for mortality. SAM in HIV-infected children is associated with complications including electrolyte disorders, micronutrient deficiencies, and severe infections, which contribute to the high mortality. Access to antiretroviral therapy (ART) has significantly improved the survival of HIV-infected children, although the response to ART of children with SAM remains undocumented in the literature. Immune and virologic responses to ART in RLS are similar to those of infected children in resource-rich settings, but delays in initiation of therapy have led to a high early mortality. Antiretroviral drug toxicities have been described in children who receive therapy and may affect their quality of life and long-term survival. Metabolic complications of ART include lipodystrophy, dyslipidemia, lactic acidosis, insulin resistance, and osteopenia. These complications have been well described in adults and children from developed countries, but data from RLS are limited, and these complications may be compounded by SAM. In this article we review the epidemiology, clinical presentation, and complications of SAM in HIV-infected children and the metabolic complications of HIV-infected children in the era of ART, and discuss future research priorities for RLS.

  14. Comparison of Various Equations for Estimating GFR in Malawi: How to Determine Renal Function in Resource Limited Settings?

    PubMed Central

    Phiri, Sam; Rothenbacher, Dietrich; Neuhann, Florian

    2015-01-01

    Background Chronic kidney disease (CKD) is a probably underrated public health problem in Sub-Saharan-Africa, in particular in combination with HIV-infection. Knowledge about the CKD prevalence is scarce and in the available literature different methods to classify CKD are used impeding comparison and general prevalence estimates. Methods This study assessed different serum-creatinine based equations for glomerular filtration rates (eGFR) and compared them to a cystatin C based equation. The study was conducted in Lilongwe, Malawi enrolling a population of 363 adults of which 32% were HIV-positive. Results Comparison of formulae based on Bland-Altman-plots and accuracy revealed best performance for the CKD-EPI equation without the correction factor for black Americans. Analyzing the differences between HIV-positive and –negative individuals CKD-EPI systematically overestimated eGFR in comparison to cystatin C and therefore lead to underestimation of CKD in HIV-positives. Conclusions Our findings underline the importance for standardization of eGFR calculation in a Sub-Saharan African setting, to further investigate the differences with regard to HIV status and to develop potential correction factors as established for age and sex. PMID:26083345

  15. Challenges in Diagnosis, Treatment and Follow-up of Patients Presenting with Central Nervous System Infections in a Resource-Limited Setting

    PubMed Central

    Leligdowicz, Aleksandra; Katwere, Michael; Piloya, Theresa; Ronald, Allan; Kambugu, Andrew; Katabira, Elly

    2006-01-01

    Central Nervous System (CNS) infections are associated with significant mortality and morbidity. Accurate diagnosis is necessary for prompt treatment and increased chances of survival. However, there are many challenges to correct diagnoses in resource-limited settings, including the HIV epidemic, late presentation of symptomatic individuals, limited availability of laboratory diagnostic tests as well as treatment, and inadequate access to funds accompanied by lack of financial support from developed countries. This article presents case reports of patients admitted to the Mulago Hospital in Kampala, Uganda that exemplify challenging diagnoses of tuberculous meningitis (TBM), cryptococcal meningitis (CM), toxoplasmosis, and primary CNS lymphoma (PCNSL). Also included is a literature review of the pathology, diagnosis, and treatment of TBM, CM, toxoplasmosis, and PCNSL in immunocompromised patients. PMID:19529809

  16. Can HIV reverse transcriptase activity assay be a low-cost alternative for viral load monitoring in resource-limited settings?

    PubMed Central

    Gupta, Soham; Palchaudhuri, Riya; Neogi, Ujjwal; Srinivasa, Hiresave; Ashorn, Per; De Costa, Ayesha; Källander, Clas; Shet, Anita

    2016-01-01

    Objective To evaluate the performance and cost of an HIV reverse transcriptase-enzyme activity (HIV-RT) assay in comparison to an HIV-1 RNA assay for routine viral load monitoring in resource limited settings. Design A cohort-based longitudinal study. Setting Two antiretroviral therapy (ART) centres in Karnataka state, South India, providing treatment under the Indian AIDS control programme. Participants A cohort of 327 HIV-1-infected Indian adult patients initiating first-line ART. Outcome measures Performance and cost of an HIV-RT assay (ExaVir Load V3) in comparison to a gold standard HIV-1 RNA assay (Abbott m2000rt) in a cohort of 327 Indian patients before (WK00) and 4 weeks (WK04) after initiation of first-line therapy. Results Plasma viral load was determined by an HIV-1 RNA assay and an HIV-RT assay in 629 samples (302 paired samples and 25 single time point samples at WK00) obtained from 327 patients. Overall, a strong correlation of r=0.96 was observed, with good correlation at WK00 (r=0.84) and at WK04 (r=0.77). Bland-Altman analysis of all samples showed a good level of agreement with a mean difference (bias) of 0.22 log10copies/mL. The performance of ExaVir Load V3 was not negatively affected by a nevirapine/efavirenz based antiretroviral regimen. The per test cost of measuring plasma viral load by the Abbott m2000rt and ExaVir Load V3 assays in a basic lab setting was $36.4 and $16.8, respectively. Conclusions The strong correlation between the HIV-RT and HIV-1 RNA assays suggests that the HIV-RT assay can be an affordable alternative option for monitoring patients on antiretroviral therapy in resource-limited settings. Trial registration number ISRCTN79261738. PMID:26817634

  17. Parallel computation using limited resources

    SciTech Connect

    Sugla, B.

    1985-01-01

    This thesis addresses itself to the task of designing and analyzing parallel algorithms when the resources of processors, communication, and time are limited. The two parts of this thesis deal with multiprocessor systems and VLSI - the two important parallel processing environments that are prevalent today. In the first part a time-processor-communication tradeoff analysis is conducted for two kinds of problems - N input, 1 output, and N input, N output computations. In the class of problems of the second kind, the problem of prefix computation, an important problem due to the number of naturally occurring computations it can model, is studied. Finally, a general methodology is given for design of parallel algorithms that can be used to optimize a given design to a wide set of architectural variations. The second part of the thesis considers the design of parallel algorithms for the VLSI model of computation when the resource of time is severely restricted.

  18. Translating vaccine policy into action: a report from the Bill & Melinda Gates Foundation Consultation on the prevention of maternal and early infant influenza in resource-limited settings.

    PubMed

    Ortiz, Justin R; Neuzil, Kathleen M; Ahonkhai, Vincent I; Gellin, Bruce G; Salisbury, David M; Read, Jennifer S; Adegbola, Richard A; Abramson, Jon S

    2012-11-26

    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

  19. On Setting Limits for Supersymmetry

    NASA Astrophysics Data System (ADS)

    Simeon, Paul; Toback, David

    2004-10-01

    When searching for new particles two separate production mechanisms from the same theory may produce the same final state. For example, in gauge mediated supersymmetry breaking with \\chi^0_1arrow γ tildeG at least two production mechanisms, \\chi^0_1\\chi^±1 and \\chi^0_2\\chi^±_1, can cascade to produce events with two photons and missing transverse energy. If there is no discovery one wants to set the best possible limits. While it seems obvious that the goal is to find the lowest possible cross section limit, one should be careful and focus on excluding the largest amount of parameter space for a theory. We show that the combined cross section limit from both (or all) production mechanisms that produce the same final state is the most sensitive way to attempt to exclude a theory.

  20. Open-source point-of-care electronic medical records for use in resource-limited settings: systematic review and questionnaire surveys

    PubMed Central

    Bru, Juan; Berger, Christopher A

    2012-01-01

    Background Point-of-care electronic medical records (EMRs) are a key tool to manage chronic illness. Several EMRs have been developed for use in treating HIV and tuberculosis, but their applicability to primary care, technical requirements and clinical functionalities are largely unknown. Objectives This study aimed to address the needs of clinicians from resource-limited settings without reliable internet access who are considering adopting an open-source EMR. Study eligibility criteria Open-source point-of-care EMRs suitable for use in areas without reliable internet access. Study appraisal and synthesis methods The authors conducted a comprehensive search of all open-source EMRs suitable for sites without reliable internet access. The authors surveyed clinician users and technical implementers from a single site and technical developers of each software product. The authors evaluated availability, cost and technical requirements. Results The hardware and software for all six systems is easily available, but they vary considerably in proprietary components, installation requirements and customisability. Limitations This study relied solely on self-report from informants who developed and who actively use the included products. Conclusions and implications of key findings Clinical functionalities vary greatly among the systems, and none of the systems yet meet minimum requirements for effective implementation in a primary care resource-limited setting. The safe prescribing of medications is a particular concern with current tools. The dearth of fully functional EMR systems indicates a need for a greater emphasis by global funding agencies to move beyond disease-specific EMR systems and develop a universal open-source health informatics platform. PMID:22763661

  1. Feasibility intervention trial of two types of improved cookstoves in three resource-limited settings: study protocol for a randomized controlled trial

    PubMed Central

    2013-01-01

    Background Exposure to biomass fuel smoke is one of the leading risk factors for disease burden worldwide. International campaigns are currently promoting the widespread adoption of improved cookstoves in resource-limited settings, yet little is known about the cultural and social barriers to successful improved cookstove adoption and how these barriers affect environmental exposures and health outcomes. Design We plan to conduct a one-year crossover, feasibility intervention trial in three resource-limited settings (Kenya, Nepal and Peru). We will enroll 40 to 46 female primary cooks aged 20 to 49 years in each site (total 120 to 138). Methods At baseline, we will collect information on sociodemographic characteristics and cooking practices, and measure respiratory health and blood pressure for all participating women. An initial observational period of four months while households use their traditional, open-fire design cookstoves will take place prior to randomization. All participants will then be randomized to receive one of two types of improved, ventilated cookstoves with a chimney: a commercially-constructed cookstove (Envirofit G3300/G3355) or a locally-constructed cookstove. After four months of observation, participants will crossover and receive the other improved cookstove design and be followed for another four months. During each of the three four-month study periods, we will collect monthly information on self-reported respiratory symptoms, cooking practices, compliance with cookstove use (intervention periods only), and measure peak expiratory flow, forced expiratory volume at 1 second, exhaled carbon monoxide and blood pressure. We will also measure pulmonary function testing in the women participants and 24-hour kitchen particulate matter and carbon monoxide levels at least once per period. Discussion Findings from this study will help us better understand the behavioral, biological, and environmental changes that occur with a cookstove

  2. Thoracic ultrasound: An adjunctive and valuable imaging tool in emergency, resource-limited settings and for a sustainable monitoring of patients

    PubMed Central

    Trovato, Francesca M; Catalano, Daniela; Trovato, Guglielmo M

    2016-01-01

    Imaging workup of patients referred for elective assessment of chest disease requires an articulated approach: Imaging is asked for achieving timely diagnosis. The concurrent or subsequent use of thoracic ultrasound (TUS) with conventional (chest X-rays-) and more advanced imaging procedures (computed tomography and magnetic resonance imaging) implies advantages, limitations and actual problems. Indeed, despite TUS may provide useful imaging of pleura, lung and heart disease, emergency scenarios are currently the most warranted field of application of TUS: Pleural effusion, pneumothorax, lung consolidation. This stems from its role in limited resources subsets; actually, ultrasound is an excellent risk reducing tool, which acts by: (1) increasing diagnostic certainty; (2) shortening time to definitive therapy; and (3) decreasing problems from blind procedures that carry an inherent level of complications. In addition, paediatric and newborn disease are particularly suitable for TUS investigation, aimed at the detection of congenital or acquired chest disease avoiding, limiting or postponing radiological exposure. TUS improves the effectiveness of elective medical practice, in resource-limited settings, in small point of care facilities and particularly in poorer countries. Quality and information provided by the procedure are increased avoiding whenever possible artefacts that can prevent or mislead the achievement of the correct diagnosis. Reliable monitoring of patients is possible, taking into consideration that appropriate expertise, knowledge, skills, training, and even adequate equipment’s suitability are not always and everywhere affordable or accessible. TUS is complementary imaging procedure for the radiologist and an excellent basic diagnostic tool suitable to be shared with pneumologists, cardiologists and emergency physicians. PMID:27721940

  3. Genotype assays and third-line ART in resource-limited settings: A simulation and cost-effectiveness analysis of a planned clinical trial

    PubMed Central

    Lorenzana, Sarah B.; Hughes, Michael D.; Grinsztejn, Beatriz; Collier, Ann C.; Luz, Paula Mendes; Freedberg, Kenneth A.; Wood, Robin; Levison, Julie H.; Mugyenyi, Peter N.; Salata, Robert; Wallis, Carole L.; Weinstein, Milton C.; Schooley, Robert T.; Walensky, Rochelle P.

    2012-01-01

    Objectives To project the clinical and economic outcomes of a genotype assay for selection of third-line antiretroviral therapy (ART) in resource-limited settings, as per the planned international A5288 trial (MULTI-OCTAVE). Methods We used the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-International Model to compare three strategies for subjects who have failed second-line ART in South Africa: (1) Sustained second-line: no genotype assay, all subjects remain on second-line ART; (2) A5288: genotype to determine the resistance profile and assign an appropriate regimen; or (3) Population-based third-line: no genotype, all subjects switch to a potent third-line regimen. Model inputs are from published data in South Africa. Resistance profiles, ART regimens, and efficacy data were those used for trial planning. Results Projected life expectancy for sustained second-line, A5288, and population-based third-line are 61.1, 103.8, and 104.2 months. Compared to sustained second-line ($12,460), per person lifetime costs increase for the A5288 ($39,250) and population-based ($44,120) strategies. The incremental cost-effectiveness ratio of A5288, compared to sustained second-line, is $7,500/year of life saved (YLS), and for population-based third-line, compared to A5288, is $154,500/YLS. In the A5288 strategy, very late presentation to care, coupled with lengthy delays to obtain the genotype, dramatically reduces 5-yr survival, making the population-based third-line strategy more attractive. Conclusions We project that, while the public health approach to third-line therapy is unaffordable, genotype assays and third-line ART in resource-limited settings will increase survival and be cost-effective compared to the population-based approach, supporting the value of an efficacy study. PMID:22343964

  4. The Clinical and Economic Impact of Point-of-Care CD4 Testing in Mozambique and Other Resource-Limited Settings: A Cost-Effectiveness Analysis

    PubMed Central

    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.

    2014-01-01

    Background 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. Methods and Findings 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

  5. The accountability for reasonableness approach to guide priority setting in health systems within limited resources – findings from action research at district level in Kenya, Tanzania, and Zambia

    PubMed Central

    2014-01-01

    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

  6. Melt-and-mold fabrication (MnM-Fab) of reconfigurable low-cost devices for use in resource-limited settings.

    PubMed

    Li, Zhi; Tevis, Ian D; Oyola-Reynoso, Stephanie; Newcomb, Lucas B; Halbertsma-Black, Julian; Bloch, Jean-Francis; Thuo, Martin

    2015-12-01

    Interest in low-cost analytical devices (especially for diagnostics) has recently increased; however, concomitant translation to the field has been slow, in part due to personnel and supply-chain challenges in resource-limited settings. Overcoming some of these challenges require the development of a method that takes advantage of locally available resources and/or skills. We report a Melt-and-mold fabrication (MnM Fab) approach to low-cost and simple devices that has the potential to be adapted locally since it requires a single material that is recyclable and simple skills to access multiple devices. We demonstrated this potential by fabricating entry level bio-analytical devices using an affordable low-melting metal alloy, Field's metal, with molds produced from known materials such as plastic (acrylonitrile-butadiene-styrene (ABS)), glass, and paper. We fabricated optical gratings then 4×4 well plates using the same recycled piece of metal. We then reconfigured the well plates into rapid prototype microfluidic devices with which we demonstrated laminar flow, droplet generation, and bubble formation from T-shaped channels. We conclude that this MnM-Fab method is capable of addressing some challenges typically encountered with device translation, such as technical know-how or material supply, and that it can be applied to other devices, as needed in the field, using a single moldable material. PMID:26459439

  7. Computational models can predict response to HIV therapy without a genotype and may reduce treatment failure in different resource-limited settings

    PubMed Central

    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.

    2013-01-01

    Objectives 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. Methods 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. Results 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. Conclusions 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. PMID:23485767

  8. How Can We Improve Outcomes for Patients and Families Under Palliative Care? Implementing Clinical Audit for Quality Improvement in Resource Limited Settings

    PubMed Central

    Selman, Lucy; Harding, Richard

    2010-01-01

    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. PMID:20859465

  9. Effectiveness of flow inflating device in providing Continuous Positive Airway Pressure for critically ill children in limited-resource settings: A prospective observational study

    PubMed Central

    Anitha, G. Fatima Shirly; Velmurugan, Lakshmi; Sangareddi, Shanthi; Nedunchelian, Krishnamurthy; Selvaraj, Vinoth

    2016-01-01

    Background and Aims: Noninvasive ventilation (NIV) is an emerging popular concept, which includes bi-level positive airway pressure or continuous positive airway pressure (CPAP). In settings with scarce resources for NIV machines, CPAP can be provided through various indigenous means and one such mode is flow inflating device - Jackson-Rees circuit (JR)/Bain circuit. The study analyses the epidemiology, various clinical indications, predictors of CPAP failure, and stresses the usefulness of flow inflating device as an indigenous way of providing CPAP. Methods: A prospective observational study was undertaken in the critical care unit of a Government Tertiary Care Hospital, from November 2013 to September 2014. All children who required CPAP in the age group 1 month to 12 years of both sexes were included in this study. They were started on indigenous CPAP through flow inflating device on clinical grounds based on the pediatric assessment triangle, and the duration and outcome were analyzed. Results: This study population included 214 children. CPAP through flow inflating device was successful in 89.7% of cases, of which bronchiolitis accounted for 98.3%. A prolonged duration of CPAP support of >96 h was required in pneumonia. CPAP failure was noted in 10.3% of cases, the major risk factors being children <1 year and pneumonia with septic shock. Conclusion: We conclude that flow inflating devices - JR/Bain circuit are effective as an indigenous CPAP in limited resource settings. Despite its benefits, CPAP is not a substitute for invasive ventilation, as when the need for intubation arises timely intervention is needed.

  10. Effectiveness of flow inflating device in providing Continuous Positive Airway Pressure for critically ill children in limited-resource settings: A prospective observational study

    PubMed Central

    Anitha, G. Fatima Shirly; Velmurugan, Lakshmi; Sangareddi, Shanthi; Nedunchelian, Krishnamurthy; Selvaraj, Vinoth

    2016-01-01

    Background and Aims: Noninvasive ventilation (NIV) is an emerging popular concept, which includes bi-level positive airway pressure or continuous positive airway pressure (CPAP). In settings with scarce resources for NIV machines, CPAP can be provided through various indigenous means and one such mode is flow inflating device - Jackson-Rees circuit (JR)/Bain circuit. The study analyses the epidemiology, various clinical indications, predictors of CPAP failure, and stresses the usefulness of flow inflating device as an indigenous way of providing CPAP. Methods: A prospective observational study was undertaken in the critical care unit of a Government Tertiary Care Hospital, from November 2013 to September 2014. All children who required CPAP in the age group 1 month to 12 years of both sexes were included in this study. They were started on indigenous CPAP through flow inflating device on clinical grounds based on the pediatric assessment triangle, and the duration and outcome were analyzed. Results: This study population included 214 children. CPAP through flow inflating device was successful in 89.7% of cases, of which bronchiolitis accounted for 98.3%. A prolonged duration of CPAP support of >96 h was required in pneumonia. CPAP failure was noted in 10.3% of cases, the major risk factors being children <1 year and pneumonia with septic shock. Conclusion: We conclude that flow inflating devices - JR/Bain circuit are effective as an indigenous CPAP in limited resource settings. Despite its benefits, CPAP is not a substitute for invasive ventilation, as when the need for intubation arises timely intervention is needed. PMID:27630454

  11. Retention of HIV-Infected Children in the First 12 Months of Anti-Retroviral Therapy and Predictors of Attrition in Resource Limited Settings: A Systematic Review

    PubMed Central

    Smith, Christiana; McFarland, Elizabeth J.

    2016-01-01

    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. PMID:27280404

  12. Understanding the barriers to setting up a healthcare quality improvement process in resource-limited settings: a situational analysis at the Medical Department of Kamuzu Central Hospital in Lilongwe, Malawi

    PubMed Central

    2014-01-01

    Background Knowledge regarding the best approaches to improving the quality of healthcare and their implementation is lacking in many resource-limited settings. The Medical Department of Kamuzu Central Hospital in Malawi set out to improve the quality of care provided to its patients and establish itself as a recognized centre in teaching, operations research and supervision of district hospitals. Efforts in the past to achieve these objectives were short-lived, and largely unsuccessful. Against this background, a situational analysis was performed to aid the Medical Department to define and prioritize its quality improvement activities. Methods A mix of quantitative and qualitative methods was applied using checklists for observed practice, review of registers, key informant interviews and structured patient interviews. The mixed methods comprised triangulation by including the perspectives of the clients, healthcare providers from within and outside the department, and the field researcher’s perspectives by means of document review and participatory observation. Results Human resource shortages, staff attitudes and shortage of equipment were identified as major constraints to patient care, and the running of the Medical Department. Processes, including documentation in registers and files and communication within and across cadres of staff were also found to be insufficient and thus undermining the effort of staff and management in establishing a sustained high quality culture. Depending on their past experience and knowledge, the stakeholder interviewees revealed different perspectives and expectations of quality healthcare and the intended quality improvement process. Conclusions Establishing a quality improvement process in resource-limited settings is an enormous task, considering the host of challenges that these facilities face. The steps towards changing the status quo for improved quality care require critical self-assessment, the willingness to change

  13. Optimising the manufacture, formulation, and dose of antiretroviral drugs for more cost-efficient delivery in resource-limited settings: a consensus statement.

    PubMed

    Crawford, Keith W; Ripin, David H Brown; Levin, Andrew D; Campbell, Jennifer R; Flexner, Charles

    2012-07-01

    It is expected that funding limitations for worldwide HIV treatment and prevention in resource-limited settings will continue, and, because the need for treatment scale-up is urgent, the emphasis on value for money has become an increasing priority. The Conference on Antiretroviral Drug Optimization--a collaborative project between the Clinton Health Access Initiative, the Johns Hopkins University School of Medicine, and the Bill & Melinda Gates Foundation--brought together process chemists, clinical pharmacologists, pharmaceutical scientists, physicians, pharmacists, and regulatory specialists to explore strategies for the reduction of antiretroviral drug costs. The antiretroviral drugs discussed were prioritised for consideration on the basis of their market impact, and the objectives of the conference were framed as discussion questions generated to guide scientific assessment of potential strategies. These strategies included modifications to the synthesis of the active pharmaceutical ingredient (API) and use of cheaper sources of raw materials in synthesis of these ingredients. Innovations in product formulation could improve bioavailability thus needing less API. For several antiretroviral drugs, studies show efficacy is maintained at doses below the approved dose (eg, efavirenz, lopinavir plus ritonavir, atazanavir, and darunavir). Optimising pharmacoenhancement and extending shelf life are additional strategies. The conference highlighted a range of interventions; optimum cost savings could be achieved through combining approaches. PMID:22742638

  14. Optimising the manufacture, formulation, and dose of antiretroviral drugs for more cost-efficient delivery in resource-limited settings: a consensus statement.

    PubMed

    Crawford, Keith W; Ripin, David H Brown; Levin, Andrew D; Campbell, Jennifer R; Flexner, Charles

    2012-07-01

    It is expected that funding limitations for worldwide HIV treatment and prevention in resource-limited settings will continue, and, because the need for treatment scale-up is urgent, the emphasis on value for money has become an increasing priority. The Conference on Antiretroviral Drug Optimization--a collaborative project between the Clinton Health Access Initiative, the Johns Hopkins University School of Medicine, and the Bill & Melinda Gates Foundation--brought together process chemists, clinical pharmacologists, pharmaceutical scientists, physicians, pharmacists, and regulatory specialists to explore strategies for the reduction of antiretroviral drug costs. The antiretroviral drugs discussed were prioritised for consideration on the basis of their market impact, and the objectives of the conference were framed as discussion questions generated to guide scientific assessment of potential strategies. These strategies included modifications to the synthesis of the active pharmaceutical ingredient (API) and use of cheaper sources of raw materials in synthesis of these ingredients. Innovations in product formulation could improve bioavailability thus needing less API. For several antiretroviral drugs, studies show efficacy is maintained at doses below the approved dose (eg, efavirenz, lopinavir plus ritonavir, atazanavir, and darunavir). Optimising pharmacoenhancement and extending shelf life are additional strategies. The conference highlighted a range of interventions; optimum cost savings could be achieved through combining approaches.

  15. Detection of cytomegalovirus DNA on dried blood spots collected from infants infected with HIV: an in-house method adaptable in resource-limited settings.

    PubMed

    Leruez-Ville, Marianne; Ngin, Sopeak; Guilleminot, Tiffany; Kfutwah, Anfumbom; Moussa, Sandrine; Tran, Ton; Nerrienet, Eric

    2013-11-01

    In countries with limited resources, infants infected with HIV are highly exposed to CMV co-infection which probably represents a major risk factor for disease progression in this population. This study aimed to evaluate the performance of a low cost CMV DNA extraction method from DBS and the feasibility of its implementation in laboratories of 4 countries with limited resources. DNA was extracted from DBS with a cationic resin (chelex 100) and amplified with an "in house" real time CMV PCR. Dilutions of a quantified whole blood sample were spotted on paper to evaluate the 95% detection limit. A DBS quality control panel was analyzed in all laboratories. CMV PCR was compared between DBS and liquid whole blood (gold standard) in 2 populations: 418 transplanted patients and 59 infants infected with HIV (median age of 2 months). The CMV PCR 95% detection limit in DBS was 3.87 log10 copies/mL. Its positive and negative predictive values for CMV diagnosis in infants infected with HIV were 100% and 87.5% respectively. Quality control panels gave consistent qualitative results in all laboratories. This assay had high predictive values for CMV diagnosis in infants infected with HIV and its implementation in resource-limited countries with limited resources is feasible. PMID:23891874

  16. Factors Associated with Immunological Discordance in HIV-Infected Patients Receiving Antiretroviral Therapy with Complete Viral Suppression in a Resource-Limited Setting.

    PubMed

    Mingbunjerdsuk, Pornpimol; Asdamongkol, Nakhon; Sungkanuparph, Somnuek

    2015-01-01

    "Immunological discordance," i.e., immunological failure despite complete viral suppression in human immunodeficiency virus (HIV)-infected patients receiving antiretroviral therapy (ART), is associated with increased risk of AIDS or death. To evaluate risk factors for immunological discordance in a resource-limited setting in which patients usually present late with low CD4 cell counts, we conducted a case-control study among HIV-infected patients receiving ART and having undetectable HIV RNA. The study included patients with immunological discordance (cases), which was defined as CD4 cell count < 30% above baseline and absolute CD4 cell count < 200 cells/mm(3) at the first 12 months of undetectable HIV RNA (<50 copies/mL). Patients without immunological discordance were included as controls. Of 142 patients (44 cases; 98 controls), the mean age was 38.6 ± 9.4 years and 67.6% were men; 65.5% had history of opportunistic infections. In multivariate analysis, only baseline CD4 cell count < 100 cells/mm(3) (odd ratio [OR], 2.53; 95% confidence interval [CI], 1.04-6.14; P = 0.040) and history of lost to follow-up (OR, 11.04; 95% CI, 2.87-42.46; P < 0.001) were significantly associated with immunological discordance. Early initiation of ART and intervention to improve regular clinic visit compliance and adherence to ART are crucial to prevent immunological discordance among HIV-infected patients.

  17. Strategies for more effective monitoring and evaluation systems in HIV programmatic scale-up in resource-limited settings: Implications for health systems strengthening.

    PubMed

    Nash, Denis; Elul, Batya; Rabkin, Miriam; Tun, May; Saito, Suzue; Becker, Mark; Nuwagaba-Biribonwoha, Harriet

    2009-11-01

    Program monitoring and evaluation (M&E) has the potential to be a cornerstone of health systems strengthening and of evidence-informed implementation and scale-up of HIV-related services in resource-limited settings. We discuss common challenges to M&E systems used in the rapid scale-up of HIV services as well as innovations that may have relevance to systems used to monitor, evaluate, and inform health systems strengthening. These include (1) Web-based applications with decentralized data entry and real-time access to summary reporting; (2) timely feedback of information to site and district staff; (3) site-level integration of traditionally siloed program area indicators; (4) longitudinal tracking of program and site characteristics; (5) geographic information systems; and (6) use of routinely collected aggregate data for epidemiologic analysis and operations research. Although conventionally used in the context of vertical programs, these approaches can form a foundation on which data relevant to other health services and systems can be layered, including prevention services, primary care, maternal-child health, and chronic disease management. Guiding principles for sustainable national M&E systems include country-led development and ownership, support for national programs and policies, interoperability, and employment of an open-source approach to software development. PMID:19858942

  18. Efficacy of loop mediated isothermal amplification (LAMP) assay for the laboratory identification of Mycobacterium tuberculosis isolates in a resource limited setting.

    PubMed

    Geojith, G; Dhanasekaran, S; Chandran, Salesh P; Kenneth, John

    2011-01-01

    Current methods of TB diagnosis are time consuming and less suited for developing countries. The LAMP (loop mediated isothermal amplification) is a rapid method more suitable for diagnosis in resource limited settings and has been proposed as a viable test requiring further evaluation for use as a laboratory method as well. We evaluated two LAMP assays, using culture lysates of clinical sputum samples (from Southern India) and compared it to a proprietary multiplex PCR reverse-hybridization line probe assay ('GenoType MTBC' from HAIN Lifescience GmbH, Germany). The LAMP procedure was modified to suit the local conditions. The Mycobacterium tuberculosis specific LAMP assay ('MTB LAMP') showed sensitivity and specificity, of 44.7% and 94.4% respectively in a 60 min format, 85.7% and 93.9% respectively in a 90 min format and 91.7%, and 90.9% respectively in a 120 min format. The Mycobacteria universal LAMP assay ('Muniv LAMP') showed a sensitivity of 99.1%. The LAMP was shown to be a rapid and accessible assay for the laboratory identification of M. tuberculosis isolates. Initial denaturation of template was shown to be essential for amplification in unpurified/dilute samples and longer incubation was shown to increase the sensitivity. The need for modification of protocols to yield better efficacy in this scenario needs to be addressed in subsequent studies. PMID:21047534

  19. Efficacy of loop mediated isothermal amplification (LAMP) assay for the laboratory identification of Mycobacterium tuberculosis isolates in a resource limited setting.

    PubMed

    Geojith, G; Dhanasekaran, S; Chandran, Salesh P; Kenneth, John

    2011-01-01

    Current methods of TB diagnosis are time consuming and less suited for developing countries. The LAMP (loop mediated isothermal amplification) is a rapid method more suitable for diagnosis in resource limited settings and has been proposed as a viable test requiring further evaluation for use as a laboratory method as well. We evaluated two LAMP assays, using culture lysates of clinical sputum samples (from Southern India) and compared it to a proprietary multiplex PCR reverse-hybridization line probe assay ('GenoType MTBC' from HAIN Lifescience GmbH, Germany). The LAMP procedure was modified to suit the local conditions. The Mycobacterium tuberculosis specific LAMP assay ('MTB LAMP') showed sensitivity and specificity, of 44.7% and 94.4% respectively in a 60 min format, 85.7% and 93.9% respectively in a 90 min format and 91.7%, and 90.9% respectively in a 120 min format. The Mycobacteria universal LAMP assay ('Muniv LAMP') showed a sensitivity of 99.1%. The LAMP was shown to be a rapid and accessible assay for the laboratory identification of M. tuberculosis isolates. Initial denaturation of template was shown to be essential for amplification in unpurified/dilute samples and longer incubation was shown to increase the sensitivity. The need for modification of protocols to yield better efficacy in this scenario needs to be addressed in subsequent studies.

  20. Developing the Botswana Primary Care Guideline: an integrated, symptom-based primary care guideline for the adult patient in a resource-limited setting

    PubMed Central

    Tsima, Billy M; Setlhare, Vincent; Nkomazana, Oathokwa

    2016-01-01

    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 patient outcomes as similar projects elsewhere have done. PMID:27570457

  1. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders

    PubMed Central

    Pop-Eleches, Cristian; Thirumurthy, Harsha; Habyarimana, James P.; Zivin, Joshua G.; Goldstein, Markus P.; de Walque, Damien; MacKeen, Leslie; Haberer, Jessica; Kimaiyo, Sylvester; Sidle, John; Ngare, Duncan; Bangsberg, David R.

    2013-01-01

    Objective There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. Design A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Methods Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. Results In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P=0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). Conclusion These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings. PMID:21252632

  2. The Cost-Effectiveness of Monitoring Strategies for Antiretroviral Therapy of HIV Infected Patients in Resource-Limited Settings: Software Tool

    PubMed Central

    Estill, Janne; Salazar-Vizcaya, Luisa; Blaser, Nello; Egger, Matthias; Keiser, Olivia

    2015-01-01

    Background The cost-effectiveness of routine viral load (VL) monitoring of HIV-infected patients on antiretroviral therapy (ART) depends on various factors that differ between settings and across time. Low-cost point-of-care (POC) tests for VL are in development and may make routine VL monitoring affordable in resource-limited settings. We developed a software tool to study the cost-effectiveness of switching to second-line ART with different monitoring strategies, and focused on POC-VL monitoring. Methods We used a mathematical model to simulate cohorts of patients from start of ART until death. We modeled 13 strategies (no 2nd-line, clinical, CD4 (with or without targeted VL), POC-VL, and laboratory-based VL monitoring, with different frequencies). We included a scenario with identical failure rates across strategies, and one in which routine VL monitoring reduces the risk of failure. We compared lifetime costs and averted disability-adjusted life-years (DALYs). We calculated incremental cost-effectiveness ratios (ICER). We developed an Excel tool to update the results of the model for varying unit costs and cohort characteristics, and conducted several sensitivity analyses varying the input costs. Results Introducing 2nd-line ART had an ICER of US$1651-1766/DALY averted. Compared with clinical monitoring, the ICER of CD4 monitoring was US$1896-US$5488/DALY averted and VL monitoring US$951-US$5813/DALY averted. We found no difference between POC- and laboratory-based VL monitoring, except for the highest measurement frequency (every 6 months), where laboratory-based testing was more effective. Targeted VL monitoring was on the cost-effectiveness frontier only if the difference between 1st- and 2nd-line costs remained large, and if we assumed that routine VL monitoring does not prevent failure. Conclusion Compared with the less expensive strategies, the cost-effectiveness of routine VL monitoring essentially depends on the cost of 2nd-line ART. Our Excel tool is

  3. Change in Vitamin D Levels Occurs Early after Antiretroviral Therapy Initiation and Depends on Treatment Regimen in Resource-Limited Settings

    PubMed Central

    Havers, Fiona P.; Detrick, Barbara; Cardoso, Sandra W.; Berendes, Sima; Lama, Javier R.; Sugandhavesa, Patcharaphan; Mwelase, Noluthando H.; Campbell, Thomas B.; Gupta, Amita

    2014-01-01

    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

  4. Dried tube specimens: a simple and cost-effective method for preparation of HIV proficiency testing panels and quality control materials for use in resource-limited settings.

    PubMed

    Parekh, Bharat S; Anyanwu, Juliana; Patel, Hetal; Downer, Marie; Kalou, Mireille; Gichimu, Catherine; Keipkerich, Bera Steven; Clement, Nelly; Omondi, Michael; Mayer, Oren; Ou, Chin-Yih; Nkengasong, John N

    2010-02-01

    HIV testing has rapidly expanded worldwide, but proficiency testing (PT) programs to monitor and improve the quality of testing are often lacking in resource-limited settings (RLS). Traditional PT programs and quality control reagents use serum or plasma specimens requiring stringent conditions for storage and transportation. A novel, simple and easy to use approach, based on dried tube specimens (DTS), was developed that can help monitor the quality of HIV antibody testing in RLS. DTS were prepared by drying 20 microl of specimen overnight at room temperature. The addition of a green dye (0.1%) made the DTS pellets visible without affecting the test results. Before testing, the DTS were rehydrated with 200 microl of PBS-Tween buffer. A panel of 303 DTS samples (135 HIV positive and 168 HIV negative) was evaluated with two rapid tests. Sensitivity and specificity with the Determine HIV-1/2 test were 99.3% and 99.4%, respectively, and with OraQuick were 98.5% and 100%, respectively. Stability studies showed that HIV-specific antibodies in the DTS specimens were stable at 4 degrees C and 25 degrees C for 4 weeks, with only marginal decline at 37 degrees C and 45 degrees C over 4 weeks. The DTS-based PT program was piloted successfully in 24 testing sites in Kenya. Results demonstrate that the DTS is a simple to use, practical method to prepare and distribute PT panels and quality control specimens to monitor HIV testing practices in RLS. PMID:19878697

  5. Typhoid intestinal perforations at a University teaching hospital in Northwestern Tanzania: A surgical experience of 104 cases in a resource-limited setting

    PubMed Central

    2012-01-01

    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 (< 200 cells/μl), high ASA classes (III

  6. Estimating Gestational Age in Late Presenters to Antenatal Care in a Resource-Limited Setting on the Thai-Myanmar Border

    PubMed Central

    Moore, Kerryn A.; Simpson, Julie A.; Thomas, Kyla H.; Rijken, Marcus J.; White, Lisa J.; Lu Moo Dwell, Saw; Paw, Moo Kho; Wiladphaingern, Jacher; Pukrittayakamee, Sasithon; Nosten, François; Fowkes, Freya J. I.; McGready, Rose

    2015-01-01

    Estimating gestational age in resource-limited settings is prone to considerable inaccuracy because crown-rump length measured by ultrasound before 14 weeks gestation, the recommended method for estimating gestational age, is often unavailable. Judgements regarding provision of appropriate obstetric and neonatal care are dependent on accurate estimation of gestational age. We determined the accuracy of the Dubowitz Gestational Age Assessment, a population-specific symphysis-fundal height formula, and ultrasound biometry performed between 16 and 40 weeks gestation in estimating gestational age using pre-existing data from antenatal clinics of the Shoklo Malaria Research Unit on the Thai-Myanmar border, where malaria is endemic. Two cohorts of women who gave birth to live singletons were analysed: 1) 250 women who attended antenatal care between July 2001 and May 2006 and had both ultrasound crown-rump length (reference) and a Dubowitz Gestational Age Assessment; 2) 975 women attending antenatal care between April 2007 and October 2010 who had ultrasound crown-rump length, symphysis-fundal measurements, and an additional study ultrasound (biparietal diameter and head circumference) randomly scheduled between 16 and 40 weeks gestation. Mean difference in estimated newborn gestational age between methods and 95% limits of agreement (LOA) were determined from linear mixed-effects models. The Dubowitz method and the symphysis-fundal height formula performed well in term newborns, but overestimated gestational age of preterms by 2.57 weeks (95% LOA: 0.49, 4.65) and 3.94 weeks (95% LOA: 2.50, 5.38), respectively. Biparietal diameter overestimated gestational age by 0.83 weeks (95% LOA: -0.93, 2.58). Head circumference underestimated gestational age by 0.39 weeks (95% LOA: -2.60, 1.82), especially if measured after 24 weeks gestation. The results of this study can be used to quantify biases associated with alternative methods for estimating gestational age in the absence of

  7. Estimating Gestational Age in Late Presenters to Antenatal Care in a Resource-Limited Setting on the Thai-Myanmar Border.

    PubMed

    Moore, Kerryn A; Simpson, Julie A; Thomas, Kyla H; Rijken, Marcus J; White, Lisa J; Dwell, Saw Lu Moo; Paw, Moo Kho; Wiladphaingern, Jacher; Pukrittayakamee, Sasithon; Nosten, François; Fowkes, Freya J I; McGready, Rose

    2015-01-01

    Estimating gestational age in resource-limited settings is prone to considerable inaccuracy because crown-rump length measured by ultrasound before 14 weeks gestation, the recommended method for estimating gestational age, is often unavailable. Judgements regarding provision of appropriate obstetric and neonatal care are dependent on accurate estimation of gestational age. We determined the accuracy of the Dubowitz Gestational Age Assessment, a population-specific symphysis-fundal height formula, and ultrasound biometry performed between 16 and 40 weeks gestation in estimating gestational age using pre-existing data from antenatal clinics of the Shoklo Malaria Research Unit on the Thai-Myanmar border, where malaria is endemic. Two cohorts of women who gave birth to live singletons were analysed: 1) 250 women who attended antenatal care between July 2001 and May 2006 and had both ultrasound crown-rump length (reference) and a Dubowitz Gestational Age Assessment; 2) 975 women attending antenatal care between April 2007 and October 2010 who had ultrasound crown-rump length, symphysis-fundal measurements, and an additional study ultrasound (biparietal diameter and head circumference) randomly scheduled between 16 and 40 weeks gestation. Mean difference in estimated newborn gestational age between methods and 95% limits of agreement (LOA) were determined from linear mixed-effects models. The Dubowitz method and the symphysis-fundal height formula performed well in term newborns, but overestimated gestational age of preterms by 2.57 weeks (95% LOA: 0.49, 4.65) and 3.94 weeks (95% LOA: 2.50, 5.38), respectively. Biparietal diameter overestimated gestational age by 0.83 weeks (95% LOA: -0.93, 2.58). Head circumference underestimated gestational age by 0.39 weeks (95% LOA: -2.60, 1.82), especially if measured after 24 weeks gestation. The results of this study can be used to quantify biases associated with alternative methods for estimating gestational age in the absence of

  8. Limits set on lobbying deductions

    SciTech Connect

    Nelson, G.L. )

    1994-01-01

    Many utilities devote substantial resources to addressing issues through the legislative process. Under pre-1994 law, a taxpayer could deduct certain [open quotes]direct lobbying expenses.[close quotes] However, pre-1994 law barred deductions for political campaign expenses and [open quotes]grass roots[close quotes] lobbying expenses (costs incurred to influence the general public with respect to legislation, elections, or referenda). The law also barred deductions for dues paid to trade associations to the extent that their activities were composed of political campaign or grass-roots lobbying activities. The Omnibus Budget Reconciliation Act of 1993, signed by President Clinton on August 10, 1993, contains a provision that denies deductions for a broad range of lobbying expenses that were deductible before 1994. The new legislation will have a significant effect on the utility industry, both in terms of an increased after-tax cost of lobbying activities and an increased administrative burden to comply with the new rules. The new rules took effect January 1, 1994.

  9. Should viral load thresholds be lowered?: Revisiting the WHO definition for virologic failure in patients on antiretroviral therapy in resource-limited settings.

    PubMed

    Labhardt, Niklaus D; Bader, Joëlle; Lejone, Thabo Ishmael; Ringera, Isaac; Hobbins, Michael A; Fritz, Christiane; Ehmer, Jochen; Cerutti, Bernard; Puga, Daniel; Klimkait, Thomas

    2016-07-01

    The World Health Organization (WHO) guidelines on antiretroviral therapy (ART) define treatment failure as 2 consecutive viral loads (VLs) ≥1000 copies/mL. There is, however, little evidence supporting 1000 copies as an optimal threshold to define treatment failure. Objective of this study was to assess the correlation of the WHO definition with the presence of drug-resistance mutations in patients who present with 2 consecutive unsuppressed VL in a resource-limited setting.In 10 nurse-led clinics in rural Lesotho children and adults on first-line ART for ≥6 months received a first routine VL. Those with plasma VL ≥80 copies/mL were enrolled in a prospective study, receiving enhanced adherence counseling (EAC) and a follow-up VL after 3 months. After a second unsuppressed VL genotypic resistance testing was performed. Viruses with major mutations against ≥2 drugs of the current regimen were classified as "resistant".A total of 1563 adults and 191 children received a first routine VL. Of the 138 adults and 53 children with unsuppressed VL (≥80 copies/mL), 165 (116 adults; 49 children) had a follow-up VL after EAC; 108 (74 adults; 34 children) remained unsuppressed and resistance testing was successful. Ninety of them fulfilled the WHO definition of treatment failure (both VL ≥1000 copies/mL); for another 18 both VL were unsuppressed but with <1000 copies/mL. The positive predictive value (PPV) for the WHO failure definition was 81.1% (73/90) for the presence of resistant virus. Among the 18 with VL levels between 80 and 1000 copies/mL, thereby classified as "non-failures", 17 (94.4%) harbored resistant viruses. Lowering the VL threshold from 1000 copies/mL to 80 copies/mL at both determinations had no negative influence on the PPV (83.3%; 90/108).The current WHO-definition misclassifies patients who harbor resistant virus at VL below 1000 c/mL as "nonfailing." Lowering the threshold to VL ≥80 copies/mL identifies a significantly

  10. Neonatal hypothermia in low-resource settings

    PubMed Central

    Mullany, LC

    2010-01-01

    Hypothermia among newborns is considered an important contributor to neonatal morbidity and mortality in low resource settings. However, in these settings only limited progress has been made towards understanding the risk of mortality subsequent to hypothermia, describing how this relationship is dependent on both the degree or severity of exposure and the gestational age and weight status of the baby, and implementing interventions to mitigate both exposure and the associated risk of poor outcomes. Given the centrality of averting neonatal mortality to achieving global milestones towards reductions in child mortality by 2015, recent years have seen substantial resources and efforts to improve understanding of global epidemiology of neonatal health. In this seminar, a summary of the burden, consequences, and risk factors of neonatal hypothermia in low-resources settings is presented, with a particular focus on community-based data. Context-appropriate interventions for reducing hypothermia exposure and the role of these interventions in reducing global neonatal mortality burden are explored. PMID:21094417

  11. Prevalence of low bone mineral density among HIV patients on long-term suppressive antiretroviral therapy in resource limited setting of western India

    PubMed Central

    Dravid, Ameet; Kulkarni, Milind; Borkar, Amit; Dhande, Sachin

    2014-01-01

    Introduction Bone mineral density (BMD) assessment in HIV patients is sparsely done in resource limited settings. Materials and Methods 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. Results 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/m2 and median CD4 count 146 cells/mm3. All ART experienced patients had plasma viral load<400 copies/ml. Prevalence of low BMD amongst ART naive and ART experienced patients was 67% (osteopenia: 70.4%, osteoporosis: 29.6%) and 80.4% (osteopenia: 63.4%, osteoporosis: 36.6%), respectively (p=0.05). Mean T scores at lumbar spine and hip for ART naive and ART experienced patients were −1.37 and −0.9 versus −1.56 and −1.48 (p=0.05), respectively. Age, low BMI, current smoking, menopause, baseline CD4 count and exposure to ART were factors significantly associated with low overall BMD on univariate regression analysis. On multivariable logistic regression analysis age (p<0.001), low BMI (p<0.001), current smoking (0.05) and menopause (0.03) were associated

  12. Evaluation in Cameroon of a Novel, Simplified Methodology to Assist Molecular Microbiological Analysis of V. cholerae in Resource-Limited Settings

    PubMed Central

    Debes, Amanda K.; Ateudjieu, Jerome; Guenou, Etiene; Lopez, Anna Lena; Bugayong, Mark Philip; Retiban, Pearl Joy; Garrine, Marcelino; Mandomando, Inacio; Li, Shan; Stine, O. Colin; Sack, David A.

    2016-01-01

    Background 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. Methods and Findings 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. Conclusions 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

  13. Prospective Optimization with Limited Resources.

    PubMed

    Snider, Joseph; Lee, Dongpyo; Poizner, Howard; Gepshtein, Sergei

    2015-09-01

    The future is uncertain because some forthcoming events are unpredictable and also because our ability to foresee the myriad consequences of our own actions is limited. Here we studied how humans select actions under such extrinsic and intrinsic uncertainty, in view of an exponentially expanding number of prospects on a branching multivalued visual stimulus. A triangular grid of disks of different sizes scrolled down a touchscreen at a variable speed. The larger disks represented larger rewards. The task was to maximize the cumulative reward by touching one disk at a time in a rapid sequence, forming an upward path across the grid, while every step along the path constrained the part of the grid accessible in the future. This task captured some of the complexity of natural behavior in the risky and dynamic world, where ongoing decisions alter the landscape of future rewards. By comparing human behavior with behavior of ideal actors, we identified the strategies used by humans in terms of how far into the future they looked (their "depth of computation") and how often they attempted to incorporate new information about the future rewards (their "recalculation period"). We found that, for a given task difficulty, humans traded off their depth of computation for the recalculation period. The form of this tradeoff was consistent with a complete, brute-force exploration of all possible paths up to a resource-limited finite depth. A step-by-step analysis of the human behavior revealed that participants took into account very fine distinctions between the future rewards and that they abstained from some simple heuristics in assessment of the alternative paths, such as seeking only the largest disks or avoiding the smaller disks. The participants preferred to reduce their depth of computation or increase the recalculation period rather than sacrifice the precision of computation.

  14. Prospective Optimization with Limited Resources

    PubMed Central

    Snider, Joseph; Lee, Dongpyo; Poizner, Howard; Gepshtein, Sergei

    2015-01-01

    The future is uncertain because some forthcoming events are unpredictable and also because our ability to foresee the myriad consequences of our own actions is limited. Here we studied how humans select actions under such extrinsic and intrinsic uncertainty, in view of an exponentially expanding number of prospects on a branching multivalued visual stimulus. A triangular grid of disks of different sizes scrolled down a touchscreen at a variable speed. The larger disks represented larger rewards. The task was to maximize the cumulative reward by touching one disk at a time in a rapid sequence, forming an upward path across the grid, while every step along the path constrained the part of the grid accessible in the future. This task captured some of the complexity of natural behavior in the risky and dynamic world, where ongoing decisions alter the landscape of future rewards. By comparing human behavior with behavior of ideal actors, we identified the strategies used by humans in terms of how far into the future they looked (their “depth of computation”) and how often they attempted to incorporate new information about the future rewards (their “recalculation period”). We found that, for a given task difficulty, humans traded off their depth of computation for the recalculation period. The form of this tradeoff was consistent with a complete, brute-force exploration of all possible paths up to a resource-limited finite depth. A step-by-step analysis of the human behavior revealed that participants took into account very fine distinctions between the future rewards and that they abstained from some simple heuristics in assessment of the alternative paths, such as seeking only the largest disks or avoiding the smaller disks. The participants preferred to reduce their depth of computation or increase the recalculation period rather than sacrifice the precision of computation. PMID:26367309

  15. Prospective Optimization with Limited Resources.

    PubMed

    Snider, Joseph; Lee, Dongpyo; Poizner, Howard; Gepshtein, Sergei

    2015-09-01

    The future is uncertain because some forthcoming events are unpredictable and also because our ability to foresee the myriad consequences of our own actions is limited. Here we studied how humans select actions under such extrinsic and intrinsic uncertainty, in view of an exponentially expanding number of prospects on a branching multivalued visual stimulus. A triangular grid of disks of different sizes scrolled down a touchscreen at a variable speed. The larger disks represented larger rewards. The task was to maximize the cumulative reward by touching one disk at a time in a rapid sequence, forming an upward path across the grid, while every step along the path constrained the part of the grid accessible in the future. This task captured some of the complexity of natural behavior in the risky and dynamic world, where ongoing decisions alter the landscape of future rewards. By comparing human behavior with behavior of ideal actors, we identified the strategies used by humans in terms of how far into the future they looked (their "depth of computation") and how often they attempted to incorporate new information about the future rewards (their "recalculation period"). We found that, for a given task difficulty, humans traded off their depth of computation for the recalculation period. The form of this tradeoff was consistent with a complete, brute-force exploration of all possible paths up to a resource-limited finite depth. A step-by-step analysis of the human behavior revealed that participants took into account very fine distinctions between the future rewards and that they abstained from some simple heuristics in assessment of the alternative paths, such as seeking only the largest disks or avoiding the smaller disks. The participants preferred to reduce their depth of computation or increase the recalculation period rather than sacrifice the precision of computation. PMID:26367309

  16. Role of Diffusion-weighted Imaging in Acute Stroke Management using Low-field Magnetic Resonance Imaging in Resource-limited Settings

    PubMed Central

    Okorie, Chinonye K; Ogbole, Godwin I; Owolabi, Mayowa O; Ogun, Olufunmilola; Adeyinka, Abiodun; Ogunniyi, Adesola

    2015-01-01

    A variety of imaging modalities exist for the diagnosis of stroke. Several studies have been carried out to ascertain their contribution to the management of acute stroke and to compare the benefits and limitations of each modality. Diffusion-weighted imaging (DWI) has been described as the optimal imaging technique for diagnosing acute ischemic stroke, yet limited evidence is available on the value of DWI in the management of ischemic stroke with low-field magnetic resonance (MR) systems. Although high-field MR imaging (MRI) is desirable for DWI, low-field scanners provide an acceptable clinical compromise which is of importance to developing countries posed with the challenge of limited availability of high-field units. The purpose of this paper was to systematically review the literature on the usefulness of DWI in acute stroke management with low-field MRI scanners and present the experience in Nigeria. PMID:26709342

  17. Social determinants of health: Social forces that shape women and men's knowledge of reproductive health in a resource-limited setting.

    PubMed

    Namasasu, Jane; Chivers, Sarah; Costello, Leesa

    2016-10-01

    Social forces shape people's reproductive health in many ways. We examined people's knowledge about reproductive health using focus group data collected from 93 participants in rural districts of Malawi. Participants' perspectives were contextualized by explaining the socioeconomic, cultural, and gender factors that determine reproductive health for rural Malawians. Strategies to improve reproductive health care in environments lacking in health infrastructure, staff, and economic resources are then provided. We call for a reproductive health agenda to target preventive care by providing information about anatomy and biology, communicating information in culturally competent ways, and educating men and women over the life course.

  18. Novel molecular diagnostic tools for malaria elimination: a review of options from the point of view of high-throughput and applicability in resource limited settings.

    PubMed

    Britton, Sumudu; Cheng, Qin; McCarthy, James S

    2016-01-01

    As malaria transmission continues to decrease, an increasing number of countries will enter pre-elimination and elimination. To interrupt transmission, changes in control strategies are likely to require more accurate identification of all carriers of Plasmodium parasites, both symptomatic and asymptomatic, using diagnostic tools that are highly sensitive, high throughput and with fast turnaround times preferably performed in local health service settings. Currently available immunochromatographic lateral flow rapid diagnostic tests and field microscopy are unlikely to consistently detect infections at parasite densities less than 100 parasites/µL making them insufficiently sensitive for detecting all carriers. Molecular diagnostic platforms, such as PCR and LAMP, are currently available in reference laboratories, but at a cost both financially and in turnaround time. This review describes the recent progress in developing molecular diagnostic tools in terms of their capacity for high throughput and potential for performance in non-reference laboratories for malaria elimination. PMID:26879936

  19. Target Product Profile for a Diagnostic Assay to Differentiate between Bacterial and Non-Bacterial Infections and Reduce Antimicrobial Overuse in Resource-Limited Settings: An Expert Consensus.

    PubMed

    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

    2016-01-01

    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 <2 days of training to perform the assay. Further, given that the aim is to reduce inappropriate antimicrobial use as well as to deliver appropriate treatment for patients with bacterial infections, the group agreed on minimal diagnostic performance requirements of >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

  20. Target Product Profile for a Diagnostic Assay to Differentiate between Bacterial and Non-Bacterial Infections and Reduce Antimicrobial Overuse in Resource-Limited Settings: An Expert Consensus

    PubMed Central

    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.

    2016-01-01

    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 <2 days of training to perform the assay. Further, given that the aim is to reduce inappropriate antimicrobial use as well as to deliver appropriate treatment for patients with bacterial infections, the group agreed on minimal diagnostic performance requirements of >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

  1. Target Product Profile for a Diagnostic Assay to Differentiate between Bacterial and Non-Bacterial Infections and Reduce Antimicrobial Overuse in Resource-Limited Settings: An Expert Consensus.

    PubMed

    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

    2016-01-01

    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 <2 days of training to perform the assay. Further, given that the aim is to reduce inappropriate antimicrobial use as well as to deliver appropriate treatment for patients with bacterial infections, the group agreed on minimal diagnostic performance requirements of >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

  2. Using the Lives Saved Tool (LiST) to Model mHealth Impact on Neonatal Survival in Resource-Limited Settings

    PubMed Central

    Jo, Youngji; Labrique, Alain B.; Lefevre, Amnesty E.; Mehl, Garrett; Pfaff, Teresa; Walker, Neff; Friberg, Ingrid K.

    2014-01-01

    While the importance of mHealth scale-up has been broadly emphasized in the mHealth community, it is necessary to guide scale up efforts and investment in ways to help achieve the mortality reduction targets set by global calls to action such as the Millennium Development Goals, not merely to expand programs. We used the Lives Saved Tool (LiST)–an evidence-based modeling software–to identify priority areas for maternal and neonatal health services, by formulating six individual and combined interventions scenarios for two countries, Bangladesh and Uganda. Our findings show that skilled birth attendance and increased facility delivery as targets for mHealth strategies are likely to provide the biggest mortality impact relative to other intervention scenarios. Although further validation of this model is desirable, tools such as LiST can help us leverage the benefit of mHealth by articulating the most appropriate delivery points in the continuum of care to save lives. PMID:25014008

  3. Local innovation for improving primary care cardiology in resource-limited African settings: an insight on the Cardio Pad® project in Cameroon

    PubMed Central

    Jingi, Ahmadou M.; Kengne, André Pascal

    2014-01-01

    Cardiovascular disease (CVD) is an emerging threat to the health of populations in Africa. With the inadequate health infrastructures, understaffed and underfunded health systems, African countries are ill-prepared to cope with the increasing demand for care for CVD, particularly for populations in remote and underserved rural areas, where 60% of the population currently reside. Task shifting and telehealth have been suggested as strategies to overcome the current health workforce shortage in African countries, and to increase access to prevention and curative services for emerging CVD. However, strategies for promoting their incorporation into the existing health systems, have yet to be developed. The Cardio Pad® initiative (originating from Cameroon) seeks to provide appropriate solutions to improve the application of telemedicine for CVD prevention and control in remote African settings. The Cardio Pad® is a tele-cardiology device which provides a number of advantages in terms of cost, ease of use, autonomy and reduced technology requirements. It is a fully touch screen medical device which enables cardiac tests such as electrocardiograms (ECG) to be performed in remote underserved areas (rural areas for instance), while the test results are transferred wirelessly via mobile phone connection, to specialist physicians who can interpret them and provide assistance with case management. While most of the current telemedicine clinical services on the African continent receive most expertise from developed countries, the Cardio Pad®, a local invention by a 26-year-old Cameroon-trained engineer demonstrates how much innovative solutions to combat CVD and other health issues could and should be developed locally in Africa. PMID:25414826

  4. Making family planning accessible in resource-poor settings.

    PubMed

    Prata, Ndola

    2009-10-27

    It is imperative to make family planning more accessible in low resource settings. The poorest couples have the highest fertility, the lowest contraceptive use and the highest unmet need for contraception. It is also in the low resource settings where maternal and child mortality is the highest. Family planning can contribute to improvements in maternal and child health, especially in low resource settings where overall access to health services is limited. Four critical steps should be taken to increase access to family planning in resource-poor settings: (i) increase knowledge about the safety of family planning methods; (ii) ensure contraception is genuinely affordable to the poorest families; (iii) ensure supply of contraceptives by making family planning a permanent line item in healthcare system's budgets and (iv) take immediate action to remove barriers hindering access to family planning methods. In Africa, there are more women with an unmet need for family planning than women currently using modern methods. Making family planning accessible in low resource settings will help decrease the existing inequities in achieving desired fertility at individual and country level. In addition, it could help slow population growth within a human rights framework. The United Nations Population Division projections for the year 2050 vary between a high of 10.6 and a low of 7.4 billion. Given that most of the growth is expected to come from today's resource-poor settings, easy access to family planning could make a difference of billions in the world in 2050. PMID:19770158

  5. Efavirenz-based antiretroviral therapy versus nevirapine-including regimens for prevention of mother-to-child transmission of HIV option B plus in resource-limited settings: is there anything missing?

    PubMed

    De Nardo, Pasquale; Gentilotti, Elisa; Nguhuni, Boniface; Vairo, Francesco; Chaula, Zainab; Nicastri, Emanuele; Ippolito, Giuseppe

    2016-01-01

    In 2013, an estimated 1.5 million HIV-positive pregnant women gave birth, with 240,000 children worldwide acquiring HIV. More than 90% of new pediatric infections occurred in Sub-Saharan Africa. The latest WHO guidelines recommended efavirenz (EFV)-based antiretroviral therapy as the first-line regimen for prevention of mother-to-child transmission of HIV (PMTCT). On the other hand, some data suggest that nevirapine (NVP), a well-known antiretroviral, could still play a relevant role in PMTCT, especially in resource-limited settings (RLSs) where the fertility rate is dramatically high compared to developed countries. Given the lack of an unanimous consensus and definitive opinions, this paper goes through the reasons for WHO decisions and aims at refreshing the debate about NVP and EFV pros and cons for PMTCT in RLSs.

  6. Efavirenz-based antiretroviral therapy versus nevirapine-including regimens for prevention of mother-to-child transmission of HIV option B plus in resource-limited settings: is there anything missing?

    PubMed

    De Nardo, Pasquale; Gentilotti, Elisa; Nguhuni, Boniface; Vairo, Francesco; Chaula, Zainab; Nicastri, Emanuele; Ippolito, Giuseppe

    2016-01-01

    In 2013, an estimated 1.5 million HIV-positive pregnant women gave birth, with 240,000 children worldwide acquiring HIV. More than 90% of new pediatric infections occurred in Sub-Saharan Africa. The latest WHO guidelines recommended efavirenz (EFV)-based antiretroviral therapy as the first-line regimen for prevention of mother-to-child transmission of HIV (PMTCT). On the other hand, some data suggest that nevirapine (NVP), a well-known antiretroviral, could still play a relevant role in PMTCT, especially in resource-limited settings (RLSs) where the fertility rate is dramatically high compared to developed countries. Given the lack of an unanimous consensus and definitive opinions, this paper goes through the reasons for WHO decisions and aims at refreshing the debate about NVP and EFV pros and cons for PMTCT in RLSs. PMID:26559430

  7. Postpartum hemorrhage in resource-poor settings.

    PubMed

    Geller, S E; Adams, M G; Kelly, P J; Kodkany, B S; Derman, R J

    2006-03-01

    Despite the strong interest of international health agencies, worldwide maternal mortality has not declined substantially over the past 10 years. Postpartum hemorrhage (PPH) is the most common cause of maternal death across the world, responsible for more than 25% of deaths annually. Although effective tools for prevention and treatment of PPH are available, most are not feasible or practical for use in the developing world where many births still occur at home with untrained birth attendants. Application of many available clinical solutions in rural areas would necessitate substantial changes in government infrastructure and in local culture and customs surrounding pregnancy and childbirth. Before treatment can be administered, prompt and accurate diagnosis must be made, which requires training and appropriate blood measurement tools. After diagnosis, appropriate interventions that can be applied in remote settings are needed. Many uterotonics known to be effective in reducing PPH in tertiary care settings may not be useful in community settings because they require refrigeration and/or skilled administration. Moreover, rapid transfer to a higher level of care must be available, a challenge in many settings because of distance and lack of transportation. In light of these barriers, low-technological replacements for treatments commonly applied in the developed-world must be utilized. Community education, improvements to emergency care systems, training for birth attendants, misoprostol, and Uniject have shown promise as potential solutions. In the short term, it is expedient to capitalize on practical opportunities that utilize the existing strengths and resources in each community or region in order to implement appropriate solutions to save the lives of women during childbirth.

  8. Postpartum hemorrhage in resource-poor settings.

    PubMed

    Geller, S E; Adams, M G; Kelly, P J; Kodkany, B S; Derman, R J

    2006-03-01

    Despite the strong interest of international health agencies, worldwide maternal mortality has not declined substantially over the past 10 years. Postpartum hemorrhage (PPH) is the most common cause of maternal death across the world, responsible for more than 25% of deaths annually. Although effective tools for prevention and treatment of PPH are available, most are not feasible or practical for use in the developing world where many births still occur at home with untrained birth attendants. Application of many available clinical solutions in rural areas would necessitate substantial changes in government infrastructure and in local culture and customs surrounding pregnancy and childbirth. Before treatment can be administered, prompt and accurate diagnosis must be made, which requires training and appropriate blood measurement tools. After diagnosis, appropriate interventions that can be applied in remote settings are needed. Many uterotonics known to be effective in reducing PPH in tertiary care settings may not be useful in community settings because they require refrigeration and/or skilled administration. Moreover, rapid transfer to a higher level of care must be available, a challenge in many settings because of distance and lack of transportation. In light of these barriers, low-technological replacements for treatments commonly applied in the developed-world must be utilized. Community education, improvements to emergency care systems, training for birth attendants, misoprostol, and Uniject have shown promise as potential solutions. In the short term, it is expedient to capitalize on practical opportunities that utilize the existing strengths and resources in each community or region in order to implement appropriate solutions to save the lives of women during childbirth. PMID:16427056

  9. Food Cravings Consume Limited Cognitive Resources

    ERIC Educational Resources Information Center

    Kemps, Eva; Tiggemann, Marika; Grigg, Megan

    2008-01-01

    Using Tiffany's (1990) cognitive model of drug use and craving as a theoretical basis, the present experiments investigated whether cravings for food expend limited cognitive resources. Cognitive performance was assessed by simple reaction time (Experiment 1) and an established measure of working memory capacity, the operation span task…

  10. Molecular diagnostics for low resource settings

    NASA Astrophysics Data System (ADS)

    Weigl, Bernhard H.

    2010-03-01

    As traditional high quality diagnostic laboratories are not widely available or affordable in developing country health care settings, microfluidics-based point-of-care diagnostics may be able to address the need to perform complex assays in under-resourced areas. Many instrument-based as well as non-instrumented microfluidic prototype diagnostics are currently being developed. In addition to various engineering challenges, the greatest remaining issue is the search for truly low-cost disposable manufacturing methods. Diagnostics for global health, and specifically microfluidics and molecular-based low resource diagnostics, have become a very active research area over the last five years, thanks in part to new funding that became available from the Bill and Melinda Gates Foundation, the National Institutes of Health, and other sources. This has led to a number of interesting prototype devices that are now in advanced development or clinical validation. These devices include disposables and instruments that perform multiplexed PCR-based lab-on-a-chips for enteric, febrile, and vaginal diseases, as well as immunoassays for diseases such as malaria, HIV, and various sexually transmitted diseases. More recently, instrument-free diagnostic disposables based on isothermal nucleic acid amplification have been developed as well. Regardless of platform, however, the search for truly low-cost manufacturing methods that would result in cost of goods per disposable of around US1/unit at volume remains a big challenge. This talk will give an overview over existing platform development efforts as well as present some original research in this area at PATH.

  11. Microfluidic diagnostics for low-resource settings

    NASA Astrophysics Data System (ADS)

    Hawkins, Kenneth R.; Weigl, Bernhard H.

    2010-02-01

    Diagnostics for low-resource settings need to be foremost inexpensive, but also accurate, reliable, rugged and suited to the contexts of the developing world. Diagnostics for global health, based on minimally-instrumented, microfluidicsbased platforms employing low-cost disposables, has become a very active research area recently-thanks, in part, to new funding from the Bill & Melinda Gates Foundation, the National Institutes of Health, and other sources. This has led to a number of interesting prototype devices that are now in advanced development or clinical validation. These devices include disposables and instruments that perform multiplexed PCR-based assays for enteric, febrile, and vaginal diseases, as well as immunoassays for diseases such as malaria, HIV, and various sexually transmitted diseases. More recently, instrument-free diagnostic disposables based on isothermal nucleic-acid amplification have been developed. Regardless of platform, however, the search for truly low-cost manufacturing methods that would enable affordable systems (at volume, in the appropriate context) remains a significant challenge. Here we give an overview of existing platform development efforts, present some original research in this area at PATH, and reiterate a call to action for more.

  12. Long-term effectiveness of initiating non-nucleoside reverse transcriptase inhibitor- versus ritonavir-boosted protease inhibitor-based antiretroviral therapy: implications for first-line therapy choice in resource-limited settings

    PubMed Central

    Lima, Viviane D; Hull, Mark; McVea, David; Chau, William; Harrigan, P Richard; Montaner, Julio SG

    2016-01-01

    Introduction In many resource-limited settings, combination antiretroviral therapy (cART) failure is diagnosed clinically or immunologically. As such, there is a high likelihood that patients may stay on a virologically failing regimen for a substantial period of time. Here, we compared the long-term impact of initiating non-nucleoside reverse transcriptase inhibitor (NNRTI)- versus boosted protease inhibitor (bPI)-based cART in British Columbia (BC), Canada. Methods We followed prospectively 3925 ART-naïve patients who started NNRTIs (N=1963, 50%) or bPIs (N=1962; 50%) from 1 January 2000 until 30 June 2013 in BC. At six months, we assessed whether patients virologically failed therapy (a plasma viral load (pVL) >50 copies/mL), and we stratified them based on the pVL at the time of failure ≤500 versus >500 copies/mL. We then followed these patients for another six months and calculated their probability of achieving subsequent viral suppression (pVL <50 copies/mL twice consecutively) and of developing drug resistance. These probabilities were adjusted for fixed and time-varying factors, including cART adherence. Results At six months, virologic failure rates were 9.5 and 14.3 cases per 100 person-months for NNRTI and bPI initiators, respectively. NNRTI initiators who failed with a pVL ≤500 copies/mL had a 16% higher probability of achieving subsequent suppression at 12 months than bPI initiators (0.81 (25th–75th percentile 0.75–0.83) vs. 0.72 (0.61–0.75)). However, if failing NNRTI initiators had a pVL >500 copies/mL, they had a 20% lower probability of suppressing at 12 months than pVL-matched bPI initiators (0.37 (0.29–0.45) vs. 0.46 (0.38–0.54)). In terms of evolving HIV drug resistance, those who failed on NNRTI performed worse than bPI in all scenarios, especially if they failed with a viral load >500 copies/mL. Conclusions Our results show that patients who virologically failed at six months on NNRTI and continued on the same regimen had a

  13. Linking resources with demography to understand resource limitation for bears

    USGS Publications Warehouse

    Reynolds-Hogland, M. J.; Pacifici, L.B.; Mitchell, M.S.

    2007-01-01

    1. Identifying the resources that limit growth of animal populations is essential for effective conservation; however, resource limitation is difficult to quantify. Recent advances in geographical information systems (GIS) and resource modelling can be combined with demographic modelling to yield insights into resource limitation. 2. Using long-term data on a population of black bears Ursus americanus, we evaluated competing hypotheses about whether availability of hard mast (acorns and nuts) or soft mast (fleshy fruits) limited bears in the southern Appalachians, USA, during 1981-2002. The effects of clearcutting on habitat quality were also evaluated. Annual survival, recruitment and population growth rate were estimated using capture-recapture data from 101 females. The availability of hard mast, soft mast and clearcuts was estimated with a GIS, as each changed through time as a result of harvest and succession, and then availabilities were incorporated as covariates for each demographic parameter. 3. The model with the additive availability of hard mast and soft mast across the landscape predicted survival and population growth rate. Availability of young clearcuts predicted recruitment, but not population growth or survival. 4. Availability of hard mast stands across the landscape and availability of soft mast across the landscape were more important than hard mast production and availability of soft mast in young clearcuts, respectively. 5. Synthesis and applications. Our results indicate that older stands, which support high levels of hard mast and moderate levels of soft mast, should be maintained to sustain population growth of bears in the southern Appalachians. Simultaneously, the acreage of intermediate aged stands (10-25 years), which support very low levels of both hard mast and soft mast, should be minimized. The approach used in this study has broad application for wildlife management and conservation. State and federal wildlife agencies often

  14. On priority setting in preventive care resources.

    PubMed

    Courbage, Christophe

    2010-04-01

    Using an expected utility approach, we show that within a population that differs with respect to the probability of developing a disease, the allocation of preventive care resources should be prioritized based on the efficiency of prevention and not on whether individuals are at high or low risk of developing the disease. Should the efficiency of prevention be the same within the population, we show that the gravity of the disease, the presence of co-morbidities and the existence of uncertainty on health status can alternatively be considered so as to prioritize among preventive care resources. PMID:19353516

  15. Managing severe infection in infancy in resource poor settings

    PubMed Central

    Seale, Anna C.; Berkley, James A.

    2012-01-01

    Reducing childhood mortality in resource-poor regions depends on effective interventions to decrease neonatal mortality from severe infection, which contributes up to a half of all neonatal deaths. There are key differences in resource-poor, compared to resource-rich, countries in terms of diagnosis, supportive care and treatment. In resource-poor settings, diagnosis is based on identifying clinical syndromes from international guidelines; microbiological investigations are restricted to a few research facilities. Low levels of staffing and equipment limit the provision of basic supportive care, and most facilities cannot provide respiratory support. Empiric antibiotic treatment guidelines are based on few aetiological and antimicrobial susceptibility data. Research on improving health care systems to provide effective supportive care, and implementation of simple pragmatic interventions, such as low-cost respiratory support, are essential, together with improved surveillance to monitor emerging drug resistance and treatment failures. Reductions in mortality will also be achieved through prevention of infection; including emerging vaccination and anti-sepsis strategies. PMID:23031387

  16. Exploring nurses' and patients' perspectives of limit setting in a forensic mental health setting.

    PubMed

    Maguire, Tessa; Daffern, Michael; Martin, Trish

    2014-04-01

    Limit setting is an intervention that is frequently used by mental health nurses. However, limit setting is poorly conceptualized, its purpose is unclear, and there are few evidence-based guidelines to assist nurses to set limits in a safe and effective manner. What is known is that the manner in which nurses set limits influences patients' perceptions of the interactions and their emotional and behavioural responses. In this qualitative study, 12 nurses and 12 patients participated in personal, semistructured interviews that aimed to explore limit setting and to propose principles to guide practice. The findings suggested that: (i) limit setting is important to safety in mental health hospitals; (ii) engaging patients in an empathic manner is necessary when setting limits (when nurses engage in an empathic manner, the therapeutic relationship is more likely to be preserved and the risk of aggressive responses is reduced); and (iii) an authoritative (fair, respectful, consistent, and knowledgeable), rather than authoritarian (controlling and indifferent), limit-setting style enhances positive outcomes with regards to adherence, reduced likelihood of aggression, and preservation of the therapeutic relationship. In conclusion, a limit-setting style characterized by empathic responding and an authoritative, rather than authoritarian interpersonal, style is recommended. Elucidating the components of this style is critical for effective training and best practice of mental health nurses, and to reduce aggressive responses from limit setting.

  17. Exploring nurses' and patients' perspectives of limit setting in a forensic mental health setting.

    PubMed

    Maguire, Tessa; Daffern, Michael; Martin, Trish

    2014-04-01

    Limit setting is an intervention that is frequently used by mental health nurses. However, limit setting is poorly conceptualized, its purpose is unclear, and there are few evidence-based guidelines to assist nurses to set limits in a safe and effective manner. What is known is that the manner in which nurses set limits influences patients' perceptions of the interactions and their emotional and behavioural responses. In this qualitative study, 12 nurses and 12 patients participated in personal, semistructured interviews that aimed to explore limit setting and to propose principles to guide practice. The findings suggested that: (i) limit setting is important to safety in mental health hospitals; (ii) engaging patients in an empathic manner is necessary when setting limits (when nurses engage in an empathic manner, the therapeutic relationship is more likely to be preserved and the risk of aggressive responses is reduced); and (iii) an authoritative (fair, respectful, consistent, and knowledgeable), rather than authoritarian (controlling and indifferent), limit-setting style enhances positive outcomes with regards to adherence, reduced likelihood of aggression, and preservation of the therapeutic relationship. In conclusion, a limit-setting style characterized by empathic responding and an authoritative, rather than authoritarian interpersonal, style is recommended. Elucidating the components of this style is critical for effective training and best practice of mental health nurses, and to reduce aggressive responses from limit setting. PMID:23822138

  18. Addition of multiple limiting resources reduces grassland diversity

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Niche dimensionality is the most general theoretical explanation for biodiversity: more niches allow for more ecological tradeoffs between species and thus greater opportunities for coexistence. Resource competition theory predicts that removing resource limitations, by increasing resource availabil...

  19. Asthma Care in Resource-Poor Settings

    PubMed Central

    2011-01-01

    Asthma prevalence in low-to middle-income countries is at least the same or higher than in rich countries, but with increased severity. Lack of control in these settings is due to various factors such as low accessibility to effective medications, multiple and uncoordinated weak infrastructures of medical services for the management of chronic diseases such as asthma, poor compliance with prescribed therapy, lack of asthma education, and social and cultural factors. There is an urgent requirement for the implementation of better ways to treat asthma in underserved populations, enhancing the access to preventive medications and educational approaches with modern technological methods. PMID:23282401

  20. Neonatal Resuscitation in Low-Resource Settings.

    PubMed

    Berkelhamer, Sara K; Kamath-Rayne, Beena D; Niermeyer, Susan

    2016-09-01

    Almost one quarter of newborn deaths are attributed to birth asphyxia. Systematic implementation of newborn resuscitation programs has the potential to avert many of these deaths as basic resuscitative measures alone can reduce neonatal mortality. Simplified resuscitation training provided through Helping Babies Breathe decreases early neonatal mortality and stillbirth. However, challenges remain in providing every newborn the needed care at birth. Barriers include ineffective educational systems and programming; inadequate equipment, personnel and data monitoring; and limited political and social support to improve care. Further progress calls for renewed commitments to closing gaps in the quality of newborn resuscitative care. PMID:27524455

  1. 20 CFR 416.1205 - Limitation on resources.

    Code of Federal Regulations, 2013 CFR

    2013-04-01

    ... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false Limitation on resources. 416.1205 Section 416..., BLIND, AND DISABLED Resources and Exclusions § 416.1205 Limitation on resources. (a) Individual with no... XVI of the Act if his or her nonexcludable resources do not exceed $1,500 prior to January 1,...

  2. 20 CFR 416.1205 - Limitation on resources.

    Code of Federal Regulations, 2014 CFR

    2014-04-01

    ... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false Limitation on resources. 416.1205 Section 416..., BLIND, AND DISABLED Resources and Exclusions § 416.1205 Limitation on resources. (a) Individual with no... XVI of the Act if his or her nonexcludable resources do not exceed $1,500 prior to January 1,...

  3. 20 CFR 416.1205 - Limitation on resources.

    Code of Federal Regulations, 2012 CFR

    2012-04-01

    ... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false Limitation on resources. 416.1205 Section 416..., BLIND, AND DISABLED Resources and Exclusions § 416.1205 Limitation on resources. (a) Individual with no... XVI of the Act if his or her nonexcludable resources do not exceed $1,500 prior to January 1,...

  4. 20 CFR 416.1205 - Limitation on resources.

    Code of Federal Regulations, 2010 CFR

    2010-04-01

    ... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Limitation on resources. 416.1205 Section 416..., BLIND, AND DISABLED Resources and Exclusions § 416.1205 Limitation on resources. (a) Individual with no... XVI of the Act if his or her nonexcludable resources do not exceed $1,500 prior to January 1,...

  5. 20 CFR 416.1205 - Limitation on resources.

    Code of Federal Regulations, 2011 CFR

    2011-04-01

    ... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false Limitation on resources. 416.1205 Section 416..., BLIND, AND DISABLED Resources and Exclusions § 416.1205 Limitation on resources. (a) Individual with no... XVI of the Act if his or her nonexcludable resources do not exceed $1,500 prior to January 1,...

  6. Thermal protection of the newborn in resource-limited environments.

    PubMed

    Lunze, K; Hamer, D H

    2012-05-01

    Appropriate thermal protection of the newborn prevents hypothermia and its associated burden of morbidity and mortality. Yet, current global birth practices tend to not adequately address this challenge. Here, we discuss the pathophysiology of hypothermia in the newborn, its prevention and therapeutic options with particular attention to resource-limited environments. Newborns are equipped with sophisticated mechanisms of body temperature regulation. Neonatal thermoregulation is a critical function for newborn survival, regulated in the hypothalamus and mediated by endocrine pathways. Hypothermia activates cellular metabolism through shivering and non-shivering thermogenesis. In newborns, optimal temperature ranges are narrow and thermoregulatory mechanisms easily overwhelmed, particularly in premature and low-birth weight infants. Hyperthermia most commonly is associated with dehydration and potentially sepsis. The lack of thermal protection promptly leads to hypothermia, which is associated with detrimental metabolic and other pathophysiological processes. Simple thermal protection strategies are feasible at community and institutional levels in resource-limited environments. Appropriate interventions include skin-to-skin care, breastfeeding and protective clothing or devices. Due to poor provider training and limited awareness of the problem, appropriate thermal care of the newborn is often neglected in many settings. Education and appropriate devices might foster improved hypothermia management through mothers, birth attendants and health care workers. Integration of relatively simple thermal protection interventions into existing mother and child health programs can effectively prevent newborn hypothermia even in resource-limited environments. PMID:22382859

  7. Frugal innovation in medicine for low resource settings.

    PubMed

    Tran, Viet-Thi; Ravaud, Philippe

    2016-01-01

    Whilst it is clear that technology is crucial to advance healthcare: innovation in medicine is not just about high-tech tools, new procedures or genome discoveries. In constrained environments, healthcare providers often create unexpected solutions to provide adequate healthcare to patients. These inexpensive but effective frugal innovations may be imperfect, but they have the power to ensure that health is within reach of everyone. Frugal innovations are not limited to low-resource settings: ingenuous ideas can be adapted to offer simpler and disruptive alternatives to usual care all around the world, representing the concept of "reverse innovation". In this article, we discuss the different types of frugal innovations, illustrated with examples from the literature, and argue for the need to give voice to this neglected type of innovation in medicine. PMID:27383644

  8. Frugal innovation in medicine for low resource settings.

    PubMed

    Tran, Viet-Thi; Ravaud, Philippe

    2016-07-07

    Whilst it is clear that technology is crucial to advance healthcare: innovation in medicine is not just about high-tech tools, new procedures or genome discoveries. In constrained environments, healthcare providers often create unexpected solutions to provide adequate healthcare to patients. These inexpensive but effective frugal innovations may be imperfect, but they have the power to ensure that health is within reach of everyone. Frugal innovations are not limited to low-resource settings: ingenuous ideas can be adapted to offer simpler and disruptive alternatives to usual care all around the world, representing the concept of "reverse innovation". In this article, we discuss the different types of frugal innovations, illustrated with examples from the literature, and argue for the need to give voice to this neglected type of innovation in medicine.

  9. The oncology pharmacy in cancer care delivery in a resource-constrained setting in western Kenya.

    PubMed

    Strother, R Matthew; Rao, Kamakshi V; Gregory, Kelly M; Jakait, Beatrice; Busakhala, Naftali; Schellhase, Ellen; Pastakia, Sonak; Krzyzanowska, Monika; Loehrer, Patrick J

    2012-12-01

    The movement to deliver cancer care in resource-limited settings is gaining momentum, with particular emphasis on the creation of cost-effective, rational algorithms utilizing affordable chemotherapeutics to treat curable disease. The delivery of cancer care in resource-replete settings is a concerted effort by a team of multidisciplinary care providers. The oncology pharmacy, which is now considered integral to cancer care in resourced medical practice, developed over the last several decades in an effort to limit healthcare provider exposure to workplace hazards and to limit risk to patients. In developing cancer care services in resource-constrained settings, creation of oncology pharmacies can help to both mitigate the risks to practitioners and patients, and also limit the costs of cancer care and the environmental impact of chemotherapeutics. This article describes the experience and lessons learned in establishing a chemotherapy pharmacy in western Kenya.

  10. Habitat, not resource availability, limits consumer production in lake ecosystems

    USGS Publications Warehouse

    Craig, Nicola; Jones, Stuart E.; Weidel, Brian C.; Solomon, Christopher T.

    2015-01-01

    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.

  11. Cardiac rehabilitation delivery model for low-resource settings

    PubMed Central

    Grace, Sherry L; Turk-Adawi, Karam I; Contractor, Aashish; Atrey, Alison; Campbell, Norm; Derman, Wayne; Melo Ghisi, Gabriela L; Oldridge, Neil; Sarkar, Bidyut K; Yeo, Tee Joo; Lopez-Jimenez, Francisco; Mendis, Shanthi; Oh, Paul; Hu, Dayi; Sarrafzadegan, Nizal

    2016-01-01

    Objective Cardiovascular disease is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be cost-effective and efficacious in high-income countries. CR could represent an important approach to mitigate the epidemic of cardiovascular disease in lower-resource settings. The purpose of this consensus statement was to review low-cost approaches to delivering the core components of CR, to propose a testable model of CR which could feasibly be delivered in middle-income countries. Methods A literature review regarding delivery of each core CR component, namely: (1) lifestyle risk factor management (ie, physical activity, diet, tobacco and mental health), (2) medical risk factor management (eg, lipid control, blood pressure control), (3) education for self-management and (4) return to work, in low-resource settings was undertaken. Recommendations were developed based on identified articles, using a modified GRADE approach where evidence in a low-resource setting was available, or consensus where evidence was not. Results Available data on cost of CR delivery in low-resource settings suggests it is not feasible to deliver CR in low-resource settings as is delivered in high-resource ones. Strategies which can be implemented to deliver all of the core CR components in low-resource settings were summarised in practice recommendations, and approaches to patient assessment proffered. It is suggested that CR be adapted by delivery by non-physician healthcare workers, in non-clinical settings. Conclusions Advocacy to achieve political commitment for broad delivery of adapted CR services in low-resource settings is needed. PMID:27181874

  12. Evaluating intercepts from demographic models to understand resource limitation and resource thresholds

    USGS Publications Warehouse

    Reynolds-Hogland, M. J.; Hogland, J.S.; Mitchell, M.S.

    2008-01-01

    Understanding resource limitation is critical to effective management and conservation of wild populations, however resource limitation is difficult to quantify partly because resource limitation is a dynamic process. Specifically, a resource that is limiting at one time may become non-limiting at another time, depending upon changes in its availability and changes in the availability of other resources. Methods for understanding resource limitation, therefore, must consider the dynamic effects of resources on demography. We present approaches for interpreting results of demographic modeling beyond analyzing model rankings, model weights, slope estimates, and model averaging. We demonstrate how interpretation of y-intercepts, odds ratios, and rates of change can yield insights into resource limitation as a dynamic process, assuming logistic regression is used to link estimates of resources with estimates of demography. In addition, we show how x-intercepts can be evaluated with respect to odds ratios to understand resource thresholds. ?? 2007 Elsevier B.V. All rights reserved.

  13. Setting Win Limits: An Alternative Approach to "Responsible Gambling"?

    PubMed

    Walker, Douglas M; Litvin, Stephen W; Sobel, Russell S; St-Pierre, Renée A

    2015-09-01

    Social scientists, governments, and the casino industry have all emphasized the need for casino patrons to "gamble responsibly." Strategies for responsible gambling include self-imposed time limits and loss limits on gambling. Such strategies help prevent people from losing more than they can afford and may help prevent excessive gambling behavior. Yet, loss limits also make it more likely that casino patrons leave when they are losing. Oddly, the literature makes no mention of "win limits" as a potential approach to responsible gambling. A win limit would be similar to a loss limit, except the gambler would leave the casino upon reaching a pre-set level of winnings. We anticipate that a self-imposed win limit will reduce the gambler's average loss and, by default, also reduce the casino's profit. We test the effect of a self-imposed win limit by running slot machine simulations in which the treatment group of players has self-imposed and self-enforced win and loss limits, while the control group has a self-imposed loss limit or no limit. We find that the results conform to our expectations: the win limit results in improved player performance and reduced casino profits. Additional research is needed, however, to determine whether win limits could be a useful component of a responsible gambling strategy.

  14. Pollen source and resource limitation to fruit production in the rare species Eremosparton songoricum (Fabaceae)

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Eremosparton songoricum (Litv.) Vass. is a rare, central Asian desert species which shows lower fruit set and seed set (<16%) than most hermaphroditic species. We hypothesized that fruit production was limited by pollen and resources. To evaluate potential fruit abortion due to pollen limitation, su...

  15. Maternal characteristics and maternal limit-setting styles.

    PubMed

    LeCuyer-Maus, Elizabeth A; Houck, Gail M

    2002-01-01

    In a longitudinal study of 126 mothers and toddlers during toddlerhood, maternal limit-setting styles were assessed at 12, 24, and 36 months in relation to selected maternal characteristics. Mothers using teaching-based limit-setting styles at 12 months reported more optimal relationship histories of care and overprotection/control in their own families of origin. The main contributor to a maternal teaching-based limit-setting style in this sample was years of formal education, followed by a more multicausal conceptualization of how children develop. Thus, while years of formal education appear to facilitate the use of a teaching-based limit-setting style, formal education is not the only way to develop these skills. Maternal conceptualization of development may be amenable to intervention through a number of alternative learning activities. Further research is needed to explore the effects of different types of educational and learning opportunities on current maternal behavior, with the goal of optimizing socialization skills related to the development of toddler self-regulation.

  16. Nanoplasmonics simulations at the basis set limit through completeness-optimized, local numerical basis sets

    SciTech Connect

    Rossi, Tuomas P. Sakko, Arto; Puska, Martti J.; Lehtola, Susi; Nieminen, Risto M.

    2015-03-07

    We present an approach for generating local numerical basis sets of improving accuracy for first-principles nanoplasmonics simulations within time-dependent density functional theory. The method is demonstrated for copper, silver, and gold nanoparticles that are of experimental interest but computationally demanding due to the semi-core d-electrons that affect their plasmonic response. The basis sets are constructed by augmenting numerical atomic orbital basis sets by truncated Gaussian-type orbitals generated by the completeness-optimization scheme, which is applied to the photoabsorption spectra of homoatomic metal atom dimers. We obtain basis sets of improving accuracy up to the complete basis set limit and demonstrate that the performance of the basis sets transfers to simulations of larger nanoparticles and nanoalloys as well as to calculations with various exchange-correlation functionals. This work promotes the use of the local basis set approach of controllable accuracy in first-principles nanoplasmonics simulations and beyond.

  17. Nanoplasmonics simulations at the basis set limit through completeness-optimized, local numerical basis sets.

    PubMed

    Rossi, Tuomas P; Lehtola, Susi; Sakko, Arto; Puska, Martti J; Nieminen, Risto M

    2015-03-01

    We present an approach for generating local numerical basis sets of improving accuracy for first-principles nanoplasmonics simulations within time-dependent density functional theory. The method is demonstrated for copper, silver, and gold nanoparticles that are of experimental interest but computationally demanding due to the semi-core d-electrons that affect their plasmonic response. The basis sets are constructed by augmenting numerical atomic orbital basis sets by truncated Gaussian-type orbitals generated by the completeness-optimization scheme, which is applied to the photoabsorption spectra of homoatomic metal atom dimers. We obtain basis sets of improving accuracy up to the complete basis set limit and demonstrate that the performance of the basis sets transfers to simulations of larger nanoparticles and nanoalloys as well as to calculations with various exchange-correlation functionals. This work promotes the use of the local basis set approach of controllable accuracy in first-principles nanoplasmonics simulations and beyond. PMID:25747068

  18. Where and When do Species Interactions Set Range Limits?

    PubMed

    Louthan, Allison M; Doak, Daniel F; Angert, Amy L

    2015-12-01

    A long-standing theory, originating with Darwin, suggests that abiotic forces set species range limits at high latitude, high elevation, and other abiotically 'stressful' areas, while species interactions set range limits in apparently more benign regions. This theory is of considerable importance for both basic and applied ecology, and while it is often assumed to be a ubiquitous pattern, it has not been clearly defined or broadly tested. We review tests of this idea and dissect how the strength of species interactions must vary across stress gradients to generate the predicted pattern. We conclude by suggesting approaches to better test this theory, which will deepen our understanding of the forces that determine species ranges and govern responses to climate change.

  19. Estimating the CCSD basis-set limit energy from small basis sets: basis-set extrapolations vs additivity schemes

    NASA Astrophysics Data System (ADS)

    Spackman, Peter R.; Karton, Amir

    2015-05-01

    Coupled cluster calculations with all single and double excitations (CCSD) converge exceedingly slowly with the size of the one-particle basis set. We assess the performance of a number of approaches for obtaining CCSD correlation energies close to the complete basis-set limit in conjunction with relatively small DZ and TZ basis sets. These include global and system-dependent extrapolations based on the A + B/Lα two-point extrapolation formula, and the well-known additivity approach that uses an MP2-based basis-set-correction term. We show that the basis set convergence rate can change dramatically between different systems(e.g.it is slower for molecules with polar bonds and/or second-row elements). The system-dependent basis-set extrapolation scheme, in which unique basis-set extrapolation exponents for each system are obtained from lower-cost MP2 calculations, significantly accelerates the basis-set convergence relative to the global extrapolations. Nevertheless, we find that the simple MP2-based basis-set additivity scheme outperforms the extrapolation approaches. For example, the following root-mean-squared deviations are obtained for the 140 basis-set limit CCSD atomization energies in the W4-11 database: 9.1 (global extrapolation), 3.7 (system-dependent extrapolation), and 2.4 (additivity scheme) kJ mol-1. The CCSD energy in these approximations is obtained from basis sets of up to TZ quality and the latter two approaches require additional MP2 calculations with basis sets of up to QZ quality. We also assess the performance of the basis-set extrapolations and additivity schemes for a set of 20 basis-set limit CCSD atomization energies of larger molecules including amino acids, DNA/RNA bases, aromatic compounds, and platonic hydrocarbon cages. We obtain the following RMSDs for the above methods: 10.2 (global extrapolation), 5.7 (system-dependent extrapolation), and 2.9 (additivity scheme) kJ mol-1.

  20. Estimating the CCSD basis-set limit energy from small basis sets: basis-set extrapolations vs additivity schemes

    SciTech Connect

    Spackman, Peter R.; Karton, Amir

    2015-05-15

    Coupled cluster calculations with all single and double excitations (CCSD) converge exceedingly slowly with the size of the one-particle basis set. We assess the performance of a number of approaches for obtaining CCSD correlation energies close to the complete basis-set limit in conjunction with relatively small DZ and TZ basis sets. These include global and system-dependent extrapolations based on the A + B/L{sup α} two-point extrapolation formula, and the well-known additivity approach that uses an MP2-based basis-set-correction term. We show that the basis set convergence rate can change dramatically between different systems(e.g.it is slower for molecules with polar bonds and/or second-row elements). The system-dependent basis-set extrapolation scheme, in which unique basis-set extrapolation exponents for each system are obtained from lower-cost MP2 calculations, significantly accelerates the basis-set convergence relative to the global extrapolations. Nevertheless, we find that the simple MP2-based basis-set additivity scheme outperforms the extrapolation approaches. For example, the following root-mean-squared deviations are obtained for the 140 basis-set limit CCSD atomization energies in the W4-11 database: 9.1 (global extrapolation), 3.7 (system-dependent extrapolation), and 2.4 (additivity scheme) kJ mol{sup –1}. The CCSD energy in these approximations is obtained from basis sets of up to TZ quality and the latter two approaches require additional MP2 calculations with basis sets of up to QZ quality. We also assess the performance of the basis-set extrapolations and additivity schemes for a set of 20 basis-set limit CCSD atomization energies of larger molecules including amino acids, DNA/RNA bases, aromatic compounds, and platonic hydrocarbon cages. We obtain the following RMSDs for the above methods: 10.2 (global extrapolation), 5.7 (system-dependent extrapolation), and 2.9 (additivity scheme) kJ mol{sup –1}.

  1. Infertility in resource-constrained settings: moving towards amelioration.

    PubMed

    Hammarberg, Karin; Kirkman, Maggie

    2013-02-01

    It is often presumed that infertility is not a problem in resource-poor areas where fertility rates are high. This is challenged by consistent evidence that the consequences of childlessness are very severe in low-income countries, particularly for women. In these settings, childless women are frequently stigmatized, isolated, ostracized, disinherited and neglected by the family and local community. This may result in physical and psychological abuse, polygamy and even suicide. Attitudes among people in high-income countries towards provision of infertility care in low-income countries have mostly been either dismissive or indifferent as it is argued that scarce healthcare resources should be directed towards reducing fertility and restricting population growth. However, recognition of the plight of infertile couples in low-income settings is growing. One of the United Nation's Millennium Development Goals was for universal access to reproductive health care by 2015, and WHO has recommended that infertility be considered a global health problem and stated the need for adaptation of assisted reproductive technology in low-resource countries. This paper challenges the construct that infertility is not a serious problem in resource-constrained settings and argues that there is a need for infertility care, including affordable assisted reproduction treatment, in these settings. It is often presumed that infertility is not a problem in densely populated, resource-poor areas where fertility rates are high. This presumption is challenged by consistent evidence that the consequences of childlessness are very severe in low-income countries, particularly for women. In these settings, childless women are frequently stigmatized, isolated, ostracized, disinherited and neglected by the family and local community. This may result in physical and psychological abuse, polygamy and even suicide. Because many families in low-income countries depend on children for economic survival

  2. Ultimate Limits to Resource Efficiency in Photonic Communication

    NASA Technical Reports Server (NTRS)

    Erkmen, Baris I.; Moision, Bruce E.; Dolinar, Sam

    2013-01-01

    We review resource-efficiency metrics for transferring classical information with photon, present an overview of the ultimate limits to photon and dimensional efficiency permitted by quantum mechanics, as well as that acheived with structured transmitter-receiver pairs.

  3. Electromagnetic field limits set by the V-Curve.

    SciTech Connect

    Warne, Larry Kevin; Jorgenson, Roy Eberhardt; Hudson, Howard Gerald

    2014-07-01

    When emitters of electromagnetic energy are operated in the vicinity of sensitive components, the electric field at the component location must be kept below a certain level in order to prevent the component from being damaged, or in the case of electro-explosive devices, initiating. The V-Curve is a convenient way to set the electric field limit because it requires minimal information about the problem configuration. In this report we will discuss the basis for the V-Curve. We also consider deviations from the original V-Curve resulting from inductive versus capacitive antennas, increases in directivity gain for long antennas, decreases in input impedance when operating in a bounded region, and mismatches dictated by transmission line losses. In addition, we consider mitigating effects resulting from limited antenna sizes.

  4. Limits to rationality: economics, economists and priority setting.

    PubMed

    Robinson, R

    1999-10-01

    This paper investigates why economic approaches to priority setting have had only limited impact in practice. It argues that obstacles to the take-up of the economic approach centre on (1) limitations in the theory and practice of economic evaluations, and (2) the nature of the wider context within which decisions on priority setting take place. On the first point, it argues that, despite advances in research methods, there is still debate about the theoretical basis of measures typically used in economic evaluations, such as QALYs, and that much of the extant empirical data is of questionable quality. On the second point, it maintains that politicians, health care professionals and local people attach importance to other factors besides allocative efficiency. If economic approaches are to have more impact in the future, it argues that health economists need to adopt a wider research agenda, focusing on public sector decision-making and, in particular, the incentives and constraints governing the use of economic data in different types of health care organisation.

  5. Diffusion of novel healthcare technologies to resource poor settings.

    PubMed

    Malkin, Robert; von Oldenburg Beer, Kim

    2013-09-01

    A new product has completed clinical trials in a distant, resource poor hospital using a few dozen prototypes. The data looks great. The novel medical device solves a widely felt problem. The next goal is to integrate the device into the country's healthcare system and spread the device to other countries. But how? In order to be widely used, the device must be manufactured and distributed. One option is to license the intellectual property (IP) to an interested third party, if one can be found. However, it is possible to manage the manufacturing and distribution without licensing. There are at least two common means for manufacturing a novel medical device targeted to resource poor settings: (a) formal (contract) manufacturing and (b) informal (local) manufacturing. There are three primary routes to diffusion of novel medical devices in the developing world: (1) local distributors (2) direct international sales and (3) international donations. Perhaps surprisingly, the least effective mechanism is direct importation through donation. The most successful mechanism, the method used by nearly all working medical devices in resource-poor settings, is the use of contract manufacturing and a local distributor. This article is written for the biomedical innovator and entrepreneur who wishes to make a novel healthcare technology or product available and accessible to healthcare providers and patients in the developing world. There are very few documented cases and little formal research in this area. To this end, this article describes and explores the manufacturing and distribution options in order to provide insights into when and how each can be applied to scale up a novel technology to make a difference in a resource poor setting.

  6. Diffusion of novel healthcare technologies to resource poor settings.

    PubMed

    Malkin, Robert; von Oldenburg Beer, Kim

    2013-09-01

    A new product has completed clinical trials in a distant, resource poor hospital using a few dozen prototypes. The data looks great. The novel medical device solves a widely felt problem. The next goal is to integrate the device into the country's healthcare system and spread the device to other countries. But how? In order to be widely used, the device must be manufactured and distributed. One option is to license the intellectual property (IP) to an interested third party, if one can be found. However, it is possible to manage the manufacturing and distribution without licensing. There are at least two common means for manufacturing a novel medical device targeted to resource poor settings: (a) formal (contract) manufacturing and (b) informal (local) manufacturing. There are three primary routes to diffusion of novel medical devices in the developing world: (1) local distributors (2) direct international sales and (3) international donations. Perhaps surprisingly, the least effective mechanism is direct importation through donation. The most successful mechanism, the method used by nearly all working medical devices in resource-poor settings, is the use of contract manufacturing and a local distributor. This article is written for the biomedical innovator and entrepreneur who wishes to make a novel healthcare technology or product available and accessible to healthcare providers and patients in the developing world. There are very few documented cases and little formal research in this area. To this end, this article describes and explores the manufacturing and distribution options in order to provide insights into when and how each can be applied to scale up a novel technology to make a difference in a resource poor setting. PMID:23377566

  7. Mental training affects distribution of limited brain resources.

    PubMed

    Slagter, Heleen A; Lutz, Antoine; Greischar, Lawrence L; Francis, Andrew D; Nieuwenhuis, Sander; Davis, James M; Davidson, Richard J

    2007-06-01

    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.

  8. Optimal vaccination policies for an SIR model with limited resources.

    PubMed

    Zhou, Yinggao; Yang, Kuan; Zhou, Kai; Liang, Yiting

    2014-06-01

    The purpose of the paper is to use analytical method and optimization tool to suggest a vaccination program intensity for a basic SIR epidemic model with limited resources for vaccination. We show that there are two different scenarios for optimal vaccination strategies, and obtain analytical solutions for the optimal control problem that minimizes the total cost of disease under the assumption of daily vaccine supply being limited. These solutions and their corresponding optimal control policies are derived explicitly in terms of initial conditions, model parameters and resources for vaccination. With sufficient resources, the optimal control strategy is the normal Bang-Bang control. However, with limited resources, the optimal control strategy requires to switch to time-variant vaccination.

  9. C-Reactive Protein (CRP), Interferon Gamma-Inducible Protein 10 (IP-10), and Lipopolysaccharide (LPS) Are Associated with Risk of Tuberculosis after Initiation of Antiretroviral Therapy in Resource-Limited Settings

    PubMed Central

    Tenforde, Mark W.; Gupte, Nikhil; Dowdy, David W.; Asmuth, David M.; Balagopal, Ashwin; Pollard, Richard B.; Sugandhavesa, Patcharaphan; Lama, Javier R.; Pillay, Sandy; Cardoso, Sandra W.; Pawar, Jyoti; Santos, Breno; Riviere, Cynthia; Mwelase, Noluthando; Kanyama, Cecilia; Kumwenda, Johnstone; Hakim, James G.; Kumarasamy, Nagalingeswaran; Bollinger, Robert; Semba, Richard D.; Campbell, Thomas B.; Gupta, Amita

    2015-01-01

    Objective The association between pre-antiretroviral (ART) inflammation and immune activation and risk for incident tuberculosis (TB) after ART initiation among adults is uncertain. Design Nested case-control study (n = 332) within ACTG PEARLS trial of three ART regimens among 1571 HIV-infected, treatment-naïve adults in 9 countries. We compared cases (participants with incident TB diagnosed by 96 weeks) to a random sample of controls (participants who did not develop TB, stratified by country and treatment arm). Methods We measured pre-ART C-reactive protein (CRP), EndoCab IgM, ferritin, interferon gamma (IFN-γ), interleukin 6 (IL-6), interferon gamma-inducible protein 10 (IP-10), lipopolysaccharide (LPS), soluble CD14 (sCD14), tumor necrosis factor alpha (TNF-α), and CD4/DR+/38+ and CD8/DR+/38+ T cells. Markers were defined according to established cutoff definitions when available, 75th percentile of measured values when not, and detectable versus undetectable for LPS. Using logistic regression, we measured associations between biomarkers and incident TB, adjusting for age, sex, study site, treatment arm, baseline CD4 and log10 viral load. We assessed the discriminatory value of biomarkers using receiver operating characteristic (ROC) analysis. Results Seventy-seven persons (4.9%) developed incident TB during follow-up. Elevated baseline CRP (aOR 3.25, 95% CI: 1.55–6.81) and IP-10 (aOR 1.89, 95% CI: 1.05–3.39), detectable plasma LPS (aOR 2.39, 95% CI: 1.13–5.06), and the established TB risk factors anemia and hypoalbuminemia were independently associated with incident TB. In ROC analysis, CRP, albumin, and LPS improved discrimination only modestly for TB risk when added to baseline routine patient characteristics including CD4 count, body mass index, and prior TB. Conclusion Incident TB occurs commonly after ART initiation. Although associated with higher post-ART TB risk, baseline CRP, IP-10, and LPS add limited value to routine patient characteristics

  10. Setting heat stress limits for acclimatised soldiers exercising in heat.

    PubMed

    Bricknell, M C

    1997-02-01

    Heat illness is a recognised risk of military training. The Combat Fitness Test (CFT) has been identified as an activity that has been associated with heat casualties. The aim of this study was to establish whether a heat stress limit could be set for acclimatised soldiers performing the CFT by measuring the group mean rises in core temperature whilst performing the CFT at various environmental temperatures. The study showed that CFTs should not be undertaken when the start or expected end Wet Bulb Globe Test (WBGT) is greater than 25 degrees C if the group mean rise in core temperature is not to exceed 0.6 degree C (95% CI 0.2 degree C to 1 degree C).

  11. Point-of-Care Diagnostics in Low Resource Settings: Present Status and Future Role of Microfluidics.

    PubMed

    Sharma, Shikha; Zapatero-Rodríguez, Julia; Estrela, Pedro; O'Kennedy, Richard

    2015-08-13

    The inability to diagnose numerous diseases rapidly is a significant cause of the disparity of deaths resulting from both communicable and non-communicable diseases in the developing world in comparison to the developed world. Existing diagnostic instrumentation usually requires sophisticated infrastructure, stable electrical power, expensive reagents, long assay times, and highly trained personnel which is not often available in limited resource settings. This review will critically survey and analyse the current lateral flow-based point-of-care (POC) technologies, which have made a major impact on diagnostic testing in developing countries over the last 50 years. The future of POC technologies including the applications of microfluidics, which allows miniaturisation and integration of complex functions that facilitate their usage in limited resource settings, is discussed The advantages offered by such systems, including low cost, ruggedness and the capacity to generate accurate and reliable results rapidly, are well suited to the clinical and social settings of the developing world.

  12. Point-of-Care Diagnostics in Low Resource Settings: Present Status and Future Role of Microfluidics

    PubMed Central

    Sharma, Shikha; Zapatero-Rodríguez, Julia; Estrela, Pedro; O’Kennedy, Richard

    2015-01-01

    The inability to diagnose numerous diseases rapidly is a significant cause of the disparity of deaths resulting from both communicable and non-communicable diseases in the developing world in comparison to the developed world. Existing diagnostic instrumentation usually requires sophisticated infrastructure, stable electrical power, expensive reagents, long assay times, and highly trained personnel which is not often available in limited resource settings. This review will critically survey and analyse the current lateral flow-based point-of-care (POC) technologies, which have made a major impact on diagnostic testing in developing countries over the last 50 years. The future of POC technologies including the applications of microfluidics, which allows miniaturisation and integration of complex functions that facilitate their usage in limited resource settings, is discussed The advantages offered by such systems, including low cost, ruggedness and the capacity to generate accurate and reliable results rapidly, are well suited to the clinical and social settings of the developing world. PMID:26287254

  13. Strategies for setting occupational exposure limits for particles.

    PubMed Central

    Greim, H A; Ziegler-Skylakakis, K

    1997-01-01

    To set occupational exposure limits (OELs) for aerosol particles, dusts, or chemicals, one has to evaluate whether mechanistic considerations permit identification of a no observed effect level (NOEL). In the case of carcinogenic effects, this can be assumed if no genotoxicity is involved, and exposure is considered safe if it does not exceed the NOEL. If tumor induction is associated with genotoxicity, any exposure is considered to be of risk, although a NOEL may be identified in the animal or human exposure studies. This must also be assumed when no information on the carcinogenic mechanism, including genotoxicity, is available. Aerosol particles, especially fibrous dusts, which include man-made mineral fiber(s) (MMMF), present a challenge for toxicological evaluation. Many MMMF that have been investigated have induced tumors in animals and genotoxicity in vitro. Since these effects have been associated with long-thin fiber geometry and high durability in vivo, all fibers meeting such criteria are considered carcinogenic unless the opposite has been demonstrated. This approach is practicable. Investigations on fiber tumorigenicity/genotoxicity should include information on dose response, pathobiochemistry, particle clearance, and persistence of the material in the target organ. Such information will introduce quantitative aspects into the qualitative approach that has so far been used to classify fibrous dusts as carcinogens. The rationales for classifying the potential carcinogenicity of MMMF and for setting OELs used by the different European committees and regulatory agencies are described. PMID:9400750

  14. Microbial limitation in a changing world: A stoichiometric approach for predicting microbial resource limitation and fluxes

    NASA Astrophysics Data System (ADS)

    Midgley, M.; Phillips, R.

    2014-12-01

    Microbes mediate fluxes of carbon (C), nitrogen (N), and phosphorus (P) in soils depending on ratios of available C, N, and P relative to microbial demand. Hence, characterizing microbial C and nutrient limitation in soils is critical for predicting how ecosystems will respond to human alterations of climate and nutrient availability. Here, we take a stoichiometric approach to assessing microbial C, N, and P limitation by using threshold element ratios (TERs). TERs enable shifting resource limitation to be assessed by matching C, N and P ratios from microbial biomass, extracellular enzyme activities, and soil nutrient concentrations. We assessed microbial nutrient limitation in temperate forests dominated by trees that associate with one of two mycorrhizal symbionts: arbsucular mycorrhizal (AM) or ectomycorrhizal (ECM) fungi. We found that both ECM and AM microbial communities were co-limited by C and N, supporting conventional wisdom that microbes are C-limited and temperate forests are N-limited. However, AM microbial communities were relatively more C-limited than ECM communities (P=0.001). In response to chronic field N fertilization, both AM and ECM communities became relatively more P-limited (P=0.011), but they remained N- and C-limited overall. Thus, realistic levels of N deposition may not dampen microbial N limitation. Reflecting differences in relative limitation, N mineralization rates were higher in AM soils than in ECM soils (P=0.004) while C mineralization rates were higher in ECM soils than in AM soils (P=0.023). There were no significant differences in P flux between AM and ECM soils or detectable mineralization responses to N addition, indicating that mineralization rates are closely tied to C and nutrient limitation. Overall, we found that 1) microbial resource limitation can be detected without resource addition; and 2) TERs and ratios of labile resources are viable tools for predicting mineralization responses to resource additions.

  15. Interrogating scarcity: how to think about 'resource-scarce settings'.

    PubMed

    Schrecker, Ted

    2013-07-01

    The idea of resource scarcity permeates health ethics and health policy analysis in various contexts. However, health ethics inquiry seldom asks-as it should-why some settings are 'resource-scarce' and others not. In this article I describe interrogating scarcity as a strategy for inquiry into questions of resource allocation within a single political jurisdiction and, in particular, as an approach to the issue of global health justice in an interconnected world. I demonstrate its relevance to the situation of low- and middle-income countries (LMICs) with brief descriptions of four elements of contemporary globalization: trade agreements; the worldwide financial marketplace and capital flight; structural adjustment; imperial geopolitics and foreign policy. This demonstration involves not only health care, but also social determinants of health. Finally, I argue that interrogating scarcity provides the basis for a new, critical approach to health policy at the interface of ethics and the social sciences, with specific reference to market fundamentalism as the value system underlying contemporary globalization. PMID:22899597

  16. Interrogating scarcity: how to think about 'resource-scarce settings'.

    PubMed

    Schrecker, Ted

    2013-07-01

    The idea of resource scarcity permeates health ethics and health policy analysis in various contexts. However, health ethics inquiry seldom asks-as it should-why some settings are 'resource-scarce' and others not. In this article I describe interrogating scarcity as a strategy for inquiry into questions of resource allocation within a single political jurisdiction and, in particular, as an approach to the issue of global health justice in an interconnected world. I demonstrate its relevance to the situation of low- and middle-income countries (LMICs) with brief descriptions of four elements of contemporary globalization: trade agreements; the worldwide financial marketplace and capital flight; structural adjustment; imperial geopolitics and foreign policy. This demonstration involves not only health care, but also social determinants of health. Finally, I argue that interrogating scarcity provides the basis for a new, critical approach to health policy at the interface of ethics and the social sciences, with specific reference to market fundamentalism as the value system underlying contemporary globalization.

  17. ICU Microcomputing on a Shoestring: Decisions When Resources Are Limited

    PubMed Central

    Gladen, Herbert E.

    1984-01-01

    Limited resources need not be a bar to clinical application of advanced technology. By careful planning, our VA medical center has been able to secure and use a microcomputer for our surgical intensive care unit with negligible initial and continuing costs. Careful attention was required to balance prioritized needs with resources; a rather limited system was found more suitable than a more complex one. Problems with program loading and power-line fluctuations were met by storing the program in a permanent Read-Only-Memory chip on a plug-in cartridge. Since then, the system has remained trouble-free and highly cost-effective. Programs are available through the author.

  18. Communicating vaccine safety in the context of immunization programs in low resource settings.

    PubMed

    Arwanire, Edison M; Mbabazi, William; Mugyenyi, Possy

    2015-01-01

    Vaccines are effective in preventing infectious diseases and their complications, hence reducing morbidity and infectious disease mortaity. Successful immunization programs, however, depend on high vaccine acceptance and coverage rates. In recent years there has been an increased level of public concern towards real or perceived adverse events associated with immunizations, leading to many people in high- as well as low-resource settings to refuse vaccines. Health care workers therefore must be able to provide parents and guardians of children with the most current and accurate information about the benefits and risks of vaccination. Communicating vaccine safety using appropriate channels plays a crucial role in maintaining public trust and confidence in vaccination programs. Several factors render this endeavor especially challenging in low-resource settings where literacy rates are low and access to information is often limited. Many languages are spoken in most countries in low-resource settings, making the provision of appropriate information difficult. Poor infrastructure often results in inadequate logistics. Recently, some concerned consumer groups have been able to propagate misinformation and rumors. To successfully communicate vaccine safety in a resource limited setting it is crucial to use a mix of communication channels that are both culturally acceptable and effective. Social mobilization through cultural, administrative and political leaders, the media or text messages (SMS) as well as the adoption of the Village Health Team (VHT) strategy whereby trained community members (Community Health Workers (CHWs)) are providing primary healthcare, can all be effective in increasing the demand for immunization. PMID:25859678

  19. Communicating vaccine safety in the context of immunization programs in low resource settings.

    PubMed

    Arwanire, Edison M; Mbabazi, William; Mugyenyi, Possy

    2015-01-01

    Vaccines are effective in preventing infectious diseases and their complications, hence reducing morbidity and infectious disease mortaity. Successful immunization programs, however, depend on high vaccine acceptance and coverage rates. In recent years there has been an increased level of public concern towards real or perceived adverse events associated with immunizations, leading to many people in high- as well as low-resource settings to refuse vaccines. Health care workers therefore must be able to provide parents and guardians of children with the most current and accurate information about the benefits and risks of vaccination. Communicating vaccine safety using appropriate channels plays a crucial role in maintaining public trust and confidence in vaccination programs. Several factors render this endeavor especially challenging in low-resource settings where literacy rates are low and access to information is often limited. Many languages are spoken in most countries in low-resource settings, making the provision of appropriate information difficult. Poor infrastructure often results in inadequate logistics. Recently, some concerned consumer groups have been able to propagate misinformation and rumors. To successfully communicate vaccine safety in a resource limited setting it is crucial to use a mix of communication channels that are both culturally acceptable and effective. Social mobilization through cultural, administrative and political leaders, the media or text messages (SMS) as well as the adoption of the Village Health Team (VHT) strategy whereby trained community members (Community Health Workers (CHWs)) are providing primary healthcare, can all be effective in increasing the demand for immunization.

  20. Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings.

    PubMed

    Modesti, Pietro A; Agostoni, Piergiuseppe; Agyemang, Charles; Basu, Sanjay; Benetos, Athanase; Cappuccio, Francesco P; Ceriello, Antonio; Del Prato, Stefano; Kalyesubula, Robert; O'Brien, Eoin; Kilama, Michael O; Perlini, Stefano; Picano, Eugenio; Reboldi, Gianpaolo; Remuzzi, Giuseppe; Stuckler, David; Twagirumukiza, Marc; Van Bortel, Luc M; Watfa, Ghassan; Zhao, Dong; Parati, Gianfranco

    2014-05-01

    The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on 'Hypertension and Cardiovascular risk in low resource settings', which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs. PMID:24577410

  1. Resource Limitation, Controphic Ostracod Density and Larval Mosquito Development.

    PubMed

    Rowbottom, Raylea; Carver, Scott; Barmuta, Leon A; Weinstein, Philip; Foo, Dahlia; Allen, Geoff R

    2015-01-01

    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. PMID:26558896

  2. Resource Limitation, Controphic Ostracod Density and Larval Mosquito Development

    PubMed Central

    Rowbottom, Raylea; Carver, Scott; Barmuta, Leon A.; Weinstein, Philip; Foo, Dahlia; Allen, Geoff R.

    2015-01-01

    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. PMID:26558896

  3. Antibiotic use and emerging resistance: how can resource-limited countries turn the tide?

    PubMed

    Bebell, Lisa M; Muiru, Anthony N

    2014-09-01

    Antibiotic resistance is a global crisis driven by appropriate and inappropriate antibiotic use to treat human illness and promote animal growth. The antimicrobial resistance epidemic continues to spread due to the triple threat of unfettered access, minimal product regulation and oversight of antibiotic prescription, and lack of clinical diagnostic tools to support antibiotic de-escalation in low-resource settings. In high-resource settings, evidence-based strategies have improved the appropriateness of antibiotic use, limiting the spread of drug-resistant organisms and reducing hospital-associated infections, strategies which may also be effective to stop the spread of resistance in resource-poor countries. Current research and surveillance efforts on antimicrobial resistance and hospital-associated infections in low-resource settings are extremely limited and largely focused on intensive care units. Many challenges exist to improving antibiotic use and infection control in resource-limited settings, and turning the tide requires intensifying research and surveillance, antimicrobial stewardship, and developing new bedside diagnostic tools for bacterial infections and antimicrobial susceptibility.

  4. Antibiotic use and emerging resistance—how can resource-limited countries turn the tide?

    PubMed Central

    Bebell, LM; Muiru, AN

    2015-01-01

    Antibiotic resistance is a global crisis driven by appropriate and inappropriate antibiotic use to treat human illness and promote animal growth. The antimicrobial resistance epidemic continues to spread due to the triple threat of unfettered access, minimal product regulation and oversight of antibiotic prescription, and lack of clinical diagnostic tools to support antibiotic de-escalation in low-resource settings. In high-resource settings, evidence-based strategies have improved appropriateness of antibiotic use, limiting the spread of drug-resistant organisms and reducing hospital-associated infections, which may also be effective to stop the spread of resistance in resource-poor countries. Current research and surveillance efforts on antimicrobial resistance and hospital-associated infections in low-resource settings are extremely limited, largely focused intensive care units. Many challenges exist to improving antibiotic use and infection control in resource-limited settings, and turning the tide requires intensifying research and surveillance, antimicrobial stewardship, and developing new bedside diagnostic tools for bacterial infections and antimicrobial susceptibility. PMID:25667187

  5. Food insecurity: limitations of emergency food resources for our patients.

    PubMed

    Gany, Francesca; Bari, Sehrish; Crist, Michael; Moran, Alyssa; Rastogi, Natasha; Leng, Jennifer

    2013-06-01

    Rates of food insecurity are high among medically underserved patients. We analyzed food pantry responsiveness to the needs of medically ill cancer patients in New York City with the intent ofidentifying barriers to available food resources. Our data, collected from 60 pantries, suggest that the emergency food system is currently unable to accommodate patient needs. Accessibility issues include restricted service hours and documentation requirements. Food services were limited in quantity of food provided and the number of nutritious, palatable options. Additional emergency food resources and long-term approaches that provide ongoing food support to patients throughout their treatment period are needed.

  6. The Setting Up of a Resources Centre. 1: Basic Ideas.

    ERIC Educational Resources Information Center

    Malcolm, Adam H.

    This guidebook reviews the basic educational role of learning resources centers in elementary-secondary education, and outlines the facility requirements, material requirements, and functions of a basic resources center. The educational issues surrounding the development of resources centers are briefly addressed, including resource-based…

  7. Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings

    PubMed Central

    Modesti, Pietro A.; Agostoni, Piergiuseppe; Agyemang, Charles; Basu, Sanjay; Benetos, Athanase; Cappuccio, Francesco P.; Ceriello, Antonio; Del Prato, Stefano; Kalyesubula, Robert; O’Brien, Eoin; Kilama, Michael O.; Perlini, Stefano; Picano, Eugenio; Reboldi, Gianpaolo; Remuzzi, Giuseppe; Stuckler, David; Twagirumukiza, Marc; Van Bortel, Luc M.; Watfa, Ghassan; Zhao, Dong; Parati, Gianfranco

    2014-01-01

    The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on ‘Hypertension and Cardiovascular risk in low resource settings’, which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs. PMID:24577410

  8. iBIOMES Lite: summarizing biomolecular simulation data in limited settings.

    PubMed

    Thibault, Julien C; Cheatham, Thomas E; Facelli, Julio C

    2014-06-23

    As the amount of data generated by biomolecular simulations dramatically increases, new tools need to be developed to help manage this data at the individual investigator or small research group level. In this paper, we introduce iBIOMES Lite, a lightweight tool for biomolecular simulation data indexing and summarization. The main goal of iBIOMES Lite is to provide a simple interface to summarize computational experiments in a setting where the user might have limited privileges and limited access to IT resources. A command-line interface allows the user to summarize, publish, and search local simulation data sets. Published data sets are accessible via static hypertext markup language (HTML) pages that summarize the simulation protocols and also display data analysis graphically. The publication process is customized via extensible markup language (XML) descriptors while the HTML summary template is customized through extensible stylesheet language (XSL). iBIOMES Lite was tested on different platforms and at several national computing centers using various data sets generated through classical and quantum molecular dynamics, quantum chemistry, and QM/MM. The associated parsers currently support AMBER, GROMACS, Gaussian, and NWChem data set publication. The code is available at https://github.com/jcvthibault/ibiomes . PMID:24830957

  9. Injury surveillance in low-resource settings using Geospatial and Social Web technologies

    PubMed Central

    2010-01-01

    Background Extensive public health gains have benefited high-income countries in recent decades, however, citizens of low and middle-income countries (LMIC) have largely not enjoyed the same advancements. This is in part due to the fact that public health data - the foundation for public health advances - are rarely collected in many LMIC. Injury data are particularly scarce in many low-resource settings, despite the huge associated burden of morbidity and mortality. Advances in freely-accessible and easy-to-use information and communication (ICT) technology may provide the impetus for increased public health data collection in settings with limited financial and personnel resources. Methods and Results A pilot study was conducted at a hospital in Cape Town, South Africa to assess the utility and feasibility of using free (non-licensed), and easy-to-use Social Web and GeoWeb tools for injury surveillance in low-resource settings. Data entry, geocoding, data exploration, and data visualization were successfully conducted using these technologies, including Google Spreadsheet, Mapalist, BatchGeocode, and Google Earth. Conclusion This study examined the potential for Social Web and GeoWeb technologies to contribute to public health data collection and analysis in low-resource settings through an injury surveillance pilot study conducted in Cape Town, South Africa. The success of this study illustrates the great potential for these technologies to be leveraged for public health surveillance in resource-constrained environments, given their ease-of-use and low-cost, and the sharing and collaboration capabilities they afford. The possibilities and potential limitations of these technologies are discussed in relation to the study, and to the field of public health in general. PMID:20497570

  10. System for portable nucleic acid testing in low resource settings

    NASA Astrophysics Data System (ADS)

    Lu, Hsiang-Wei; Roskos, Kristina; Hickerson, Anna I.; Carey, Thomas; Niemz, Angelika

    2013-03-01

    Our overall goal is to enable timely diagnosis of infectious diseases through nucleic acid testing at the point-of-care and in low resource settings, via a compact system that integrates nucleic acid sample preparation, isothermal DNA amplification, and nucleic acid lateral flow (NALF) detection. We herein present an interim milestone, the design of the amplification and detection subsystem, and the characterization of thermal and fluidic control and assay execution within this system. Using an earlier prototype of the amplification and detection unit, comprised of a disposable cartridge containing flexible pouches, passive valves, and electrolysis-driven pumps, in conjunction with a small heater, we have demonstrated successful execution of an established and clinically validated isothermal loop-mediated amplification (LAMP) reaction targeting Mycobacterium tuberculosis (M.tb) DNA, coupled to NALF detection. The refined design presented herein incorporates miniaturized and integrated electrolytic pumps, novel passive valves, overall design changes to facilitate integration with an upstream sample preparation unit, and a refined instrument design that automates pumping, heating, and timing. Nucleic acid amplification occurs in a two-layer pouch that facilitates fluid handling and appropriate thermal control. The disposable cartridge is manufactured using low-cost and scalable techniques and forms a closed system to prevent workplace contamination by amplicons. In a parallel effort, we are developing a sample preparation unit based on similar design principles, which performs mechanical lysis of mycobacteria and DNA extraction from liquefied and disinfected sputum. Our next step is to combine sample preparation, amplification, and detection in a final integrated cartridge and device, to enable fully automated sample-in to answer-out diagnosis of active tuberculosis in primary care facilities of low-resource and high-burden countries.

  11. Providing outreach continuing education in countries with limited resources.

    PubMed

    Wilkins, Kaye E

    2008-10-01

    Obtaining continuing education can be difficult in countries with limited resources. Members of the Pediatric Orthopaedic Society of North America (POSNA) have developed a program for providing outreach continuing education courses in pediatric orthopaedics. POSNA members provide their own transportation to the host country, while the orthopaedic physicians along with the educational institutions in the host country in turn provide the support needed to carry out the courses. They also provide lodging, meals, and local transportation. Since its inception in 1998, 30 courses have been conducted in 19 countries with limited resources. The program has expanded to develop a partnership with the European Pediatric Orthopaedic Society. The protocol for organizing the courses is discussed. PMID:18663550

  12. Setting limits and application to Higgs boson search

    NASA Astrophysics Data System (ADS)

    Lista, Luca

    2013-07-01

    This lecture summarizes the basic concept of hypothesis testing, will introduce the concepts of significance and upper limit under the frequentist and Bayesian approaches, and will discuss the benefits and limitations of the most popular approaches. Special attention will be devoted to the so-called modified frequentist approach, which is a popular method in High Energy Physics, and some application to real physics cases will be discussed.

  13. Radiotherapeutic Management of Non-Small Cell Lung Cancer in the Minimal Resource Setting.

    PubMed

    Rodin, Danielle; Grover, Surbhi; Xu, Melody J; Hanna, Timothy P; Olson, Robert; Schreiner, L John; Munshi, Anusheel; Mornex, Francoise; Palma, David; Gaspar, Laurie E

    2016-01-01

    Lung cancer is the most common cancer worldwide and the fifth most common cause of death globally. Its incidence continues to increase, especially within low- and middle-income countries (LMICs), which have limited capacity to address the growing need for treatment. The standard of care for lung cancer treatment often involves radiation therapy (RT), which plays an important therapeutic role in curative-intent treatment of early-stage to locally advanced disease, as well as in palliation. The infrastructure, equipment, and human resources required for RT may be limited in LMICs. However, this narrative review discusses the scope of the problem of lung cancer in LMICs, the role of RT technologies in lung cancer treatment, and RT capacity in developing countries. Strategies are presented for maximizing the availability and impact of RT in settings with minimal resource availability, and areas for potential future innovation are identified. Priorities for LMICs involve increasing access to RT equipment and trained health care professionals, ensuring quality of care, providing guidance on priority setting with limited resources, and encouraging innovation to increase the economic efficiency of RT delivery. Several international initiatives are currently under way and represent important first steps toward scaling up RT in LMICs to treat lung cancer. PMID:26762736

  14. The Need for Limit Setting, Structure, and Expectations

    ERIC Educational Resources Information Center

    Brazelton, T. Berry; Greenspan, Stanley I.

    2006-01-01

    Although there is a general agreement about the need for limits, structure, and guidance in a child's life, there is a strong difference of opinion among many professionals about the best ways to meet these needs. Some believe in more educational approaches, explaining to children the "why" of it, while others favor very firm disciplinary…

  15. The integration of climatic data sets for wind resource assessment

    SciTech Connect

    Schwartz, M.N.; Elliott, D.L.

    1997-09-01

    One barrier to wind energy development, in many regions of the world, is the lack of reliable information about the spacial distribution of the wind energy resource. The goal of the U.S. Department of Energy (DOE) Wind Energy Program`s wind resource assessment group is to improve the characterization of the wind resource in many of these regions in support of U.S. wind energy industry. NREL provides wind resource assessments for our clients in the form of reports, atlases, and wind resource maps. The assessments estimate the level of the wind resource, at wind turbine hub heights (typically 30m to 50m above ground level), for locations exposed to the prevailing winds.

  16. Ego depletion: is the active self a limited resource?

    PubMed

    Baumeister, R F; Bratslavsky, E; Muraven, M; Tice, D M

    1998-05-01

    Choice, active response, self-regulation, and other volition may all draw on a common inner resource. In Experiment 1, people who forced themselves to eat radishes instead of tempting chocolates subsequently quit faster on unsolvable puzzles than people who had not had to exert self-control over eating. In Experiment 2, making a meaningful personal choice to perform attitude-relevant behavior caused a similar decrement in persistence. In Experiment 3, suppressing emotion led to a subsequent drop in performance of solvable anagrams. In Experiment 4, an initial task requiring high self-regulation made people more passive (i.e., more prone to favor the passive-response option). These results suggest that the self's capacity for active volition is limited and that a range of seemingly different, unrelated acts share a common resource.

  17. Perceived barriers to information access among medical residents in Iran: obstacles to answering clinical queries in settings with limited Internet accessibility.

    PubMed

    Mazloomdoost, Danesh; Mehregan, Shervineh; Mahmoudi, Hilda; Soltani, Akbar; Embi, Peter J

    2007-01-01

    Studies performed in the US and other Western countries have documented that physicians generate many clinical questions during a typical day and rely on various information sources for answers. Little is known about the information seeking behaviors of physicians practicing in other countries, particularly those with limited Internet connectivity. We conducted this study to document the perceived barriers to information resources used by medical residents in Iran. Our findings reveal that different perceived barriers exist for electronic versus paper-based resources. Notably, paper-based resources are perceived to be limited by resident time-constraints and availability of resources, whereas electronic resources are limited by cost decentralized resources (such as PDAs) and accessibility of centralized, Internet access. These findings add to the limited literature regarding health information-seeking activities in international healthcare settings, particularly those with limited Internet connectivity, and will supplement future studies of and interventions in such settings. PMID:18693891

  18. The Setting Up of a Resources Centre. 2: Planning & Staffing.

    ERIC Educational Resources Information Center

    Tucker, Richard N.

    Produced for use by educators and administrators in Scotland involved in planning and developing learning resources centers in elementary and secondary schools, this guide contains: (1) examples and discussion of the allocation of space for resources centers in schools with different architectural layouts, (2) three case studies of schools which…

  19. Parking in the City:. AN Example of Limited Resource Sharing

    NASA Astrophysics Data System (ADS)

    Šeba, Petr

    2010-03-01

    During the attempt to park a car in the city the drivers have to share limited resources (the available roadside). We show that this fact leads to a predictable distribution of the distances between the cars that depends on the length of the street segment used for the collective parking. We demonstrate in addition that the individual parking maneuver is guided by generic psychophysical perceptual correlates. Both predictions are compared with the actual parking data collected in the city of Hradec Králové (Czech Republic).

  20. Resource limitation drives spatial organization in microbial groups.

    PubMed

    Mitri, Sara; Clarke, Ellen; Foster, Kevin R

    2016-06-01

    Dense microbial groups such as bacterial biofilms commonly contain a diversity of cell types that define their functioning. However, we have a limited understanding of what maintains, or purges, this diversity. Theory suggests that resource levels are key to understanding diversity and the spatial arrangement of genotypes in microbial groups, but we need empirical tests. Here we use theory and experiments to study the effects of nutrient level on spatio-genetic structuring and diversity in bacterial colonies. Well-fed colonies maintain larger well-mixed areas, but they also expand more rapidly compared with poorly-fed ones. Given enough space to expand, therefore, well-fed colonies lose diversity and separate in space over a similar timescale to poorly fed ones. In sum, as long as there is some degree of nutrient limitation, we observe the emergence of structured communities. We conclude that resource-driven structuring is central to understanding both pattern and process in diverse microbial communities. PMID:26613343

  1. Resource limitation drives spatial organization in microbial groups

    PubMed Central

    Mitri, Sara; Clarke, Ellen; Foster, Kevin R

    2016-01-01

    Dense microbial groups such as bacterial biofilms commonly contain a diversity of cell types that define their functioning. However, we have a limited understanding of what maintains, or purges, this diversity. Theory suggests that resource levels are key to understanding diversity and the spatial arrangement of genotypes in microbial groups, but we need empirical tests. Here we use theory and experiments to study the effects of nutrient level on spatio-genetic structuring and diversity in bacterial colonies. Well-fed colonies maintain larger well-mixed areas, but they also expand more rapidly compared with poorly-fed ones. Given enough space to expand, therefore, well-fed colonies lose diversity and separate in space over a similar timescale to poorly fed ones. In sum, as long as there is some degree of nutrient limitation, we observe the emergence of structured communities. We conclude that resource-driven structuring is central to understanding both pattern and process in diverse microbial communities. PMID:26613343

  2. Viral hepatitis in resource-limited countries and access to antiviral therapies: current and future challenges

    PubMed Central

    Lemoine, Maud; Nayagam, Shevanthi; Thursz, Mark

    2013-01-01

    Chronic viral hepatitis is a major public health issue worldwide and mostly affects resource-limited countries. These regions combine a considerable set of barriers to containing the epidemic, including shortage of healthcare workers, poor medical infrastructures, insufficient screening and poor access to care and treatment. At a time when morbidity and mortality of chronic liver disease has been widely improved in wealthy countries by new innovative strategies and potent antiviral drugs, it is now urgent to face the challenges of better management of chronic hepatitis in resource-poor countries from the perspectives of global health and social justice. PMID:23662157

  3. Free, brief, and validated: Standardized instruments for low-resource mental health settings

    PubMed Central

    Beidas, Rinad S.; Stewart, Rebecca E.; Walsh, Lucia; Lucas, Steven; Downey, Margaret Mary; Jackson, Kamilah; Fernandez, Tara; Mandell, David S.

    2014-01-01

    Evidence-based assessment has received little attention despite its critical importance to the evidence-based practice movement. Given the limited resources in the public sector, it is necessary for evidence-based assessment to utilize tools with established reliability and validity metrics that are free, easily accessible, and brief. We review tools that meet these criteria for youth and adult mental health for the most prevalent mental health disorders to provide a clinical guide and reference for the selection of assessment tools for public sector settings. We also discuss recommendations for how to move forward the evidence-based assessment agenda. PMID:25642130

  4. A Summary Catalogue of Microbial Drinking Water Tests for Low and Medium Resource Settings

    PubMed Central

    Bain, Robert; Bartram, Jamie; Elliott, Mark; Matthews, Robert; McMahan, Lanakila; Tung, Rosalind; Chuang, Patty; Gundry, Stephen

    2012-01-01

    Microbial drinking-water quality testing plays an essential role in measures to protect public health. However, such testing remains a significant challenge where resources are limited. With a wide variety of tests available, researchers and practitioners have expressed difficulties in selecting the most appropriate test(s) for a particular budget, application and setting. To assist the selection process we identified the characteristics associated with low and medium resource settings and we specified the basic information that is needed for different forms of water quality monitoring. We then searched for available faecal indicator bacteria tests and collated this information. In total 44 tests have been identified, 18 of which yield a presence/absence result and 26 of which provide enumeration of bacterial concentration. The suitability of each test is assessed for use in the three settings. The cost per test was found to vary from $0.60 to $5.00 for a presence/absence test and from $0.50 to $7.50 for a quantitative format, though it is likely to be only a small component of the overall costs of testing. This article presents the first comprehensive catalogue of the characteristics of available and emerging low-cost tests for faecal indicator bacteria. It will be of value to organizations responsible for monitoring national water quality, water service providers, researchers and policy makers in selecting water quality tests appropriate for a given setting and application. PMID:22754460

  5. A summary catalogue of microbial drinking water tests for low and medium resource settings.

    PubMed

    Bain, Robert; Bartram, Jamie; Elliott, Mark; Matthews, Robert; McMahan, Lanakila; Tung, Rosalind; Chuang, Patty; Gundry, Stephen

    2012-05-01

    Microbial drinking-water quality testing plays an essential role in measures to protect public health. However, such testing remains a significant challenge where resources are limited. With a wide variety of tests available, researchers and practitioners have expressed difficulties in selecting the most appropriate test(s) for a particular budget, application and setting. To assist the selection process we identified the characteristics associated with low and medium resource settings and we specified the basic information that is needed for different forms of water quality monitoring. We then searched for available faecal indicator bacteria tests and collated this information. In total 44 tests have been identified, 18 of which yield a presence/absence result and 26 of which provide enumeration of bacterial concentration. The suitability of each test is assessed for use in the three settings. The cost per test was found to vary from $0.60 to $5.00 for a presence/absence test and from $0.50 to $7.50 for a quantitative format, though it is likely to be only a small component of the overall costs of testing. This article presents the first comprehensive catalogue of the characteristics of available and emerging low-cost tests for faecal indicator bacteria. It will be of value to organizations responsible for monitoring national water quality, water service providers, researchers and policy makers in selecting water quality tests appropriate for a given setting and application.

  6. Aggression, containment, and treatment enactments in the psychodynamics of limit setting.

    PubMed

    Henry, Charles

    2010-01-01

    Limit setting has an important role in psychotherapeutic treatment. Despite this, the psychodynamics of limit setting have been a largely neglected topic in the literature. This article will present a theoretical discussion on the psychodynamics of limit setting particularly as it relates to the parent-child and the therapist-patient relationship. The central roles of aggression and impulse containment will be reviewed along with an overview of the relationship between limit setting and projective identification. Potential enactments that occur during the treatment of limit testing patients will be examined. Case material of the treatment of a child with a disruptive behavior disorder will be used to elaborate the discussion.

  7. Aggression, containment, and treatment enactments in the psychodynamics of limit setting.

    PubMed

    Henry, Charles

    2010-01-01

    Limit setting has an important role in psychotherapeutic treatment. Despite this, the psychodynamics of limit setting have been a largely neglected topic in the literature. This article will present a theoretical discussion on the psychodynamics of limit setting particularly as it relates to the parent-child and the therapist-patient relationship. The central roles of aggression and impulse containment will be reviewed along with an overview of the relationship between limit setting and projective identification. Potential enactments that occur during the treatment of limit testing patients will be examined. Case material of the treatment of a child with a disruptive behavior disorder will be used to elaborate the discussion. PMID:20528143

  8. On limit sets of contractive functions on p-adic field

    NASA Astrophysics Data System (ADS)

    Mukhamedov, Farrukh; Khakimov, Otabek

    2016-06-01

    In the present paper, we define unconventional limit set of contractive functions on the unit ball of the p-adic numbers. Main result of the present paper states that the unconventional limit set is compact. Our results will open new perspective to the theory of self-similarity in a non-Archimedean setting.

  9. The Setting Up of a Resources Centre. 3: Retrieval Systems.

    ERIC Educational Resources Information Center

    Malcolm, Adam H., Ed.

    Assembled to aid educators and administrators in Scotland in selecting and applying appropriate information retrieval systems in learning resources centers, this collection contains an introductory essay and four articles on the characteristics and features of some basic information retrieval systems. The articles include (1) a discussion of the…

  10. Research Using Government Data Sets: An Underutilised Resource

    ERIC Educational Resources Information Center

    Knipe, Sally

    2011-01-01

    The use of existing data for education research activities can be a valuable resource. Improvement in statistical analysis and data management and retrieval techniques, as well as access to government data bases, has expanded opportunities for researchers seeking to investigate issues that are institutional in nature, such as participation…

  11. Theme: Land Laboratories--Urban Settings, Liability, Natural Resources Labs.

    ERIC Educational Resources Information Center

    Whaley, David, Ed.; And Others

    1994-01-01

    Includes "With a Little Imagination"; "From Fallow to Fertile"; "Operating a School Enterprise in Agriculture"; "Using a Nontraditional Greenhouse to Enhance Lab Instruction"; "Risk Management for Liability in Operating Land Laboratories"; "Working Land and Water Laboratory for Natural Resources"; "Dreams Becoming Realities"; "Small Scale Land…

  12. Quantum resources for purification and cooling: fundamental limits and opportunities

    NASA Astrophysics Data System (ADS)

    Ticozzi, Francesco; Viola, Lorenza

    2014-06-01

    Preparing a quantum system in a pure state is ultimately limited by the nature of the system's evolution in the presence of its environment and by the initial state of the environment itself. We show that, when the system and environment are initially uncorrelated and arbitrary joint unitary dynamics is allowed, the system may be purified up to a certain (possibly arbitrarily small) threshold if and only if its environment, either natural or engineered, contains a ``virtual subsystem'' which has the same dimension and is in a state with the desired purity. Beside providing a unified understanding of quantum purification dynamics in terms of a ``generalized swap process,'' our results shed light on the significance of a no-go theorem for exact ground-state cooling, as well as on the quantum resources needed for achieving an intended purification task.

  13. Resource limitation, tolerance, and the future of ecological plant classification

    PubMed Central

    Craine, Joseph M.; Engelbrecht, Bettina M. J.; Lusk, Christopher H.; McDowell, Nate G.; Poorter, Hendrik

    2012-01-01

    Throughout the evolutionary history of plants, drought, shade, and scarcity of nutrients have structured ecosystems and communities globally. Humans have begun to drastically alter the prevalence of these environmental factors with untold consequences for plant communities and ecosystems worldwide. Given limitations in using organ-level traits to predict ecological performance of species, recent advances using tolerances of low resource availability as plant functional traits are revealing the often hidden roles these factors have in structuring communities and are becoming central to classifying plants ecologically. For example, measuring the physiological drought tolerance of plants has increased the predictability of differences among species in their ability to survive drought as well as the distribution of species within and among ecosystems. Quantifying the shade tolerance of species has improved our understanding of local and regional species diversity and how species have sorted within and among regions. As the stresses on ecosystems continue to shift, coordinated studies of whole-plant growth centered on tolerance of low resource availability will be central in predicting future ecosystem functioning and biodiversity. This will require efforts that quantify tolerances for large numbers of species and develop bioinformatic and other techniques for comparing large number of species. PMID:23115561

  14. Resource limitation, tolerance, and the future of ecological plant classification.

    PubMed

    Craine, Joseph M; Engelbrecht, Bettina M J; Lusk, Christopher H; McDowell, Nate G; Poorter, Hendrik

    2012-01-01

    Throughout the evolutionary history of plants, drought, shade, and scarcity of nutrients have structured ecosystems and communities globally. Humans have begun to drastically alter the prevalence of these environmental factors with untold consequences for plant communities and ecosystems worldwide. Given limitations in using organ-level traits to predict ecological performance of species, recent advances using tolerances of low resource availability as plant functional traits are revealing the often hidden roles these factors have in structuring communities and are becoming central to classifying plants ecologically. For example, measuring the physiological drought tolerance of plants has increased the predictability of differences among species in their ability to survive drought as well as the distribution of species within and among ecosystems. Quantifying the shade tolerance of species has improved our understanding of local and regional species diversity and how species have sorted within and among regions. As the stresses on ecosystems continue to shift, coordinated studies of whole-plant growth centered on tolerance of low resource availability will be central in predicting future ecosystem functioning and biodiversity. This will require efforts that quantify tolerances for large numbers of species and develop bioinformatic and other techniques for comparing large number of species.

  15. Philippine geothermal resources: General geological setting and development

    SciTech Connect

    Datuin, R.T.; Troncales, A.C.

    1986-01-01

    The Phillippine Archipelago has a composite geologic structure arising from the multi-stage development of volcanic-tectonic events evidenced by volcanism and seismic activity occurring along the active blocks of the major structural lines which traverse most of the major islands of the Phillipines. The widespread volcanic activity located along the active tectonic block has generated regions of high heat flow, where a vast number of potential rich geothermal resources could be exploited as an alternative source of energy. As part of a systematic geothermal development program launched by the Philippine government after the successful pilot study at the Tiwi geothermal field in 1967 by the Commission on Volcanology (now called the Philippine Institute of Volcanology-PIV), the Philippines developed four geothermal fields in the period 1972-84. These four areas, Tiwi in Albay, Mak-Ban in Laguna, Tongonan in Leyte, and Palinpinon in Southern Negros, have already contributed 891 MW installed capacity to the total electrical power supply of the country, which is mainly dependent on oil resources. The Philippines envisaged that, with its accelerated geothermal energy programme, it would be able to achieve its target of reducing the country's dependence on imported fossil fuel by about 20% within the next decade through the utilization of its vast geothermal energy resources.

  16. Quantifying benefits of resource recovery from sanitation provision in a developing world setting.

    PubMed

    Cornejo, Pablo K; Zhang, Qiong; Mihelcic, James R

    2013-12-15

    Despite concerns of sanitation provision, water scarcity, climate change, and resource depletion, limited research has been conducted to assess the environmental impact of wastewater treatment and resource recovery strategies to improve access to sanitation and resource utilization in developing world settings. Accordingly, the goal of this study is to evaluate the potential benefits of mitigating the environmental impact of two small community-managed wastewater treatment systems in rural Bolivia using resource recovery (i.e., water reuse and energy recovery). Life Cycle Assessment (LCA) is used to estimate the embodied energy, carbon footprint, and eutrophication potential of these systems under existing and resource recovery conditions. Two distinct technologies are analyzed: (1) an upflow anaerobic sludge blanket reactor (UASB) followed by two maturation ponds in series (UASB-Pond system) and (2) a facultative pond followed by two maturation ponds in series (3-Pond system). For the existing systems, bathroom and collection infrastructure had a higher energy intensity than the treatment processes, whereas direct methane emissions from treatment were the primary contributors to the carbon footprint. Taking advantage of reclaimed water was found to greatly reduce the eutrophication potential for both systems, in which the reduction increases proportionally to the percentage of water that is reclaimed. Energy recovery from the UASB-Pond system provided a 19% reduction in embodied energy and a 57% reduction in carbon footprint. Combining water reuse and energy recovery for the UASB-Pond system reduced the eutrophication potential, embodied energy and carbon footprint simultaneously. This highlights the benefits of integrated resource recovery.

  17. ABDOMINAL LYMPHOMA: IMAGING WORK UP CHALLENGES AND RECOMMENDATIONS IN RESOURCE LIMITED SETUP.

    PubMed

    Kebede, Asfaw Atnafu; Bekele, Frehiwot; Assefa, Getachew

    2014-10-01

    Lymphoma management begins with an accurate diagnosis & staging. Major advances in imaging techniques, make cross sectional imaging and nuclear medicine technique an excellent tool for patient work up. However, limited access to modern imaging modality in resource limited set up and luck of standardized imaging work up challenged patient's management. Assess the local lymphoma imaging work up and management challenges in patients with lymphoma and develop local imaging and reporting guideline. A semistructured qualitative interview to six conveniently selected physicians (hematologists, oncologists & pathologists) who primarily takes care of lymphoma patient and literature review on the role of various imaging modalities, recommendation and experience of other countries were used as a methodology Conventional and basic imaging modalities are used in the work up of patient in our set up. The imaging recommendation for these patients requires at least CT of the chest, abdomen and pelvis for initial diagnosis and FDG-PET and/or PET-CTfor follow up and recurrence. Due to the comparable diagnostic potentials of US and its wide spread availability, makes US still the primary imaging modality. Luck of required information's and inconsistency in the radiologists report found to challenge physicians in their patient management. The study concluded that US should still stay as the most important imaging modality in the initial treatment, staging and follow up patients in resource limited set up. It also recommended the general imaging work up and reporting framework. PMID:26410993

  18. Limited Resources, Limited Opportunities, and the Accumulation of Disadvantage: Evidence from the Global Survey of Physicists

    NASA Astrophysics Data System (ADS)

    Ivie, Rachel

    2012-03-01

    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.

  19. Mapping of Florida's Coastal and Marine Resources: Setting Priorities Workshop

    USGS Publications Warehouse

    Robbins, Lisa; Wolfe, Steven; Raabe, Ellen

    2008-01-01

    The importance of mapping habitats and bioregions as a means to improve resource management has become increasingly clear. Large areas of the waters surrounding Florida are unmapped or incompletely mapped, possibly hindering proper management and good decisionmaking. Mapping of these ecosystems is among the top priorities identified by the Florida Oceans and Coastal Council in their Annual Science Research Plan. However, lack of prioritization among the coastal and marine areas and lack of coordination of agency efforts impede efficient, cost-effective mapping. A workshop on Mapping of Florida's Coastal and Marine Resources was sponsored by the U.S. Geological Survey (USGS), Florida Department of Environmental Protection (FDEP), and Southeastern Regional Partnership for Planning and Sustainability (SERPPAS). The workshop was held at the USGS Florida Integrated Science Center (FISC) in St. Petersburg, FL, on February 7-8, 2007. The workshop was designed to provide State, Federal, university, and non-governmental organizations (NGOs) the opportunity to discuss their existing data coverage and create a prioritization of areas for new mapping data in Florida. Specific goals of the workshop were multifold, including to: * provide information to agencies on state-of-the-art technology for collecting data; * inform participants of the ongoing mapping programs in waters off Florida; * present the mapping needs and priorities of the State and Federal agencies and entities operating in Florida; * work with State of Florida agencies to establish an overall priority for areas needing mapping; * initiate discussion of a unified classification of habitat and bioregions; * discuss and examine the need to standardize terminology and data collection/storage so that data, in particular habitat data, can be shared; 9 identify opportunities for partnering and leveraging mapping efforts among agencies and entities; * identify impediments and organizational gaps that hinder collection

  20. Rapid Molecular Assays for the Detection of Yellow Fever Virus in Low-Resource Settings

    PubMed Central

    Escadafal, Camille; Faye, Oumar; Sall, Amadou Alpha; Faye, Ousmane; Weidmann, Manfred; Strohmeier, Oliver; von Stetten, Felix; Drexler, Josef; Eberhard, Michael; Niedrig, Matthias; Patel, Pranav

    2014-01-01

    Background Yellow fever (YF) is an acute viral hemorrhagic disease transmitted by Aedes mosquitoes. The causative agent, the yellow fever virus (YFV), is found in tropical and subtropical areas of South America and Africa. Although a vaccine is available since the 1930s, YF still causes thousands of deaths and several outbreaks have recently occurred in Africa. Therefore, rapid and reliable diagnostic methods easy to perform in low-resources settings could have a major impact on early detection of outbreaks and implementation of appropriate response strategies such as vaccination and/or vector control. Methodology The aim of this study was to develop a YFV nucleic acid detection method applicable in outbreak investigations and surveillance studies in low-resource and field settings. The method should be simple, robust, rapid and reliable. Therefore, we adopted an isothermal approach and developed a recombinase polymerase amplification (RPA) assay which can be performed with a small portable instrument and easy-to-use lyophilized reagents. The assay was developed in three different formats (real-time with or without microfluidic semi-automated system and lateral-flow assay) to evaluate their application for different purposes. Analytical specificity and sensitivity were evaluated with a wide panel of viruses and serial dilutions of YFV RNA. Mosquito pools and spiked human plasma samples were also tested for assay validation. Finally, real-time RPA in portable format was tested under field conditions in Senegal. Conclusion/Significance The assay was able to detect 20 different YFV strains and demonstrated no cross-reactions with closely related viruses. The RPA assay proved to be a robust, portable method with a low detection limit (<21 genome equivalent copies per reaction) and rapid processing time (<20 min). Results from real-time RPA field testing were comparable to results obtained in the laboratory, thus confirming our method is suitable for YFV detection in

  1. Breast cancer in limited-resource countries: health care systems and public policy.

    PubMed

    Anderson, Benjamin O; Yip, Cheng-Har; Ramsey, Scott D; Bengoa, Rafael; Braun, Susan; Fitch, Margaret; Groot, Martijn; Sancho-Garnier, Helene; Tsu, Vivien D

    2006-01-01

    to improve breast health care in a given limited-resource setting.

  2. Challenges of Organizing Mission Surgery in Resource Limited Environments.

    PubMed

    Brooke, Sebastian M; Samson, Thomas D; Mackay, Donald R

    2015-06-01

    Interest in global burden of disease that can be surgically treated is on the rise, and plastic surgeons, with a wide scope of practice, have the tools that make them integral in providing much of the needed surgical support in the world. Since the 1950 s, plastic surgeons have been closely involved in volunteer surgery, and it is through the success and growth of organizations such as Interplast and Operation Smile that we are able to take part in the current paradigm shift to local empowerment and self-sufficiency instead of service delivery alone. This kind of growth started with medical mission work that fostered international partnerships and that remain an important aspect of addressing the unmet surgical burden of disease. Building a mission comprised of an international team of volunteers that travels to a resource-limited environment and provides top-quality surgical care is not without challenges. The aim of this article is to discuss some of these challenges and how they might be overcome. PMID:26080128

  3. A method of setting limits for the purpose of quality assurance

    NASA Astrophysics Data System (ADS)

    Sanghangthum, Taweap; Suriyapee, Sivalee; Kim, Gwe-Ya; Pawlicki, Todd

    2013-10-01

    The result from any assurance measurement needs to be checked against some limits for acceptability. There are two types of limits; those that define clinical acceptability (action limits) and those that are meant to serve as a warning that the measurement is close to the action limits (tolerance limits). Currently, there is no standard procedure to set these limits. In this work, we propose an operational procedure to set tolerance limits and action limits. The approach to establish the limits is based on techniques of quality engineering using control charts and a process capability index. The method is different for tolerance limits and action limits with action limits being categorized into those that are specified and unspecified. The procedure is to first ensure process control using the I-MR control charts. Then, the tolerance limits are set equal to the control chart limits on the I chart. Action limits are determined using the Cpm process capability index with the requirements that the process must be in-control. The limits from the proposed procedure are compared to an existing or conventional method. Four examples are investigated: two of volumetric modulated arc therapy (VMAT) point dose quality assurance (QA) and two of routine linear accelerator output QA. The tolerance limits range from about 6% larger to 9% smaller than conventional action limits for VMAT QA cases. For the linac output QA, tolerance limits are about 60% smaller than conventional action limits. The operational procedure describe in this work is based on established quality management tools and will provide a systematic guide to set up tolerance and action limits for different equipment and processes.

  4. 77 FR 69548 - Price for the 2012 Limited Edition Silver Proof SetTM

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-11-19

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF THE TREASURY United States Mint Price for the 2012 Limited Edition Silver Proof Set TM AGENCY: United States Mint... for the 2012 Limited Edition Silver Proof Set TM . FOR FURTHER INFORMATION CONTACT: B.B....

  5. Paediatric emergency and acute care in resource poor settings.

    PubMed

    Duke, Trevor; Cheema, Baljit

    2016-02-01

    Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co-morbidities, treatment, monitoring and supportive care, discharge planning and follow-up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under-graduate courses and continuing professional development. Quality processes combine evidence-based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little.

  6. Paediatric emergency and acute care in resource poor settings.

    PubMed

    Duke, Trevor; Cheema, Baljit

    2016-02-01

    Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co-morbidities, treatment, monitoring and supportive care, discharge planning and follow-up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under-graduate courses and continuing professional development. Quality processes combine evidence-based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little. PMID:27062627

  7. Telemedicine for Epilepsy Support in Resource-Poor Settings

    PubMed Central

    Patterson, Victor

    2014-01-01

    The Problem: Epilepsy is a common disease worldwide causing significant physical and social disability. It is one of the most treatable neurological diseases. Yet, in rural, poorer countries like much of India and Nepal, most people with epilepsy are not undergoing any treatment often because they cannot access doctors. Conventional Approaches: It is being appreciated that perhaps doctors are not the solution and that enabling health workers to treat epilepsy may be better. Few details, however, have been put forward about how that might be achieved. Thinking Differently: Untreated epilepsy should be considered a public health problem like HIV/AIDS, the various steps needed for treatment identified and solutions found. Telemedicine Approaches: Telemedicine might contribute to two steps – diagnosis and review. A tool that enables non-doctors to diagnose episodes as epileptic has been developed as a mobile phone app and has good applicability, sensitivity, and specificity for the diagnosis. There are a number of ways in which the use of phone review or short messaging service can improve management. Conclusion: Telemedicine, as part of a public health program, can potentially help the millions of people in the resource-poor world with untreated epilepsy. PMID:25191650

  8. Engineering bacteriophage for a pragmatic low-resource setting bacterial diagnostic platform.

    PubMed

    Talbert, Joey N; Alcaine, Samuel D; Nugen, Sam R

    2016-04-01

    Bacteriophages represent multifaceted building blocks that can be incorporated as substitutes for, or in unison with other detection methods, to create powerful new diagnostics for the detection of bacteria. The ease of phage manipulation, production, and detection speed clearly highlights that there remains unrealized opportunities to leverage these phage-based components in diagnostics amenable to resource-limited settings. The passage of regulations like the Food Safety Modernization act, and the ever increasing extent of global trade and travel, will create further demand for these types of diagnostics. While phage-based diagnostics have begun to entering the market place, further research is needed to ensure the potential benefits of phage-based technologies for public health are fully realized. We are just beginning to explore the possibilities that phage-based detection can offer us in the future. The combination of engineered phages as well as engineered enzymes could result in ultrasensitive detection systems for low-resource settings. Because the reporter enzyme is synthesized in vivo, we need to consider the options outside of normal enzyme reporters. In this case, common enzyme issues such as purification and long-term stability are less important. Phage-based diagnostics were conceptualized from out-of-the box thinking and the evolution of these systems should be as well. PMID:27246532

  9. Engineering bacteriophage for a pragmatic low-resource setting bacterial diagnostic platform.

    PubMed

    Talbert, Joey N; Alcaine, Samuel D; Nugen, Sam R

    2016-04-01

    Bacteriophages represent multifaceted building blocks that can be incorporated as substitutes for, or in unison with other detection methods, to create powerful new diagnostics for the detection of bacteria. The ease of phage manipulation, production, and detection speed clearly highlights that there remains unrealized opportunities to leverage these phage-based components in diagnostics amenable to resource-limited settings. The passage of regulations like the Food Safety Modernization act, and the ever increasing extent of global trade and travel, will create further demand for these types of diagnostics. While phage-based diagnostics have begun to entering the market place, further research is needed to ensure the potential benefits of phage-based technologies for public health are fully realized. We are just beginning to explore the possibilities that phage-based detection can offer us in the future. The combination of engineered phages as well as engineered enzymes could result in ultrasensitive detection systems for low-resource settings. Because the reporter enzyme is synthesized in vivo, we need to consider the options outside of normal enzyme reporters. In this case, common enzyme issues such as purification and long-term stability are less important. Phage-based diagnostics were conceptualized from out-of-the box thinking and the evolution of these systems should be as well.

  10. Research consent from young people in resource-poor settings

    PubMed Central

    Cheah, Phaik Yeong; Parker, Michael

    2015-01-01

    Authoritative international guidelines stipulate that for minors to participate in research, consent must be obtained from their parents or guardians. Significant numbers of mature minors, particularly in low-income settings, are currently being ruled out of research participation because their parents are unavailable or refuse to provide consent despite the possibility that they might wish to do so and that such research has the potential to be of real benefit. These populations are under-represented in all types of clinical research. We propose that, for research with a prospect of direct benefit that has been approved by relevant ethics committees, the default position should be that minors who are able to provide valid consent and meet the following criteria should be able to consent for themselves regardless of age and whether they have reached majority: the minor must be competent and mature relative to the decision; their consent must be voluntary and they must be relatively independent and used to decision making of comparable complexity. In addition, the context must be appropriate, the information related to the research must be provided in a manner accessible to the minor and the consent must be obtained by a trained consent taker in surroundings conducive for decision making by the minor. In this paper, we have argued that consent by mature minors to research participation is acceptable in some situations and should be allowed. PMID:25477309

  11. [Limits of optimizing resource allocation by debiting the public health service].

    PubMed

    Schäfer, T

    1997-05-01

    Based on the Dornier consulting opinion on the public health service system of Berlin, the limits of optimising the resource allocation process are discussed with respect to austerity budgets. The discussion focuses firstly on problems of finding a consensus of opinion about public tasks and purposes in the German settings of pluralistic impact on health policy, and secondly on methodical, functional and practical limits. Methodical arguments are supported by a comparison of personal density with regard to the twelve largest cities of Western Germany, and supplemented by a factor analysis of sociodemographic characteristics in order to quantify the need of social work in an urban context. Functional and practical limits are demonstrated with respect to the realisation of the principle of subsidiary and concerning the practice of wholesale cut-downs of public health services budget.

  12. Type 1 diabetes: Syndromes in resource-challenged settings.

    PubMed

    Nagesh, V Sri; Kalra, Sanjay

    2015-06-01

    Type 1 Diabetes is a complex disorder that is made more complex by the myriad of co-morbid conditions associated with it. Mauriac Syndrome is a well-known but nowadays uncommon condition that presents with growth retardation secondary to poor glycaemic control. Limited Joint Mobility is an often-missed association of diabetes. Its importance lies in the fact that it can cause significant impairment of fine movements in T1DM children. It also indicates poor glycaemic control over a long period of time and can be used as a surrogate marker for development of diabetic microvascular complications. Anaemia in T1DM is protean and can develop due to a combination of nutritional factors, chronic renal disease, coeliac disease and worm infestation. Management is etiological. Vitamin deficiencies are ubiquitous in T1DM and if left untreated, can lead to neurological, haematological and skeletal dysfunction. The best-known co-morbid conditions are the local site reactions clubbed together under the moniker lipodystrophies. These can be either atrophic or hypertrophic and are usually due to repeated injections at the same site, improper technique and needle re-use. Management is often difficult and they are best prevented by appropriate diabetes education and emphasis on proper injection techniques at the time of T1DM diagnosis, with periodic reinforcement. Amyloidosis is a little known condition that shares a lot of features in common with the lipodystrophies and often needs to be differentiated from lipohypertrophy. T1DM is a disease which is often associated with a poor quality of life and these co-morbid conditions also need to be treated for effective general and psychological well-being.

  13. Dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution?

    PubMed Central

    Jan, Stephen; Bian, Ying; Jumpa, Manuel; Meng, Qingyue; Nyazema, Norman; Prakongsai, Phusit; Mills, Anne

    2005-01-01

    This paper examines the policy options for the regulation of dual job holding by medical professionals in highly resource-constrained settings. Such activity is generally driven by a lack of resources in the public sector and low pay, and has been associated with the unauthorized use of public resources and corruption. It is also typically poorly regulated; regulations are either lacking, or when they exist, are vague or poorly implemented because of low regulatory capacity. This paper draws on the limited evidence available on this topic to assess a number of regulatory options in relation to the objectives of quality of care and access to services, as well as some of the policy constraints that can undermine implementation in resource-poor settings. The approach taken in highlighting these broader social objectives seeks to avoid the value judgements regarding dual working and some of its associated forms of behaviour that have tended to characterize previous analyses. Dual practice is viewed as a possible system solution to issues such as limited public sector resources (and incomes), low regulatory capacity and the interplay between market forces and human resources. This paper therefore offers some support for policies that allow for the official recognition of such activity and embrace a degree of professional self-regulation. In providing clearer policy guidance, future research in this area needs to adopt a more evaluative approach than that which has been used to date. PMID:16283054

  14. Dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution?

    PubMed

    Jan, Stephen; Bian, Ying; Jumpa, Manuel; Meng, Qingyue; Nyazema, Norman; Prakongsai, Phusit; Mills, Anne

    2005-10-01

    This paper examines the policy options for the regulation of dual job holding by medical professionals in highly resource-constrained settings. Such activity is generally driven by a lack of resources in the public sector and low pay, and has been associated with the unauthorized use of public resources and corruption. It is also typically poorly regulated; regulations are either lacking, or when they exist, are vague or poorly implemented because of low regulatory capacity. This paper draws on the limited evidence available on this topic to assess a number of regulatory options in relation to the objectives of quality of care and access to services, as well as some of the policy constraints that can undermine implementation in resource-poor settings. The approach taken in highlighting these broader social objectives seeks to avoid the value judgements regarding dual working and some of its associated forms of behaviour that have tended to characterize previous analyses. Dual practice is viewed as a possible system solution to issues such as limited public sector resources (and incomes), low regulatory capacity and the interplay between market forces and human resources. This paper therefore offers some support for policies that allow for the official recognition of such activity and embrace a degree of professional self-regulation. In providing clearer policy guidance, future research in this area needs to adopt a more evaluative approach than that which has been used to date.

  15. Dimensions and Determinants of Trust in Health Care in Resource Poor Settings – A Qualitative Exploration

    PubMed Central

    Gopichandran, Vijayaprasad; Chetlapalli, Satish Kumar

    2013-01-01

    Background Trust in health care has been intensely researched in resource rich settings. Some studies in resource poor settings suggest that the dimensions and determinants of trust are likely to be different. Objectives This study was done as a qualitative exploration of the dimensions and determinants of trust in health care in Tamil Nadu, a state in south India to assess the differences from dimensions and determinants in resource rich settings. Methodology The participants included people belonging to marginalized communities with poor access to health care services and living in conditions of resource deprivation. A total of thirty five in depth interviews were conducted. The interviews were summarized and transcribed and data were analyzed following thematic analysis and grounded theory approach. Results The key dimensions of trust in health care identified during the interviews were perceived competence, assurance of treatment irrespective of ability to pay or at any time of the day, patients’ willingness to accept drawbacks in health care, loyalty to the physician and respect for the physician. Comfort with the physician and health facility, personal involvement of the doctor with the patient, behavior and approach of doctor, economic factors, and health awareness were identified as factors determining the levels of trust in health care. Conclusions The dimensions and determinants of trust in health care in resource poor settings are different from that in resource rich settings. There is a need to develop scales to measure trust in health care in resource poor settings using these specific dimensions and determinants. PMID:23874904

  16. Maternal sensitivity and responsiveness, limit-setting style, and relationship history in the transition to toddlerhood.

    PubMed

    LeCuyer-Maus, E A

    2000-01-01

    During the transition of their children to toddlerhood, mothers must learn to adapt their behaviors in a period of marked developmental change. Maternal sensitivity and responsiveness were examined across interactions with varying levels of control-saliency over children at 12 months. Mothers were significantly less sensitive as a group in more control-salient interactions (teaching task, toy clean-up, and limit-setting), than in less control-salient interactions (play and snack). Mothers' sensitivity and responsiveness, and their perceived relationship history in their own families of origin, also were related to their use of limit-setting strategies. Mothers who were less sensitive and responsive, and who reported more negative relationship histories, displayed power-based limit-setting strategies. In contrast, higher levels of maternal sensitivity and responsiveness and more positive relationship histories were associated with teaching-based limit-setting styles.

  17. Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines.

    PubMed

    Anderson, Benjamin O; Shyyan, Roman; Eniu, Alexandru; Smith, Robert A; Yip, Cheng-Har; Bese, Nuran Senel; Chow, Louis W C; Masood, Shahla; Ramsey, Scott D; Carlson, Robert W

    2006-01-01

    Breast cancer is the most common cause of cancer-related death among women worldwide, with case fatality rates highest in low-resource countries. Despite significant scientific advances in its management, most of the world faces resource constraints that limit the capacity to improve early detection, diagnosis, and treatment of the disease. The Breast Health Global Initiative (BHGI) strives to develop evidence-based, economically feasible, and culturally appropriate guidelines that can be used in nations with limited health care resources to improve breast cancer outcomes. Using an evidence-based consensus panel process, four BHGI expert panels addressed the areas of early detection and access to care, diagnosis and pathology, treatment and resource allocation, and health care systems and public policy as they relate to breast health care in limited-resource settings. To update and expand on the BHGI Guidelines published in 2003, the 2005 BHGI panels outlined a stepwise, systematic approach to health care improvement using a tiered system of resource allotment into four levels-basic, limited, enhanced, and maximal-based on the contribution of each resource toward improving clinical outcomes. Early breast cancer detection improves outcome in a cost-effective fashion assuming treatment is available, but requires public education to foster active patient participation in diagnosis and treatment. Clinical breast examination combined with diagnostic breast imaging (ultrasound +/- diagnostic mammography) can facilitate cost-effective tissue sampling techniques for cytologic or histologic diagnosis. Breast-conserving treatment with partial mastectomy and radiation therapy requires more health care resources and infrastructure than mastectomy, but can be provided in a thoughtfully designed limited-resource setting. The availability and administration of systemic therapies are critical to improving breast cancer survival. Estrogen receptor testing allows patient selection

  18. Improving HIV outcomes in resource-limited countries: the importance of quality indicators

    PubMed Central

    2012-01-01

    Background Resource-limited countries increasingly depend on quality indicators to improve outcomes within HIV treatment programs, but indicators of program performance suitable for use at the local program level remain underdeveloped. Methods Using the existing literature as a guide, we applied standard quality improvement (QI) concepts to the continuum of HIV care from HIV diagnosis, to enrollment and retention in care, and highlighted critical service delivery process steps to identify opportunities for performance indicator development. We then identified existing indicators to measure program performance, citing examples used by pivotal donor agencies, and assessed their feasibility for use in surveying local program performance. Clinical delivery steps without existing performance measures were identified as opportunities for measure development. Using National Quality Forum (NQF) criteria as a guide, we developed measurement concepts suitable for use at the local program level that address existing gaps in program performance assessment. Results This analysis of the HIV continuum of care identified seven critical process steps providing numerous opportunities for performance measurement. Analysis of care delivery process steps and the application of NQF criteria identified 24 new measure concepts that are potentially useful for improving operational performance in HIV care at the local level. Conclusion An evidence-based set of program-level quality indicators is critical for the improvement of HIV care in resource-limited settings. These performance indicators should be utilized as treatment programs continue to grow. PMID:23176556

  19. 7 CFR 766.53 - Disaster Set-Aside amount limitations.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... 7 Agriculture 7 2011-01-01 2011-01-01 false Disaster Set-Aside amount limitations. 766.53 Section..., DEPARTMENT OF AGRICULTURE SPECIAL PROGRAMS DIRECT LOAN SERVICING-SPECIAL Disaster Set-Aside § 766.53 Disaster... scheduled annual installment on the FLP loans due after the disaster occurred; or (2) The amount...

  20. 7 CFR 766.53 - Disaster Set-Aside amount limitations.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 7 Agriculture 7 2013-01-01 2013-01-01 false Disaster Set-Aside amount limitations. 766.53 Section..., DEPARTMENT OF AGRICULTURE SPECIAL PROGRAMS DIRECT LOAN SERVICING-SPECIAL Disaster Set-Aside § 766.53 Disaster... scheduled annual installment on the FLP loans due after the disaster occurred; or (2) The amount...

  1. 7 CFR 766.53 - Disaster Set-Aside amount limitations.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 7 Agriculture 7 2012-01-01 2012-01-01 false Disaster Set-Aside amount limitations. 766.53 Section..., DEPARTMENT OF AGRICULTURE SPECIAL PROGRAMS DIRECT LOAN SERVICING-SPECIAL Disaster Set-Aside § 766.53 Disaster... scheduled annual installment on the FLP loans due after the disaster occurred; or (2) The amount...

  2. 7 CFR 766.53 - Disaster Set-Aside amount limitations.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 7 Agriculture 7 2014-01-01 2014-01-01 false Disaster Set-Aside amount limitations. 766.53 Section..., DEPARTMENT OF AGRICULTURE SPECIAL PROGRAMS DIRECT LOAN SERVICING-SPECIAL Disaster Set-Aside § 766.53 Disaster... scheduled annual installment on the FLP loans due after the disaster occurred; or (2) The amount...

  3. 7 CFR 766.53 - Disaster Set-Aside amount limitations.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 7 Agriculture 7 2010-01-01 2010-01-01 false Disaster Set-Aside amount limitations. 766.53 Section..., DEPARTMENT OF AGRICULTURE SPECIAL PROGRAMS DIRECT LOAN SERVICING-SPECIAL Disaster Set-Aside § 766.53 Disaster... scheduled annual installment on the FLP loans due after the disaster occurred; or (2) The amount...

  4. Action Learning in Action: Achieving Change with Limited Resources

    ERIC Educational Resources Information Center

    Grzybowski, Anne

    2008-01-01

    Implementing change is always difficult. It is even more difficult when change is not a priority for anyone else, individuals do not have the authority to tell people to "just do it" and they do not have the resources to "do it themselves". These are some of the challenges the Records Management Section at the University of Edinburgh faces, but it…

  5. Learning with Nature and Learning from Others: Nature as Setting and Resource for Early Childhood Education

    ERIC Educational Resources Information Center

    MacQuarrie, Sarah; Nugent, Clare; Warden, Claire

    2015-01-01

    Nature-based learning is an increasingly popular type of early childhood education. Despite this, children's experiences--in particular, their form and function within different settings and how they are viewed by practitioners--are relatively unknown. Accordingly, the use of nature as a setting and a resource for learning was researched. A…

  6. ESL Resource Center. An Annotated Bibliography of Selected Resources for Vocational Preparation for Limited English Proficient Students.

    ERIC Educational Resources Information Center

    Binder, Andrea, Comp.; And Others

    This annotated bibliography contains publication data and information on the content and availability of 58 resource materials that are recommended for use in vocational preparation programs for individuals with limited English proficiency. Descriptions of the resource materials are organized into sections on the following topics: English as a…

  7. Enabling or Limiting: The Role of Pre-Packaged Curriculum Resources in Shaping Teacher Learning

    ERIC Educational Resources Information Center

    Petrie, Kirsten

    2012-01-01

    Pre-packaged curriculum resources that are purportedly designed to support teachers to deliver physical education in primary school settings have become prolific internationally. While both teachers and teacher educators use curriculum resources extensively, there has been little exploration into the effectiveness of resources in supporting…

  8. 7 CFR 1951.25 - Review of limited resource FO, OL, and SW loans.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... 7 Agriculture 14 2014-01-01 2014-01-01 false Review of limited resource FO, OL, and SW loans. 1951... Servicing Policies § 1951.25 Review of limited resource FO, OL, and SW loans. (a) Frequency of reviews. OL, FO, and SW loans will be reviewed each year at the time the analysis is conducted in accordance...

  9. 7 CFR 1951.25 - Review of limited resource FO, OL, and SW loans.

    Code of Federal Regulations, 2012 CFR

    2012-01-01

    ... 7 Agriculture 14 2012-01-01 2012-01-01 false Review of limited resource FO, OL, and SW loans. 1951... Servicing Policies § 1951.25 Review of limited resource FO, OL, and SW loans. (a) Frequency of reviews. OL, FO, and SW loans will be reviewed each year at the time the analysis is conducted in accordance...

  10. 7 CFR 1951.25 - Review of limited resource FO, OL, and SW loans.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 7 Agriculture 14 2010-01-01 2009-01-01 true Review of limited resource FO, OL, and SW loans. 1951... Servicing Policies § 1951.25 Review of limited resource FO, OL, and SW loans. (a) Frequency of reviews. OL, FO, and SW loans will be reviewed each year at the time the analysis is conducted in accordance...

  11. 7 CFR 1951.25 - Review of limited resource FO, OL, and SW loans.

    Code of Federal Regulations, 2013 CFR

    2013-01-01

    ... 7 Agriculture 14 2013-01-01 2013-01-01 false Review of limited resource FO, OL, and SW loans. 1951... Servicing Policies § 1951.25 Review of limited resource FO, OL, and SW loans. (a) Frequency of reviews. OL, FO, and SW loans will be reviewed each year at the time the analysis is conducted in accordance...

  12. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings.

    PubMed

    Olusanya, Bolajoko O; Ogunlesi, Tinuade A; Kumar, Praveen; Boo, Nem-Yun; Iskander, Iman F; de Almeida, Maria Fernanda B; Vaucher, Yvonne E; Slusher, Tina M

    2015-01-01

    Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥ 35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities

  13. Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings.

    PubMed

    Olusanya, Bolajoko O; Ogunlesi, Tinuade A; Kumar, Praveen; Boo, Nem-Yun; Iskander, Iman F; de Almeida, Maria Fernanda B; Vaucher, Yvonne E; Slusher, Tina M

    2015-04-12

    Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥ 35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities

  14. Online Nutrition Education: Enhancing Opportunities for Limited-Resource Learners

    ERIC Educational Resources Information Center

    Case, Patty; Cluskey, Mary; Hino, Jeff

    2011-01-01

    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…

  15. Ten best resources for conducting financing and benefit incidence analysis in resource-poor settings.

    PubMed

    Wiseman, Virginia; Asante, Augustine; Price, Jennifer; Hayen, Andrew; Irava, Wayne; Martins, Joao; Guinness, Lorna; Jan, Stephen

    2015-10-01

    Many low- and middle-income countries are seeking to reform their health financing systems to move towards universal coverage. This typically means that financing is based on people's ability to pay while, for service use, benefits are based on the need for health care. Financing incidence analysis (FIA) and benefit incidence analysis (BIA) are two popular tools used to assess equity in health systems financing and service use. FIA studies examine who pays for the health sector and how these contributions are distributed according to socioeconomic status (SES). BIA determines who benefits from health care spending, with recipients ranked by their relative SES. In this article, we identify 10 resources to assist researchers and policy makers seeking to undertake or interpret findings from financing and benefit incidence analyses in the health sector. The article pays particular attention to the data requirements, computations, methodological challenges and country level experiences with these types of analyses.

  16. Limited resources of genome sequencing in developing countries: Challenges and solutions.

    PubMed

    Helmy, Mohamed; Awad, Mohamed; Mosa, Kareem A

    2016-06-01

    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. PMID:27354935

  17. Limited resources of genome sequencing in developing countries: Challenges and solutions.

    PubMed

    Helmy, Mohamed; Awad, Mohamed; Mosa, Kareem A

    2016-06-01

    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.

  18. Regions of stability with unequal saturation limits and non-zero set point

    NASA Technical Reports Server (NTRS)

    Stengel, R. F.; Shrivastava, P. C.

    1985-01-01

    Constraints on the magnitudes of control variables limit the region where open-loop unstable systems can be stabilized using feedback control. Variations in regions of stability with unequal control saturation limits and non-zero set points are illustrated for single-input unstable linear systems which have one or two unstable eigenvalues. The regions of stability for saddle-point- and unstable-node-type singularities increase with the increase in one of the saturation limits, but they become invariant when the larger control limit exceeds a certain value; the stability regions vanish for non-zero set-points that saturate the controls. The unstable-focus-type singularity exhibits strikingly different characteristics. These results suggest guidelines for obtaining desired stability regions for different types of singularities.

  19. Sharing limited Ethernet resources with a client-server model

    NASA Astrophysics Data System (ADS)

    Brownless, D. M.; Burton, P. D.

    1994-12-01

    The new control system proposed for the ISIS facility at Rutherford uses an Ethernet spine to provide mutual communications between disparate equipment, including the control computers. This paper describes the limitations imposed on the use of Ethernet in Local/Wide Area Networks and how a client-server based system can be used to circumvent them. The actual system we developed is discussed with particular reference to the problems we have faced, implementing data standards and the performance statistics attained.

  20. Informatics-Based Energy Fitting Scheme for Correlation Energy at Complete Basis Set Limit.

    PubMed

    Seino, Junji; Nakai, Hiromi

    2016-09-30

    Energy fitting schemes based on informatics techniques using hierarchical basis sets with small cardinal numbers were numerically investigated to estimate correlation energies at the complete basis set limits. Numerical validations confirmed that the conventional two-point extrapolation models can be unified into a simple formula with optimal parameters obtained by the same test sets. The extrapolation model was extended to two-point fitting models by a relaxation of the relationship between the extrapolation coefficients or a change of the fitting formula. Furthermore, n-scheme fitting models were developed by the combinations of results calculated at several theory levels and basis sets to compensate for the deficiencies in the fitting model at one level of theory. Systematic assessments on the Gaussian-3X and Gaussian-2 sets revealed that the fitting models drastically reduced errors with equal or smaller computational effort. © 2016 Wiley Periodicals, Inc. PMID:27454327

  1. CD4 quantification based on magneto ELISA for AIDS diagnosis in low resource settings.

    PubMed

    Carinelli, S; Xufré, C; Alegret, S; Martí, M; Pividori, M I

    2016-11-01

    The Acquired Immune Deficiency Syndrome (AIDS) affects the life of millions of people around the world. Although rapid and low cost screening tests are widely available for the diagnosis of HIV infection, the count of CD4+ T lymphocytes remains a drawback in the areas mostly affected by the HIV, being this control imperative for assessing the deterioration of the immunological system and the progression towards AIDS, when the counting of cells falls down 200cellsμL(-1). This paper describes a high-throughput, simple and rapid method for CD4+ T lymphocytes quantification, directly in whole blood, based on a magneto ELISA. The CD4 cells are separated and preconcentrated from whole blood in magnetic particles, and labeled with an enzyme for the optical readout performed with a standard microplate reader. The magneto ELISA is able to reach the whole CD4 counting range of medical interest, being the limit of detection as low as 50 CD4+ cells per μL of whole blood, without any pretreatment. This method is a highly suitable alternative diagnostic tool for the expensive flow cytometry at the community and primary care level, providing a sensitive method but by using instrumentation widely available in low-resource settings laboratories and requiring low-maintenance, as is the case of a microplate reader operated by filters.

  2. CD4 quantification based on magneto ELISA for AIDS diagnosis in low resource settings.

    PubMed

    Carinelli, S; Xufré, C; Alegret, S; Martí, M; Pividori, M I

    2016-11-01

    The Acquired Immune Deficiency Syndrome (AIDS) affects the life of millions of people around the world. Although rapid and low cost screening tests are widely available for the diagnosis of HIV infection, the count of CD4+ T lymphocytes remains a drawback in the areas mostly affected by the HIV, being this control imperative for assessing the deterioration of the immunological system and the progression towards AIDS, when the counting of cells falls down 200cellsμL(-1). This paper describes a high-throughput, simple and rapid method for CD4+ T lymphocytes quantification, directly in whole blood, based on a magneto ELISA. The CD4 cells are separated and preconcentrated from whole blood in magnetic particles, and labeled with an enzyme for the optical readout performed with a standard microplate reader. The magneto ELISA is able to reach the whole CD4 counting range of medical interest, being the limit of detection as low as 50 CD4+ cells per μL of whole blood, without any pretreatment. This method is a highly suitable alternative diagnostic tool for the expensive flow cytometry at the community and primary care level, providing a sensitive method but by using instrumentation widely available in low-resource settings laboratories and requiring low-maintenance, as is the case of a microplate reader operated by filters. PMID:27591585

  3. Effects of Crew Resource Management Training on Medical Errors in a Simulated Prehospital Setting

    ERIC Educational Resources Information Center

    Carhart, Elliot D.

    2012-01-01

    This applied dissertation investigated the effect of crew resource management (CRM) training on medical errors in a simulated prehospital setting. Specific areas addressed by this program included situational awareness, decision making, task management, teamwork, and communication. This study is believed to be the first investigation of CRM…

  4. Recommendations for blood pressure measuring devices for office/clinic use in low resource settings.

    PubMed

    Parati, Gianfranco; Mendis, Shanthi; Abegunde, Dele; Asmar, Ronald; Mieke, Stephan; Murray, Alan; Shengelia, Bakuti; Steenvoorden, Gijs; Van Montfrans, Gert; O'Brien, Eoin

    2005-02-01

    This paper, which summarizes the conclusions of a WHO Expert meeting, is aimed at proposing indications to develop technical specifications for an accurate and affordable blood pressure measuring device for office/clinic use in low resource settings. Blood pressure measuring devices to be used in low resource settings should be accurate, affordable, and easily available worldwide. Given the serious inherent inaccuracy of the auscultatory technique, validated and affordable electronic devices, that have the option to select manual readings, seem to be a suitable solution for low resource settings. The agreement on the technical specifications for automated blood pressure measuring devices for office/clinic use in low resource settings included the following features: high accuracy, adoption of electronic transducers and solar batteries for power supply, standard rates of cuff inflation and deflation, adequate cuff size, digital display powered by solar batteries, facilities for adequate calibration, environmental requirements, no need of memory function, resistance to shock and temperature changes, and low cost. Availability of a device with these features should be accompanied by adequate training of health care personnel, who should guarantee implementation of the procedures recommended in recent European and American Guidelines for accurate blood pressure measurement.

  5. MIDNY: The First Three Years: Community Resource Development in a Complex, Metropolitan Setting.

    ERIC Educational Resources Information Center

    Hahn, Alan J.

    This is an account of the first three years of the MIDNY Project, a pilot community resource development project in the five-county Central New York Region surrounding the city of Syracuse. The project was set up in 1966 by New York State Cooperative Extension with special funds provided by the Federal Extension Service. It was one of the first…

  6. Providing consumer health information in the rural setting: Planetree Health Resource Center's approach

    PubMed Central

    Spatz, Michele A.

    2000-01-01

    Both lifestyle and geography make the delivery of consumer health information in the rural setting unique. The Planetree Health Resource Center in The Dalles, Oregon, has served the public in a rural setting for the past eight years. It is a community-based consumer health library, affiliated with a small rural hospital, Mid-Columbia Medical Center. One task of providing consumer health information in rural environments is to be in relationship with individuals in the community. Integration into community life is very important for credibility and sustainability. The resource center takes a proactive approach and employs several different outreach efforts to deepen its relationship with community members. It also works hard to foster partnerships for improved health information delivery with other community organizations, including area schools. This paper describes Planetree Health Resource Center's approach to rural outreach. PMID:11055307

  7. Can Oxygen Set Thermal Limits in an Insect and Drive Gigantism?

    PubMed Central

    Verberk, Wilco C. E. P.; Bilton, David T.

    2011-01-01

    Background Thermal limits may arise through a mismatch between oxygen supply and demand in a range of animal taxa. Whilst this oxygen limitation hypothesis is supported by data from a range of marine fish and invertebrates, its generality remains contentious. In particular, it is unclear whether oxygen limitation determines thermal extremes in tracheated arthropods, where oxygen limitation may be unlikely due to the efficiency and plasticity of tracheal systems in supplying oxygen directly to metabolically active tissues. Although terrestrial taxa with open tracheal systems may not be prone to oxygen limitation, species may be affected during other life-history stages, particularly if these rely on diffusion into closed tracheal systems. Furthermore, a central role for oxygen limitation in insects is envisaged within a parallel line of research focussing on insect gigantism in the late Palaeozoic. Methodology/Principal Findings Here we examine thermal maxima in the aquatic life stages of an insect at normoxia, hypoxia (14 kPa) and hyperoxia (36 kPa). We demonstrate that upper thermal limits do indeed respond to external oxygen supply in the aquatic life stages of the stonefly Dinocras cephalotes, suggesting that the critical thermal limits of such aquatic larvae are set by oxygen limitation. This could result from impeded oxygen delivery, or limited oxygen regulatory capacity, both of which have implications for our understanding of the limits to insect body size and how these are influenced by atmospheric oxygen levels. Conclusions/Significance These findings extend the generality of the hypothesis of oxygen limitation of thermal tolerance, suggest that oxygen constraints on body size may be stronger in aquatic environments, and that oxygen toxicity may have actively selected for gigantism in the aquatic stages of Carboniferous arthropods. PMID:21818347

  8. Distance-dependent pollen limitation of seed set in some insect-pollinated dioecious plants

    NASA Astrophysics Data System (ADS)

    de Jong, Tom J.; Batenburg, Judith C.; Klinkhamer, Peter G. L.

    2005-11-01

    By applying hand pollination, we studied pollen limitation of seed set of female plants in four dioecious plant species with insect-pollination. The effect of hand pollination increased with distance to the nearest male plant. Distances at which seed set was 50% of its maximal value (after hand pollination) were: 2.3 m for Valeriana dioica, 5.3 m for Salix repens, 8.5 m for Asparagus officinale and 10.6 m for Bryonia dioica. We discuss to what extent the reduced seed set was caused by either fewer visits or by visits of a lower quality. We argue that quantifying distance-dependent seed set in dioecious plants may be a good way of studying effects of habitat fragmentation on the breakdown of mutualistic pollination systems.

  9. Satellite-Based Solar Resource Data Sets for India 2002-2012

    SciTech Connect

    Sengupta, M.; Perez, R.; Gueymard, C.; Anderberg, M.; Gotseff, P.

    2014-02-01

    A new 10-km hourly solar resource product was created for India. This product was created using satellite radiances from the Meteosat series of satellites. The product contains global horizontal irradiances (GHI) and direct normal irradiances (DNI) for the period from 2002 to 2011. An additional solar resource data set covering the period from January 2012 to June 2012 was created solely for validation because this period overlaps ground measurements that were made available from the Indian Ministry of New and Renewable Energy's (MNRE's) National Institute for Solar Energy for five stations that are part of MNRE's solar resource network. These measurements were quality checked using the SERI QC software and used to validate the satellite product. A comparison of the satellite product to the ground measurements for the five stations shows good agreement. This report also presents a comparison of the new version of solar resource data to the previous version, which covered the period from 2002 to 2008.

  10. Medical devices and diagnostics for cardiovascular diseases in low-resource settings.

    PubMed

    McGuire, Helen; Weigl, Bernhard H

    2014-11-01

    Noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes, have emerged as an underappreciated health threat with enormous economic and public health implications for populations in low-resource settings. In order to address these diseases, devices that are to be used in low-resource settings have to conform to requirements that are generally more challenging than those developed for traditional markets. Characteristics and issues that must be considered when working in low- and middle-income countries (LMICs) include challenging environmental conditions, a complex supply chain, sometimes inadequate operator training, and cost. Somewhat counterintuitively, devices for low-resource setting (LRS) markets need to be of at least as high quality and reliability as those for developed countries to be setting-appropriate and achieve impact. Finally, the devices need to be designed and tested for the populations in which they are to be used in order to achieve the performance that is needed. In this review, we focus on technologies for primary and secondary health-care settings and group them according to the continuum of care from prevention to treatment. PMID:25294168

  11. What is the most efficient way to reach the canonical MP2 basis set limit?

    NASA Astrophysics Data System (ADS)

    Liakos, Dimitrios G.; Izsák, Róbert; Valeev, Edward F.; Neese, Frank

    2013-09-01

    Various ways of reaching the complete basis set limit at the second-order Møller-Plesset perturbation theory (MP2) level are compared with respect to their cost-to-accuracy ratio. These include: (1) traditional MP2 calculations with correlation consistent basis sets of increasing size, with and without the resolution of identity for Coulomb and exchange (RIJK) or the combined RIJ and 'chain of spheres' (RIJCOSX) approximations; (2) basis set extrapolation obtained with the same MP2 variants; and (3) explicitly correlated F12-MP2 methods. The time required to solve the Hartree-Fock equations is part of the evaluation because the overall efficiency is of central interest in this work. Results were obtained for the ISO34, DC9 and S66 test sets and were analysed in terms of efficiency and accuracy for total energies, reaction energies and their effect on the basis set superposition error. Among the methods studied, the RIJK-MP2-F12 and RIJK-MP2-EP1 (where EP1 stands for 'Extrapolation Protocol 1' as explained in the text) methods perform outstandingly well. Although extrapolation is, in general, slightly faster than explicit correlation, it is found that for reaction energies, RIJK-MP2-F12 performs systematically better. This holds especially in combination with a triple zeta basis set, in which case it even outperforms the much more costly extrapolation involving quadruple- and quintuple-zeta correlation consistent basis sets.

  12. Vaginal Birth After Caesarean Section in Low Resource Settings: The Clinical and Ethical Dilemma.

    PubMed

    Wanyonyi, Sikolia; Muriithi, Francis G

    2015-10-01

    Vaginal birth after Caesarean section (VBAC) has long been practised in low resource settings using unconventional methods. This not only poses danger to the woman and her baby, but could also have serious legal and ethical implications. The adoption of this practice has been informed by observational studies with many deficiencies; this is so despite other studies from settings in which the standard of care is much better that show that elective repeat Caesarean section (ERCS) may actually be safer than VBAC. This raises questions about whether we should insist on a dangerous practice when there are safer alternatives. We highlight some of the challenges faced in making this decision, and discuss why the fear of ERCS may not be justified after all in low resource settings. Since a reduction in rates of Caesarean section may not be applicable in these regions, because their rates are already low, the emphasis should instead be on adequate birth spacing and safer primary operative delivery.

  13. The challenge of assessing infant vaccine responses in resource-poor settings

    PubMed Central

    Flanagan, Katie L; Burl, Sarah; Lohman-Payne, Barbara L; Plebanski, Magdalena

    2010-01-01

    Newborns and infants are highly susceptible to infectious diseases, resulting in high mortality and morbidity, particularly in resource-poor settings. Many vaccines require several booster doses, resulting in an extensive vaccine schedule, and yet there is still inadequate protection from some of these diseases. This is partly due to the immaturity of the neonate and infant immune system. Little is known about the specific modifications to immunological assessment protocols in early life but increasing knowledge of infant immunology has helped provide better recommendations for assessing these responses. Since most new vaccines will eventually be deployed in low-income settings such as Africa, the logistics and resources of assessing immunity in such settings also need to be understood. In this article, we will review immunity to vaccines in early life, discuss the many challenges associated with assessing immunogenicity and provide practical tips. PMID:20518720

  14. Magnetic properties with multiwavelets and DFT: the complete basis set limit achieved.

    PubMed

    Jensen, Stig Rune; Flå, Tor; Jonsson, Dan; Monstad, Rune Sørland; Ruud, Kenneth; Frediani, Luca

    2016-08-01

    Multiwavelets are emerging as an attractive alternative to traditional basis sets such as Gaussian-type orbitals and plane waves. One of their distinctive properties is the ability to reach the basis set limit (often a chimera for traditional approaches) reliably and consistently by fixing the desired precision ε. We present our multiwavelet implementation of the linear response formalism, applied to static magnetic properties, at the self-consistent field level of theory (both for Hartree-Fock and density functional theories). We demonstrate that the multiwavelets consistently improve the accuracy of the results when increasing the desired precision, yielding results that have four to five digits precision, thus providing a very useful benchmark which could otherwise only be estimated by extrapolation methods. Our results show that magnetizabilities obtained with the augmented quadruple-ζ basis (aug-cc-pCVQZ) are practically at the basis set limit, whereas absolute nuclear magnetic resonance shielding tensors are more challenging: even by making use of a standard extrapolation method, the accuracy is not substantially improved. In contrast, our results provide a benchmark that: (1) confirms the validity of the extrapolation ansatz; (2) can be used as a reference to achieve a property-specific extrapolation scheme, thus providing a means to obtain much better extrapolated results; (3) allows us to separate functional-specific errors from basis-set ones and thus to assess the level of cancellation between basis set and functional errors often exploited in density functional theory. PMID:27087397

  15. Magnetic properties with multiwavelets and DFT: the complete basis set limit achieved.

    PubMed

    Jensen, Stig Rune; Flå, Tor; Jonsson, Dan; Monstad, Rune Sørland; Ruud, Kenneth; Frediani, Luca

    2016-08-01

    Multiwavelets are emerging as an attractive alternative to traditional basis sets such as Gaussian-type orbitals and plane waves. One of their distinctive properties is the ability to reach the basis set limit (often a chimera for traditional approaches) reliably and consistently by fixing the desired precision ε. We present our multiwavelet implementation of the linear response formalism, applied to static magnetic properties, at the self-consistent field level of theory (both for Hartree-Fock and density functional theories). We demonstrate that the multiwavelets consistently improve the accuracy of the results when increasing the desired precision, yielding results that have four to five digits precision, thus providing a very useful benchmark which could otherwise only be estimated by extrapolation methods. Our results show that magnetizabilities obtained with the augmented quadruple-ζ basis (aug-cc-pCVQZ) are practically at the basis set limit, whereas absolute nuclear magnetic resonance shielding tensors are more challenging: even by making use of a standard extrapolation method, the accuracy is not substantially improved. In contrast, our results provide a benchmark that: (1) confirms the validity of the extrapolation ansatz; (2) can be used as a reference to achieve a property-specific extrapolation scheme, thus providing a means to obtain much better extrapolated results; (3) allows us to separate functional-specific errors from basis-set ones and thus to assess the level of cancellation between basis set and functional errors often exploited in density functional theory.

  16. Universal mobile electrochemical detector designed for use in resource-limited applications

    PubMed Central

    Nemiroski, Alex; Christodouleas, Dionysios C.; Hennek, Jonathan W.; Kumar, Ashok A.; Maxwell, E. Jane; Fernández-Abedul, Maria Teresa; Whitesides, George M.

    2014-01-01

    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. PMID:25092346

  17. Universal mobile electrochemical detector designed for use in resource-limited applications.

    PubMed

    Nemiroski, Alex; Christodouleas, Dionysios C; Hennek, Jonathan W; Kumar, Ashok A; Maxwell, E Jane; Fernández-Abedul, Maria Teresa; Whitesides, George M

    2014-08-19

    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. PMID:25092346

  18. 7 CFR 760.107 - Socially disadvantaged, limited resource, or beginning farmer or rancher.

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... group whose members have been subjected to racial or ethnic prejudice because of their identity as... site available through the Limited Resource Farmer and Rancher Online Self Determination Tool...

  19. 7 CFR 760.107 - Socially disadvantaged, limited resource, or beginning farmer or rancher.

    Code of Federal Regulations, 2011 CFR

    2011-01-01

    ... group whose members have been subjected to racial or ethnic prejudice because of their identity as... site available through the Limited Resource Farmer and Rancher Online Self Determination Tool...

  20. 7 CFR 760.107 - Socially disadvantaged, limited resource, or beginning farmer or rancher.

    Code of Federal Regulations, 2014 CFR

    2014-01-01

    ... group whose members have been subjected to racial or ethnic prejudice because of their identity as... a Web site available through the Limited Resource Farmer and Rancher Online Self Determination...

  1. Justification of Filter Selection for Robot Balancing in Conditions of Limited Computational Resources

    NASA Astrophysics Data System (ADS)

    Momot, M. V.; Politsinskaia, E. V.; Sushko, A. V.; Semerenko, I. A.

    2016-08-01

    The paper considers the problem of mathematical filter selection, used for balancing of wheeled robot in conditions of limited computational resources. The solution based on complementary filter is proposed.

  2. 28 CFR 16.92 - Exemption of Environment and Natural Resources Division Systems-limited access.

    Code of Federal Regulations, 2014 CFR

    2014-07-01

    ... 28 Judicial Administration 1 2014-07-01 2014-07-01 false Exemption of Environment and Natural....92 Exemption of Environment and Natural Resources Division Systems—limited access. (a)(1) The...) Environment and Natural Resources Division Case and Related Files System, JUSTICE/ENRD-003. (ii) (2)...

  3. 28 CFR 16.92 - Exemption of Environment and Natural Resources Division Systems-limited access.

    Code of Federal Regulations, 2012 CFR

    2012-07-01

    ... 28 Judicial Administration 1 2012-07-01 2012-07-01 false Exemption of Environment and Natural....92 Exemption of Environment and Natural Resources Division Systems—limited access. (a)(1) The...) Environment and Natural Resources Division Case and Related Files System, JUSTICE/ENRD-003. (ii) (2)...

  4. 28 CFR 16.92 - Exemption of Environment and Natural Resources Division Systems-limited access.

    Code of Federal Regulations, 2010 CFR

    2010-07-01

    ... 28 Judicial Administration 1 2010-07-01 2010-07-01 false Exemption of Environment and Natural....92 Exemption of Environment and Natural Resources Division Systems—limited access. (a)(1) The...) Environment and Natural Resources Division Case and Related Files System, JUSTICE/ENRD-003. (ii) (2)...

  5. 28 CFR 16.92 - Exemption of Environment and Natural Resources Division Systems-limited access.

    Code of Federal Regulations, 2011 CFR

    2011-07-01

    ... 28 Judicial Administration 1 2011-07-01 2011-07-01 false Exemption of Environment and Natural....92 Exemption of Environment and Natural Resources Division Systems—limited access. (a)(1) The...) Environment and Natural Resources Division Case and Related Files System, JUSTICE/ENRD-003. (ii) (2)...

  6. Workshop report: strategies for setting occupational exposure limits for engineered nanomaterials.

    PubMed

    Gordon, Steven C; Butala, John H; Carter, Janet M; Elder, Alison; Gordon, Terry; Gray, George; Sayre, Philip G; Schulte, Paul A; Tsai, Candace S; West, Jay

    2014-04-01

    Occupational exposure limits (OELs) are important tools for managing worker exposures to chemicals; however, hazard data for many engineered nanomaterials (ENMs) are insufficient for deriving OELs by traditional methods. Technical challenges and questions about how best to measure worker exposures to ENMs also pose barriers to implementing OELs. New varieties of ENMs are being developed and introduced into commerce at a rapid pace, further compounding the issue of OEL development for ENMs. A Workshop on Strategies for Setting Occupational Exposure Limits for Engineered Nanomaterials, held in September 2012, provided an opportunity for occupational health experts from various stakeholder groups to discuss possible alternative approaches for setting OELs for ENMs and issues related to their implementation. This report summarizes the workshop proceedings and findings, identifies areas for additional research, and suggests potential avenues for further progress on this important topic.

  7. Students' Understanding of Limiting Behavior at a Point for Functions from [Set of Real Numbers][superscript 2] to [Set of Real Numbers

    ERIC Educational Resources Information Center

    Mamona-Downs, Joanna K.; Megalou, Foteini J.

    2013-01-01

    The aim of this paper is to examine students' understanding of the limiting behavior of a function from [set of real numbers][superscript 2] to [set of real numbers] at a point "P." This understanding depends on which definition is used for a limit. Several definitions are considered; two of these concern the notion of a neighborhood of "P", while…

  8. Surveillance of fetal arrhythmias in the outpatient setting: current limitations and call for action.

    PubMed

    Freire, Grace

    2015-12-01

    Surveillance of fetal arrhythmias in the outpatient setting remains limited by lack of monitoring modalities. Despite technological advances made in the field of obstetrics, existing devices are not currently suitable to monitor fetal arrhythmias. In this report, the author describes the current and developing fetal heart rate monitoring technologies including the recent introduction of hand-held Doppler monitors for outpatient surveillance of fetal arrhythmias.

  9. Health systems and immunization financing for human papillomavirus vaccine introduction in low-resource settings.

    PubMed

    Biellik, Robin; Levin, Carol; Mugisha, Emmanuel; LaMontagne, D Scott; Bingham, Allison; Kaipilyawar, Satish; Gandhi, Sanjay

    2009-10-19

    This descriptive qualitative study synthesizes health system and immunization financing assessments performed through formative research in India, Peru, Uganda, and Vietnam using a non-probability sample of national and sub-national stakeholders; and recommends appropriate and effective strategies for HPV vaccine delivery in low-resource settings. We conclude that maximum feasibility and acceptability and lowest cost for delivering HPV vaccine can be achieved by implementing through national immunization programs; by partnering with other sectors, such as education and maternal-child health; by strengthening existing human resources and cold chain infrastructures where needed; and finally, by considering schools for reaching the target population. PMID:19698808

  10. Identifying finite-time coherent sets from limited quantities of Lagrangian data

    SciTech Connect

    Williams, Matthew O.; Rypina, Irina I.; Rowley, Clarence W.

    2015-08-15

    A data-driven procedure for identifying the dominant transport barriers in a time-varying flow from limited quantities of Lagrangian data is presented. Our approach partitions state space into coherent pairs, which are sets of initial conditions chosen to minimize the number of trajectories that “leak” from one set to the other under the influence of a stochastic flow field during a pre-specified interval in time. In practice, this partition is computed by solving an optimization problem to obtain a pair of functions whose signs determine set membership. From prior experience with synthetic, “data rich” test problems, and conceptually related methods based on approximations of the Perron-Frobenius operator, we observe that the functions of interest typically appear to be smooth. We exploit this property by using the basis sets associated with spectral or “mesh-free” methods, and as a result, our approach has the potential to more accurately approximate these functions given a fixed amount of data. In practice, this could enable better approximations of the coherent pairs in problems with relatively limited quantities of Lagrangian data, which is usually the case with experimental geophysical data. We apply this method to three examples of increasing complexity: The first is the double gyre, the second is the Bickley Jet, and the third is data from numerically simulated drifters in the Sulu Sea.

  11. Identifying finite-time coherent sets from limited quantities of Lagrangian data.

    PubMed

    Williams, Matthew O; Rypina, Irina I; Rowley, Clarence W

    2015-08-01

    A data-driven procedure for identifying the dominant transport barriers in a time-varying flow from limited quantities of Lagrangian data is presented. Our approach partitions state space into coherent pairs, which are sets of initial conditions chosen to minimize the number of trajectories that "leak" from one set to the other under the influence of a stochastic flow field during a pre-specified interval in time. In practice, this partition is computed by solving an optimization problem to obtain a pair of functions whose signs determine set membership. From prior experience with synthetic, "data rich" test problems, and conceptually related methods based on approximations of the Perron-Frobenius operator, we observe that the functions of interest typically appear to be smooth. We exploit this property by using the basis sets associated with spectral or "mesh-free" methods, and as a result, our approach has the potential to more accurately approximate these functions given a fixed amount of data. In practice, this could enable better approximations of the coherent pairs in problems with relatively limited quantities of Lagrangian data, which is usually the case with experimental geophysical data. We apply this method to three examples of increasing complexity: The first is the double gyre, the second is the Bickley Jet, and the third is data from numerically simulated drifters in the Sulu Sea.

  12. Resource limitation alters the consequences of co-infection for both hosts and parasites.

    PubMed

    Budischak, Sarah A; Sakamoto, Kaori; Megow, Lindsey C; Cummings, Kelly R; Urban, Joseph F; Ezenwa, Vanessa O

    2015-06-01

    Most animals are concurrently infected with multiple parasite species and live in environments with fluctuating resource availability. Resource limitation can influence host immune responses and the degree of competition between co-infecting parasites, yet its effects on individual health and pathogen transmission have not been studied for co-infected hosts. To test how resource limitation affects immune trade-offs and co-infection outcomes, we conducted a factorial experiment using laboratory mice. Mice were given a standard or low protein diet, dosed with two species of helminths (alone and in combination), and then challenged with a microparasite. Using a community ecology trophic framework, we found that co-infection influenced parasite survival and reproduction via host immunity, but the magnitude and direction of responses depended on resources and the combination of co-infecting parasites. Our findings highlight that resources and their consequence for host defenses are a key context that shapes the magnitude and direction of parasite interactions.

  13. Hospital preparedness in community measles outbreaks—challenges and recommendations for low-resource settings

    PubMed Central

    Shakoor, Sadia; Mir, Fatima; Zaidi, Anita K. M.; Zafar, Afia

    2015-01-01

    We have reviewed various strategies involved in containment of measles in healthcare facilities during community outbreaks. The strategies that are more applicable to resource-poor settings, such as natural ventilation, mechanical ventilation with heating and air-conditioning systems allowing unidirectional air-flow, and protection of un-infected patients and healthcare workers (HCWs), have been examined. Ventilation methods need innovative customization for resource-poor settings followed by validation and post-implementation analysis for impact. Mandatory vaccination of all HCWs with two doses of measles-containing vaccine, appropriate post-exposure prophylaxis of immunocompromised inpatients, and stringent admission criteria for measles cases can contribute toward reduction of nosocomial and secondary transmission within facilities. PMID:25882388

  14. The SIGN Nail: Factors in a Successful Device for Low-Resource Settings.

    PubMed

    Haonga, Billy Thomson; Zirkle, Lewis G

    2015-10-01

    Surgeons in low-resource settings manage an increasing number of patients presenting with high-energy fractures. The number of surgeons and the operating time available are frequently not adequate to treat these fractures in a timely manner. A common cause of delay in treating fractures is waiting for the patient to accumulate sufficient funding to pay for the surgery, including the surgical implant. The donation of the SIGN intramedullary nail interlocking screw system obviates a major delay in timing of surgery. The SIGN intramedullary nail has been designed to be used in low-resource settings as it can be placed without fluoroscopy or electricity. The SIGN-trained surgeons are very skillful in hand reaming the canal, placing the nail, and interlocking screws without fluoroscopy. As more is learned about fracture healing, the SIGN system continues to evolve. The SIGN system is expanding to include deformity correction and soft tissue coverage. PMID:26356214

  15. Maternal mortality in resource-poor settings: policy barriers to care.

    PubMed

    Mavalankar, Dileep V; Rosenfield, Allan

    2005-02-01

    Maternal mortality remains one of the most daunting public health problems in resource-poor settings, and reductions in maternal mortality have been identified as a prominent component of the United Nations Millennium Development Goals. The World Health Organization estimates that 515000 women die each year from pregnancy-related causes, and almost all of these deaths occur in developing countries. Evidence has shown that access to and utilization of high-quality emergency obstetric care (EmOC) is central to efforts aimed at reducing maternal mortality. We analyzed health care policies that restrict access to life-saving EmOC in most resource-poor settings, focusing on examples from rural India, a country of more than 1 billion people that contributes approximately 20% to 24% of the world's maternal deaths. PMID:15671450

  16. Hospital preparedness in community measles outbreaks-challenges and recommendations for low-resource settings.

    PubMed

    Shakoor, Sadia; Mir, Fatima; Zaidi, Anita K M; Zafar, Afia

    2015-01-01

    We have reviewed various strategies involved in containment of measles in healthcare facilities during community outbreaks. The strategies that are more applicable to resource-poor settings, such as natural ventilation, mechanical ventilation with heating and air-conditioning systems allowing unidirectional air-flow, and protection of un-infected patients and healthcare workers (HCWs), have been examined. Ventilation methods need innovative customization for resource-poor settings followed by validation and post-implementation analysis for impact. Mandatory vaccination of all HCWs with two doses of measles-containing vaccine, appropriate post-exposure prophylaxis of immunocompromised inpatients, and stringent admission criteria for measles cases can contribute toward reduction of nosocomial and secondary transmission within facilities.

  17. Limiting resources in sessile systems: food enhances diversity and growth of suspension feeders despite available space.

    PubMed

    Svensson, Robin J; Marshall, Dustin J

    2015-03-01

    Much of our understanding of competition comes trom onservations in sessue systems, such as rainforests and marine invertebrate communities. In terrestrial systems, sessile species often compete for multiple limiting resources (i.e., space, light, and nutrients), but in marine systems, space is viewed as the primary or sole limiting resource. Competition theory, on the other hand, suggests that competition for a single limiting resource is unlikely to maintain high species diversity, but manipulative tests of competition for other resources in marine benthic systems are exceedingly rare. Here, we manipulate the availability of food for a classic system, marine sessile invertebrate communities, and investigate the effects on species diversity, abundance, and composition during early succession as well as on the growth of bryozoan populations in the field. We found the number of species to be greater, available space to be lower, and the community composition to be different in assemblages subjected to increased food availability compared to controls. Similarly, laboratory-settled bryozoans deployed into the field grew more in the presence of enhanced food. Our results suggest that food can act as a limiting resource, affecting both diversity and abundance, even when bare space is still available in hard-substratum communities. Consequently, broadening the view of resource limitation beyond solely space may increase our understanding and predictability of marine sessile systems.

  18. Limiting resources in sessile systems: food enhances diversity and growth of suspension feeders despite available space.

    PubMed

    Svensson, Robin J; Marshall, Dustin J

    2015-03-01

    Much of our understanding of competition comes trom onservations in sessue systems, such as rainforests and marine invertebrate communities. In terrestrial systems, sessile species often compete for multiple limiting resources (i.e., space, light, and nutrients), but in marine systems, space is viewed as the primary or sole limiting resource. Competition theory, on the other hand, suggests that competition for a single limiting resource is unlikely to maintain high species diversity, but manipulative tests of competition for other resources in marine benthic systems are exceedingly rare. Here, we manipulate the availability of food for a classic system, marine sessile invertebrate communities, and investigate the effects on species diversity, abundance, and composition during early succession as well as on the growth of bryozoan populations in the field. We found the number of species to be greater, available space to be lower, and the community composition to be different in assemblages subjected to increased food availability compared to controls. Similarly, laboratory-settled bryozoans deployed into the field grew more in the presence of enhanced food. Our results suggest that food can act as a limiting resource, affecting both diversity and abundance, even when bare space is still available in hard-substratum communities. Consequently, broadening the view of resource limitation beyond solely space may increase our understanding and predictability of marine sessile systems. PMID:26236877

  19. NCBI Epigenomics: a new public resource for exploring epigenomic data sets.

    PubMed

    Fingerman, Ian M; McDaniel, Lee; Zhang, Xuan; Ratzat, Walter; Hassan, Tarek; Jiang, Zhifang; Cohen, Robert F; Schuler, Gregory D

    2011-01-01

    The Epigenomics database at the National Center for Biotechnology Information (NCBI) is a new resource that has been created to serve as a comprehensive public resource for whole-genome epigenetic data sets (www.ncbi.nlm.nih.gov/epigenomics). Epigenetics is the study of stable and heritable changes in gene expression that occur independently of the primary DNA sequence. Epigenetic mechanisms include post-translational modifications of histones, DNA methylation, chromatin conformation and non-coding RNAs. It has been observed that misregulation of epigenetic processes has been associated with human disease. We have constructed the new resource by selecting the subset of epigenetics-specific data from general-purpose archives, such as the Gene Expression Omnibus, and Sequence Read Archives, and then subjecting them to further review, annotation and reorganization. Raw data is processed and mapped to genomic coordinates to generate 'tracks' that are a visual representation of the data. These data tracks can be viewed using popular genome browsers or downloaded for local analysis. The Epigenomics resource also provides the user with a unique interface that allows for intuitive browsing and searching of data sets based on biological attributes. Currently, there are 69 studies, 337 samples and over 1100 data tracks from five well-studied species that are viewable and downloadable in Epigenomics.

  20. Cardiovascular disease prevention in low resource settings: lessons from the Heartfile experience in Pakistan.

    PubMed

    Nishtar, Sania

    2003-01-01

    This paper outlines activities of the Heartfile Program in Pakistan (http://heartfile.org). The program focuses on cardiovascular disease prevention and health promotion, and includes several initiatives that encompass building policy, reorienting health services, and developing community interventions that utilize the print and electronic media and outreach at the grass-root level to incorporate social marketing approaches. Initiated by the nonprofit private sector, the program now links with major public sector primary healthcare programs, and is currently spearheading formulation of the National Action Plan on Noncommunicable Disease Prevention and Control in Pakistan. In addition, the program is being refined, validated, and packaged as a replicable model for other developing countries and in low resource settings, utilizing appropriate principles of franchising with inbuilt components sensitive to cultural and social adaptations. A review of the planning process, implementation strategy, and fund-raising experience is presented. Strategies unique to low resource settings, such as the development of cost- and time-efficient strategic alliances and partnerships, have also been highlighted. In addition, specific caveats are identified as being helpful to private sector development of chronic disease prevention programs in resource-constrained settings, and a road map to a sustainable public-private sector partnership is provided.

  1. Obstetric perineal injury: risk factors and prevalence in a resource-constrained setting.

    PubMed

    Naidoo, T D; Moodley, J

    2015-10-01

    The prevalence of obstetric perineal injuries and risk factors vary between affluent and resource-constrained settings. This prospective observational study reports on the factors associated with perineal lacerations in a cohort of Black African and Indian women delivering at two regional hospitals in South Africa. Binary logistic regression analysis was used to test for associations between independent variables and the dependent variable on multivariate analysis. All variables significant on bivariate analysis (P < 0.05) were included in the multivariate model. There were 202 (16.2%) perineal tears. Variables significant with having a perineal tear on bivariate and multivariate analysis included: Black African race (OR: 2.4; 95% CI: 1.2-4.6); duration of labour ≥6.3h (OR: 1.5; 95% CI: 1.1-2.1); and epidural analgesia (OR: 2.9; 95% CI: 1.9-4.7). Having an episiotomy was protective against perineal tears (OR: 0.06; 95% CI: 0.03-0.1). Obstetric perineal injury commonly occurs in our resourced-constrained setting and the risk factors are similar to those in well-resourced settings. Identification of those at risk may reduce obstetric perineal injury. PMID:26446187

  2. Management of pre-invasive cervical cancer in low-resource setting.

    PubMed

    Chichareon, Saibua B

    2004-10-01

    Cervical cancer is one of the health burdens in many developing countries. The advanced knowledge in the past decade reassured the important role of human papillomavirus as the necessary cause of cervical cancer and makes a clear understanding of its natural history. Cervical cancer has a long period of pre-invasive stage, and only a small proportion of cervical intraepithelial neoplasia (CIN) that can progress to be an invasive lesion. Appropriate management of CIN can prevent invasive cervical cancer. The contemporary treatment of CIN is more conservative and requires effective follow-up process. However inappropriate management of CIN is still be found at the international and national survey of less developed countries. Although no apparent superior surgical technique for treating CIN, loop electrosurgical excision procedure (LEEP) and cryotherapy are fascinated for the low-resource setting. Other alternative approach, which eliminates cytology and colposcopy may be considered in the ultrashort- resource setting with a high prevalence of cervical cancer. In this article, the contemporary knowledge about the natural history of cervical cancer, especially the implication of human papillomavirus (HPV) for pre-invasive cervical cancer, is summarized. The current approaches for treatment of CIN are reviewed from the perspective of low-resource settings. The various strategies for management approaches are demonstrated, and the cost-effectiveness is discussed. The pattern of pre-invasive cervical cancer management in developing countries, including in the south of Thailand is exhibited, and the single-visit service for cervical cancer prevention in the northeast is challenged.

  3. The NANOGrav Nine-year Data Set: Limits on the Isotropic Stochastic Gravitational Wave Background

    NASA Astrophysics Data System (ADS)

    Arzoumanian, Z.; Brazier, A.; Burke-Spolaor, S.; Chamberlin, S. J.; Chatterjee, S.; Christy, B.; Cordes, J. M.; Cornish, N. J.; Crowter, K.; Demorest, P. B.; Deng, X.; Dolch, T.; Ellis, J. A.; Ferdman, R. D.; Fonseca, E.; Garver-Daniels, N.; Gonzalez, M. E.; Jenet, F.; Jones, G.; Jones, M. L.; Kaspi, V. M.; Koop, M.; Lam, M. T.; Lazio, T. J. W.; Levin, L.; Lommen, A. N.; Lorimer, D. R.; Luo, J.; Lynch, R. S.; Madison, D. R.; McLaughlin, M. A.; McWilliams, S. T.; Mingarelli, C. M. F.; Nice, D. J.; Palliyaguru, N.; Pennucci, T. T.; Ransom, S. M.; Sampson, L.; Sanidas, S. A.; Sesana, A.; Siemens, X.; Simon, J.; Stairs, I. H.; Stinebring, D. R.; Stovall, K.; Swiggum, J.; Taylor, S. R.; Vallisneri, M.; van Haasteren, R.; Wang, Y.; Zhu, W. W.; NANOGrav Collaboration

    2016-04-01

    We compute upper limits on the nanohertz-frequency isotropic stochastic gravitational wave background (GWB) using the 9 year data set from the North American Nanohertz Observatory for Gravitational Waves (NANOGrav) collaboration. Well-tested Bayesian techniques are used to set upper limits on the dimensionless strain amplitude (at a frequency of 1 yr-1) for a GWB from supermassive black hole binaries of {A}{{gw}}\\lt 1.5× {10}-15. We also parameterize the GWB spectrum with a broken power-law model by placing priors on the strain amplitude derived from simulations of Sesana and McWilliams et al. Using Bayesian model selection we find that the data favor a broken power law to a pure power law with odds ratios of 2.2 and 22 to one for the Sesana and McWilliams prior models, respectively. Using the broken power-law analysis we construct posterior distributions on environmental factors that drive the binary to the GW-driven regime including the stellar mass density for stellar-scattering, mass accretion rate for circumbinary disk interaction, and orbital eccentricity for eccentric binaries, marking the first time that the shape of the GWB spectrum has been used to make astrophysical inferences. Returning to a power-law model, we place stringent limits on the energy density of relic GWs, {{{Ω }}}{gw}(f){h}2\\lt 4.2\\quad × \\quad {10}-10. Our limit on the cosmic string GWB, {{{Ω }}}{gw}(f){h}2\\lt 2.2\\quad × \\quad {10}-10, translates to a conservative limit on the cosmic string tension with Gμ \\lt 3.3× {10}-8, a factor of four better than the joint Planck and high-l cosmic microwave background data from other experiments.

  4. The NANOGrav Nine-year Data Set: Limits on the Isotropic Stochastic Gravitational Wave Background

    NASA Astrophysics Data System (ADS)

    Arzoumanian, Z.; Brazier, A.; Burke-Spolaor, S.; Chamberlin, S. J.; Chatterjee, S.; Christy, B.; Cordes, J. M.; Cornish, N. J.; Crowter, K.; Demorest, P. B.; Deng, X.; Dolch, T.; Ellis, J. A.; Ferdman, R. D.; Fonseca, E.; Garver-Daniels, N.; Gonzalez, M. E.; Jenet, F.; Jones, G.; Jones, M. L.; Kaspi, V. M.; Koop, M.; Lam, M. T.; Lazio, T. J. W.; Levin, L.; Lommen, A. N.; Lorimer, D. R.; Luo, J.; Lynch, R. S.; Madison, D. R.; McLaughlin, M. A.; McWilliams, S. T.; Mingarelli, C. M. F.; Nice, D. J.; Palliyaguru, N.; Pennucci, T. T.; Ransom, S. M.; Sampson, L.; Sanidas, S. A.; Sesana, A.; Siemens, X.; Simon, J.; Stairs, I. H.; Stinebring, D. R.; Stovall, K.; Swiggum, J.; Taylor, S. R.; Vallisneri, M.; van Haasteren, R.; Wang, Y.; Zhu, W. W.; The NANOGrav Collaboration

    2016-04-01

    We compute upper limits on the nanohertz-frequency isotropic stochastic gravitational wave background (GWB) using the 9 year data set from the North American Nanohertz Observatory for Gravitational Waves (NANOGrav) collaboration. Well-tested Bayesian techniques are used to set upper limits on the dimensionless strain amplitude (at a frequency of 1 yr‑1) for a GWB from supermassive black hole binaries of {A}{{gw}}\\lt 1.5× {10}-15. We also parameterize the GWB spectrum with a broken power-law model by placing priors on the strain amplitude derived from simulations of Sesana and McWilliams et al. Using Bayesian model selection we find that the data favor a broken power law to a pure power law with odds ratios of 2.2 and 22 to one for the Sesana and McWilliams prior models, respectively. Using the broken power-law analysis we construct posterior distributions on environmental factors that drive the binary to the GW-driven regime including the stellar mass density for stellar-scattering, mass accretion rate for circumbinary disk interaction, and orbital eccentricity for eccentric binaries, marking the first time that the shape of the GWB spectrum has been used to make astrophysical inferences. Returning to a power-law model, we place stringent limits on the energy density of relic GWs, {{{Ω }}}{gw}(f){h}2\\lt 4.2\\quad × \\quad {10}-10. Our limit on the cosmic string GWB, {{{Ω }}}{gw}(f){h}2\\lt 2.2\\quad × \\quad {10}-10, translates to a conservative limit on the cosmic string tension with Gμ \\lt 3.3× {10}-8, a factor of four better than the joint Planck and high-l cosmic microwave background data from other experiments.

  5. Experiences from Occupational Exposure Limits Set on Aerosols Containing Allergenic Proteins

    PubMed Central

    Nielsen, Gunnar D.

    2012-01-01

    Occupational exposure limits (OELs) together with determined airborne exposures are used in risk assessment based managements of occupational exposures to prevent occupational diseases. In most countries, OELs have only been set for few protein-containing aerosols causing IgE-mediated allergies. They comprise aerosols of flour dust, grain dust, wood dust, natural rubber latex, and the subtilisins, which are proteolytic enzymes. These aerosols show dose-dependent effects and levels have been established, where nearly all workers may be exposed without adverse health effects, which are required for setting OELs. Our aim is to analyse prerequisites for setting OELs for the allergenic protein-containing aerosols. Opposite to the key effect of toxicological reactions, two thresholds, one for the sensitization phase and one for elicitation of IgE-mediated symptoms in sensitized individuals, are used in the OEL settings. For example, this was the case for flour dust, where OELs were based on dust levels due to linearity between flour dust and its allergen levels. The critical effects for flour and grain dust OELs were different, which indicates that conclusion by analogy (read-across) must be scientifically well founded. Except for subtilisins, no OEL have been set for other industrial enzymes, where many of which are high volume chemicals. For several of these, OELs have been proposed in the scientific literature during the last two decades. It is apparent that the scientific methodology is available for setting OELs for proteins and protein-containing aerosols where the critical effect is IgE sensitization and IgE-mediated airway diseases. PMID:22843406

  6. Setting limits for acceptable change in sediment particle size composition following marine aggregate dredging.

    PubMed

    Cooper, Keith M

    2012-08-01

    In the UK, Government policy requires marine aggregate extraction companies to leave the seabed in a similar physical condition after the cessation of dredging. This measure is intended to promote recovery, and the return of a similar faunal community to that which existed before dredging. Whilst the policy is sensible, and in line with the principles of sustainable development, the use of the word 'similar' is open to interpretation. There is, therefore, a need to set quantifiable limits for acceptable change in sediment composition. Using a case study site, it is shown how such limits could be defined by the range of sediment particle size composition naturally found in association with the faunal assemblages in the wider region. Whilst the approach offers a number of advantages over the present system, further testing would be required before it could be recommended for use in the regulatory context. PMID:22721693

  7. Towards setting credible speed limits: Identifying factors that affect driver compliance on urban roads.

    PubMed

    Gargoum, Suliman A; El-Basyouny, Karim; Kim, Amy

    2016-10-01

    Road geometry, vehicle characteristics, and weather conditions are all factors that impact a driver's perception of a safe or credible speed and, consequently, the driver's decision on whether or not to comply with the posted speed limit. In fact, the role a road's environment plays in a driver's perception of a credible speed limit is a topic that has attracted the interest of many researchers in recent years. Despite that, not many studies have considered using empirical data to investigate what features of the road environment influence a driver's compliance choice. This paper aims to address this matter by exploring the relationships between features of the road surroundings (geometric, temporal factors, and weather conditions) and driver compliance with speed limits. The paper uses data from almost 600 different urban roads in the city of Edmonton, at which over 35 million vehicle spot speeds were collected. Compliance was represented using a categorical ordered response variable, and mixed-effects-logistic-regression models were fitted. Two different models were built, one for arterials and another for collector roads. In general, the findings show that the more restricted drivers become, particularly on arterials, the more likely drivers are to comply with speed limits; potential restrictions include on-street parking and the absence of lateral shoulders. Furthermore, higher traffic activity during peak hours, and presumably on shoulder weekdays, both increase the likelihood of compliance on arterials. Similarly, posted speed limits and traffic volume are both positively correlated with compliance on both arterial and collector roads. The findings of this research provide evidence of the existence of an empirical relationship between road features and compliance, highlighting the importance of setting credible speed limits on roads and the possibility of achieving higher compliance rates through modifications to the road environment. PMID:27438484

  8. Oxygen safety margins set thermal limits in an insect model system.

    PubMed

    Boardman, Leigh; Terblanche, John S

    2015-06-01

    A mismatch between oxygen availability and metabolic demand may constrain thermal tolerance. While considerable support for this idea has been found in marine organisms, results from insects are equivocal and raise the possibility that mode of gas exchange, oxygen safety margins and the physico-chemical properties of the gas medium influence heat tolerance estimates. Here, we examined critical thermal maximum (CTmax) and aerobic scope under altered oxygen supply and in two life stages that varied in metabolic demand in Bombyx mori (Lepidoptera: Bombycidae). We also systematically examined the influence of changes in gas properties on CTmax. Larvae have a lower oxygen safety margin (higher critical oxygen partial pressure at which metabolism is suppressed relative to metabolic demand) and significantly higher CTmax under normoxia than pupae (53°C vs 50°C). Larvae, but not pupae, were oxygen limited with hypoxia (2.5 kPa) decreasing CTmax significantly from 53 to 51°C. Humidifying hypoxic air relieved the oxygen limitation effect on CTmax in larvae, whereas variation in other gas properties did not affect CTmax. Our data suggest that oxygen safety margins set thermal limits in air-breathing invertebrates and the magnitude of this effect potentially reconciles differences in oxygen limitation effects on thermal tolerance found among diverse taxa to date.

  9. Oxygen safety margins set thermal limits in an insect model system.

    PubMed

    Boardman, Leigh; Terblanche, John S

    2015-06-01

    A mismatch between oxygen availability and metabolic demand may constrain thermal tolerance. While considerable support for this idea has been found in marine organisms, results from insects are equivocal and raise the possibility that mode of gas exchange, oxygen safety margins and the physico-chemical properties of the gas medium influence heat tolerance estimates. Here, we examined critical thermal maximum (CTmax) and aerobic scope under altered oxygen supply and in two life stages that varied in metabolic demand in Bombyx mori (Lepidoptera: Bombycidae). We also systematically examined the influence of changes in gas properties on CTmax. Larvae have a lower oxygen safety margin (higher critical oxygen partial pressure at which metabolism is suppressed relative to metabolic demand) and significantly higher CTmax under normoxia than pupae (53°C vs 50°C). Larvae, but not pupae, were oxygen limited with hypoxia (2.5 kPa) decreasing CTmax significantly from 53 to 51°C. Humidifying hypoxic air relieved the oxygen limitation effect on CTmax in larvae, whereas variation in other gas properties did not affect CTmax. Our data suggest that oxygen safety margins set thermal limits in air-breathing invertebrates and the magnitude of this effect potentially reconciles differences in oxygen limitation effects on thermal tolerance found among diverse taxa to date. PMID:26041031

  10. The insulin dilemma in resource-limited countries. A way forward?

    PubMed

    Gill, G V; Yudkin, J S; Keen, H; Beran, D

    2011-01-01

    The International Insulin Foundation (IIF) has developed and validated a needs-assessment instrument called the Rapid Assessment Protocol for Insulin Access (RAPIA) which has been used in seven countries in four continents to analyse the constraints to delivering effective continuing care for people with diabetes. One major contributor to the difficulties in availability of insulin is a failure to use the least costly sources and types of insulin and other effective drugs for diabetes. The purchase of insulins can consume as much as 10% of government expenditure on drugs, this being highly sensitive to the selection of newer analogue insulins as first-choice options, which cost between three and 13 times more than biosynthetic human insulin. Insulin cartridges for use with injection pens further add to costs. Similar considerations apply to most of the newer treatments for people with type 2 diabetes, which may cost up to 40 times more than metformin and sulfonylureas, still considered first-line drugs by European and US guidelines. Both biosynthetic human insulin and the first-line oral hypoglycaemic drugs are available from generic manufacturers. With the present price differentials, there is thus a growing need for countries involved in tendering for sourcing insulin to be provided with the guarantees of Good Manufacturing Practice, quality and bioequivalence, which would come from a WHO Pre-Qualification Scheme as currently exists for a variety of drugs for chronic diseases, both communicable and non-communicable. The IIF has developed a position statement on the provision and choice of diabetes treatments in resource-limited settings which should be applicable wherever consideration of resources is a component of therapeutic decision making. PMID:20835860

  11. Medication safety and pharmacovigilance resources for the ambulatory care setting: enhancing patient safety.

    PubMed

    Gershman, Jennifer A; Fass, Andrea D

    2014-04-01

    Reputable medication safety resources are fundamental to assist in reducing medication errors and educating consumers. The purpose of this article is to describe medication safety and pharmacovigilance electronic and mobile resources that are available to pharmacists to enhance patient safety in the ambulatory care setting at the national level through the US Food and Drug Administration (FDA), Drug Enforcement Administration (DEA), American Medicine Chest Challenge, and Institute for Safe Medication Practices (ISMP). Information concerning drug disposal methods is available through the FDA, DEA, and the American Medicine Chest Challenge Rx Drop app. The ISMP provides a variety of tools for reporting and preventing medication errors including Assess-ERR and ConsumerMedSafety.org. Risk Evaluation and Mitigation Strategies (REMS) were created as a requirement of the FDA Amendments Act of 2007 to ensure that the drug's benefits outweigh the risks. Health care professionals are encouraged to report adverse drug events through the FDA's MedWatch reporting system. Pharmacists have a variety of useful resources for their medication safety and pharmacovigilance toolbox. Studies should evaluate the use of these resources by pharmacists and consumers.

  12. Effects of irrigation water supply variations on limited resource farming in Conejos County, Colorado

    NASA Astrophysics Data System (ADS)

    Eckert, Jerry B.; Wang, Erda

    1993-02-01

    Farms in NE Conejos County, Colorado, are characterized by limited resources, uncertain surface flow irrigation systems, and mixed crop-livestock enterprise combinations which are dependent on public grazing resources. To model decision making on these farms, a linear program is developed stressing enterprise choices under conditions of multiple resource constraints. Differential access to grazing resources and irrigation water is emphasized in this research. Regarding the water resource, the model reflects farms situated alternatively on high-, medium-, and low-priority irrigation ditches within the Alamosa-La Jara river system, each with and without supplemental pumping. Differences are found in optimum enterprise mixes, net returns, choice of cropping technology, level of marketings, and other characteristics in response to variations in the availability of irrigation water. Implications are presented for alternative improvement strategies.

  13. Maximum Growth Potential and Periods of Resource Limitation in Apple Tree.

    PubMed

    Reyes, Francesco; DeJong, Theodore; Franceschi, Pietro; Tagliavini, Massimo; Gianelle, Damiano

    2016-01-01

    Knowledge of seasonal maximum potential growth rates are important for assessing periods of resource limitations in fruit tree species. In this study we assessed the periods of resource limitation for vegetative (current year stems, and woody biomass) and reproductive (fruit) organs of a major agricultural crop: the apple tree. This was done by comparing relative growth rates (RGRs) of individual organs in trees with reduced competition for resources to trees grown under standard field conditions. Special attention was dedicated to disentangling patterns and values of maximum potential growth for each organ type. The period of resource limitation for vegetative growth was much longer than in another fruit tree species (peach): from late May until harvest. Two periods of resource limitation were highlighted for fruit: from the beginning of the season until mid-June, and about 1 month prior to harvest. By investigating the variability in individual organs growth we identified substantial differences in RGRs among different shoot categories (proleptic and epicormic) and within each group of monitored organs. Qualitatively different and more accurate values of growth rates for vegetative organs, compared to the use of the simple compartmental means, were estimated. Detailed, source-sink based tree growth models, commonly in need of fine parameter tuning, are expected to benefit from the results produced by these analyses.

  14. Maximum Growth Potential and Periods of Resource Limitation in Apple Tree.

    PubMed

    Reyes, Francesco; DeJong, Theodore; Franceschi, Pietro; Tagliavini, Massimo; Gianelle, Damiano

    2016-01-01

    Knowledge of seasonal maximum potential growth rates are important for assessing periods of resource limitations in fruit tree species. In this study we assessed the periods of resource limitation for vegetative (current year stems, and woody biomass) and reproductive (fruit) organs of a major agricultural crop: the apple tree. This was done by comparing relative growth rates (RGRs) of individual organs in trees with reduced competition for resources to trees grown under standard field conditions. Special attention was dedicated to disentangling patterns and values of maximum potential growth for each organ type. The period of resource limitation for vegetative growth was much longer than in another fruit tree species (peach): from late May until harvest. Two periods of resource limitation were highlighted for fruit: from the beginning of the season until mid-June, and about 1 month prior to harvest. By investigating the variability in individual organs growth we identified substantial differences in RGRs among different shoot categories (proleptic and epicormic) and within each group of monitored organs. Qualitatively different and more accurate values of growth rates for vegetative organs, compared to the use of the simple compartmental means, were estimated. Detailed, source-sink based tree growth models, commonly in need of fine parameter tuning, are expected to benefit from the results produced by these analyses. PMID:26973676

  15. Maximum Growth Potential and Periods of Resource Limitation in Apple Tree

    PubMed Central

    Reyes, Francesco; DeJong, Theodore; Franceschi, Pietro; Tagliavini, Massimo; Gianelle, Damiano

    2016-01-01

    Knowledge of seasonal maximum potential growth rates are important for assessing periods of resource limitations in fruit tree species. In this study we assessed the periods of resource limitation for vegetative (current year stems, and woody biomass) and reproductive (fruit) organs of a major agricultural crop: the apple tree. This was done by comparing relative growth rates (RGRs) of individual organs in trees with reduced competition for resources to trees grown under standard field conditions. Special attention was dedicated to disentangling patterns and values of maximum potential growth for each organ type. The period of resource limitation for vegetative growth was much longer than in another fruit tree species (peach): from late May until harvest. Two periods of resource limitation were highlighted for fruit: from the beginning of the season until mid-June, and about 1 month prior to harvest. By investigating the variability in individual organs growth we identified substantial differences in RGRs among different shoot categories (proleptic and epicormic) and within each group of monitored organs. Qualitatively different and more accurate values of growth rates for vegetative organs, compared to the use of the simple compartmental means, were estimated. Detailed, source-sink based tree growth models, commonly in need of fine parameter tuning, are expected to benefit from the results produced by these analyses. PMID:26973676

  16. Practical surveillance of water quality in a low-resource setting: a pilot program.

    PubMed

    Chang, Kenneth; Greeley, Christopher

    2012-10-01

    Diarrheal diseases represent a tremendous health burden in low-resource countries affecting child mortality. The main sources of diarrheal diseases are water source contamination and fecal-oral transmission. A major obstacle in disease control is the ability to identify and monitor water source quality for potential infectious contamination. We explore a technique for real-time surveillance of coliform bacteria contamination in water sources which is of modest cost and does not require electricity. Specifically, we used body heat as a source for thermal regulation in contrast to traditional incubation for the enumeration of coliforms on 3M petrifilm™ Escheriachia coli/coliform count plates. Our data support that the body heat incubation technique is a promising strategy for water source surveillance in low resource settings.

  17. Evaluating Developed Rule Sets Transferability For Extracting Forest Resources From Rapid Eye Data

    NASA Astrophysics Data System (ADS)

    Kindu, Mengistie; Elatawneh, Alata; Corti, Nicolas; Wallner, Adelheid; Felbermeier, Bernhard; Cabra, Ricardo A.; Schneider, Thomas; Knoke, Thomas

    2013-12-01

    This study examined transferability of developed rule sets in an Alpine test site of Germany (Oberammergau) on classifying forest/non-forest at level 1 and forest types (coniferous, deciduous and mixed) at level 2 from RapidEye satellite image. It was evaluated in test sites of three environmental settings; Ethiopia (Munessa), Ecuador (San Francisco) and China (Shangnan) with similar land use/cover types and topography. The same pre-processing steps were applied in each image of all test sites. Object-based image analysis was used to evaluate the rule sets transferability. Comparisons of direct transferability were conducted using accuracies of the classified images. The forest/non-forest classification at level 1 result reveals the direct transferability. However, accuracies decline steeply along with a disturbed nature of the forest resources. The results of forest type classification at level 2 also show the need of further refinement of the already developed rule sets. Adding more rules or adapting to each of the environmental setting is recommended for higher accuracy.

  18. Haplotype Block Partition with Limited Resources and Applications to Human Chromosome 21 Haplotype Data

    PubMed Central

    Zhang, Kui; Sun, Fengzhu; Waterman, Michael S.; Chen, Ting

    2003-01-01

    Recent studies have shown that the human genome has a haplotype block structure such that it can be decomposed into large blocks with high linkage disequilibrium (LD) and relatively limited haplotype diversity, separated by short regions of low LD. One of the practical implications of this observation is that only a small fraction of all the single-nucleotide polymorphisms (SNPs) (referred as “tag SNPs”) can be chosen for mapping genes responsible for human complex diseases, which can significantly reduce genotyping effort, without much loss of power. Algorithms have been developed to partition haplotypes into blocks with the minimum number of tag SNPs for an entire chromosome. In practice, investigators may have limited resources, and only a certain number of SNPs can be genotyped. In the present article, we first formulate this problem as finding a block partition with a fixed number of tag SNPs that can cover the maximal percentage of the whole genome, and we then develop two dynamic programming algorithms to solve this problem. The algorithms are sufficiently flexible to permit knowledge of functional polymorphisms to be considered. We apply the algorithms to a data set of SNPs on human chromosome 21, combining the information of coding and noncoding regions. We study the density of SNPs in intergenic regions, introns, and exons, and we find that the SNP density in intergenic regions is similar to that in introns and is higher than that in exons, results that are consistent with previous studies. We also calculate the distribution of block break points in intergenic regions, genes, exons, and coding regions and do not find any significant differences. PMID:12802783

  19. A Low-Cost Inkjet-Printed Glucose Test Strip System for Resource-Poor Settings

    PubMed Central

    Gainey Wilson, Kayla; Ovington, Patrick; Dean, Delphine

    2015-01-01

    Background: The prevalence of diabetes is increasing in low-resource settings; however, accessing glucose monitoring is extremely difficult and expensive in these regions. Work is being done to address the multitude of issues surrounding diabetes care in low-resource settings, but an affordable glucose monitoring solution has yet to be presented. An inkjet-printed test strip solution is being proposed as a solution to this problem. Methods: The use of a standard inkjet printer is being proposed as a manufacturing method for low-cost glucose monitoring test strips. The printer cartridges are filled with enzyme and dye solutions that are printed onto filter paper. The result is a colorimetric strip that turns a blue/green color in the presence of blood glucose. Results: Using a light-based spectroscopic reading, the strips show a linear color change with an R2 = .99 using glucose standards and an R2 = .93 with bovine blood. Initial testing with bovine blood indicates that the strip accuracy is comparable to the International Organization for Standardization (ISO) standard 15197 for glucose testing in the 0-350 mg/dL range. However, further testing with human blood will be required to confirm this. A visible color gradient was observed with both the glucose standard and bovine blood experiment, which could be used as a visual indicator in cases where an electronic glucose meter was unavailable. Conclusions: These results indicate that an inkjet-printed filter paper test strip is a feasible method for monitoring blood glucose levels. The use of inkjet printers would allow for local manufacturing to increase supply in remote regions. This system has the potential to address the dire need for glucose monitoring in low-resource settings. PMID:26071426

  20. Gastric Cancer Incidence Estimation in a Resource-Limited Nation: Use of Endoscopy Registry Methodology

    PubMed Central

    Dominguez, Ricardo L.; Crockett, Seth D.; Lund, Jennifer L.; Suazo, Lia P.; Heidt-Davis, Paris; Martin, Christopher; Morgan, Douglas R.

    2013-01-01

    performed for each new diagnosis of gastric cancer. The ASIRs for the decade were 30.8 for males and 13.9 for females. Clinically, 60.3% of gastric cancers were Borrmann type 3 (ulcerated mass), and evidence of advanced disease with pyloric obstruction was common (35.2%). Subtypes by the Lauren classification were distributed among diffuse (56%), intestinal (34%) and indeterminate (9.9%), in subjects with available pathology (526/670). Conclusions The endoscopy procedure registry may serve as a complimentary data resource for gastric cancer incidence estimation in resource-limited nation settings wherein pathology services and cancer registries are absent. The results remain an underestimation in this setting due to the challenges of access-to-care and related factors. The methodology helps to more fully characterize the high incidence of gastric cancer in western Honduras and this region of Central America, and demonstrate the need for additional epidemiology research and interventions focused on prevention and treatment. PMID:23263776

  1. A pilot randomized controlled trial of a brief parenting intervention in low-resource settings in Panama.

    PubMed

    Mejia, Anilena; Calam, Rachel; Sanders, Matthew R

    2015-07-01

    The aim of this study was to determine whether an intervention from the Triple P Positive Parenting Program system was effective in reducing parental reports of child behavioral difficulties in urban low-income settings in Panama City. A pilot parallel-group randomized controlled trial was carried out. A total of 108 parents of children 3 to 12 years old with some level of parent-rated behavioral difficulties were randomly assigned to a discussion group on "dealing with disobedience" or to a no intervention control. Blinded assessments were carried out prior to the intervention, 2 weeks, 3 months, and 6 months later. Results indicated that parental reports of child behavioral difficulties changed over time and decreased more steeply in the intervention than in the control group. The effects of the intervention on parental reports of behavioral difficulties were moderate at post-intervention and 3-month follow-up, and large at 6-month follow-up. Parents who participated in the discussion group reported fewer behavioral difficulties in their children after the intervention than those in the control condition. They also reported reduced parental stress and less use of dysfunctional parenting practices. There is a limited amount of evidence on the efficacy of parenting interventions in low-resource settings. This pilot trial was carried out using a small convenience sample living in low-income urban communities in Panama City, and therefore, the findings are of reduced generalizability to other settings. However, the methodology employed in this trial represents an example for future work in other low-resource settings. PMID:25703382

  2. Resources

    MedlinePlus

    ... Breastfeeding - resources Bulimia - resources Burns - resources Cancer - resources Cerebral palsy - resources Celiac disease - resources Child abuse - resources Chronic fatigue syndrome - resources Chronic pain - ...

  3. 78 FR 70414 - Pricing for the 2013 United States Mint Limited Edition Silver Proof SetTM

    Federal Register 2010, 2011, 2012, 2013, 2014

    2013-11-25

    ... From the Federal Register Online via the Government Publishing Office DEPARTMENT OF THE TREASURY United States Mint Pricing for the 2013 United States Mint Limited Edition Silver Proof Set TM AGENCY... announcing a price of $139.95 for the 2013 United States Mint Limited Edition Silver Proof Set. FOR...

  4. Can Focused Trauma Education Initiatives Reduce Mortality or Improve Resource Utilization in a Low-Resource Setting?

    PubMed Central

    Petroze, Robin T.; Byiringiro, Jean Claude; Ntakiyiruta, Georges; Briggs, Susan M.; Deckelbaum, Dan L.; Razek, Tarek; Riviello, Robert; Kyamanywa, Patrick; Reid, Jennifer; Sawyer, Robert G.

    2015-01-01

    Background Over 90 % of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. Methods Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October–November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using x2 and Fisher’s exact test. Results A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3 %, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3–8 had the highest injury-related mortality, which significantly decreased from 58.5 % (n = 55) to 37.1 % (n = 23), (p = 0.009, OR 0.42, 95 % CI 0.22–0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3–5 in the post-intervention period had higher utilization of head CT scans and chest X-rays. Conclusions The mortality of severely injured patients decreased after initiation of focused trauma education

  5. 77 FR 43721 - Western Pacific Pelagic Fisheries; Revised Swordfish Trip Limits in the Hawaii Deep-Set Longline...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2012-07-26

    ... fishermen may possess or land during any given Hawaii-based deep-set longline-fishing trip north of the Equator. This rule also revises the definition of deep-set longline fishing to be consistent with the... declared deep-set fishing trip. The limit has occasionally forced fishermen to discard swordfish caught...

  6. Financial Resources for Conducting Athletic Training Programs in the Collegiate and High School Settings

    PubMed Central

    Rankin, James M.

    1992-01-01

    The distribution of resources to athletic training programs varies greatly, depending on the size and scope of the athletic program. No research has been found that assesses the differences in dollars allocated within various athletic training settings or assesses whether the different program levels allocate similar proportions of their resources to like categories of expenditures. In this study, I assessed the financial resources available to athletic training programs at major football NCAA Division IA schools, small football NCAA Division IA schools, NCAA Division IAA schools, NCAA Division II schools, NCAA Division III schools, and high schools. All schools had men's and women's sports and football programs. Categories assessed included: size and scope of the athletic program, supplies and equipment, operating expenses, medical expenses, salaries and benefits, malpractice insurance, and use of competitive bids in purchasing. Data supported the conclusion of wide disparities within many categories and in total expenses. Large-scale football NCAA Division IA programs spent $925.86 per athlete, while NCAA Division III programs spent $181.22, and high school programs spent $95.62. However, athletic trainers at all levels are conducting athletic training programs governed by the same professional competencies and standards of care. PMID:16558190

  7. Allocation of scarce resources after a nuclear detonation: setting the context.

    PubMed

    Knebel, Ann R; Coleman, C Norman; Cliffer, Kenneth D; Murrain-Hill, Paula; McNally, Richard; Oancea, Victor; Jacobs, Jimmie; Buddemeier, Brooke; Hick, John L; Weinstock, David M; Hrdina, Chad M; Taylor, Tammy; Matzo, Marianne; Bader, Judith L; Livinski, Alicia A; Parker, Gerald; Yeskey, Kevin

    2011-03-01

    The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders. PMID:21402809

  8. Simplified Negative Pressure Wound Therapy Device for Application in Low-Resource Settings.

    PubMed

    Zurovcik, Danielle R; Mody, Gita N; Riviello, Robert; Slocum, Alex

    2015-10-01

    Negative pressure wound therapy (NPWT) provides proven wound healing benefits and is often a desirable wound treatment methodology. Unfortunately, NPWT devices are not widely available in low-resource settings. To overcome the identified NPWT barriers, a simplified NPWT (sNPWT) system was designed and iteratively improved during field-based testing. The sNPWT technology, our device design iterations, and the design-based results of our field tests are described in this article. The sNPWT system includes a bellows hand pump, an occlusive drape, and a tube with tube connectors, connecting the drape to the pump. The most critical property of an sNPWT system is that it must be airtight. The details of the design iterations, which are needed to achieve an occlusive system, are explained. During the design process, the sNPWT system was tested during the earthquake relief in Haiti. This testing found that a liquid sealant was necessary to seal the drape to the periwound skin. A study conducted in Rwanda verified that a liquid latex sealant was safe to use, and that the tube connector must be connected to the drape with an airtight method during the manufacturing process. This work has shown that sNPWT is feasible in low-resource settings. Since the completion of the clinical testing, the design has been further evolved, and the developers are working with contract manufacturers to produce the final design and preparing for regulatory approval applications.

  9. A Shipping Container-Based Sterile Processing Unit for Low Resources Settings.

    PubMed

    Boubour, Jean; Jenson, Katherine; Richter, Hannah; Yarbrough, Josiah; Oden, Z Maria; Schuler, Douglas A

    2016-01-01

    Deficiencies in the sterile processing of medical instruments contribute to poor outcomes for patients, such as surgical site infections, longer hospital stays, and deaths. In low resources settings, such as some rural and semi-rural areas and secondary and tertiary cities of developing countries, deficiencies in sterile processing are accentuated due to the lack of access to sterilization equipment, improperly maintained and malfunctioning equipment, lack of power to operate equipment, poor protocols, and inadequate quality control over inventory. Inspired by our sterile processing fieldwork at a district hospital in Sierra Leone in 2013, we built an autonomous, shipping-container-based sterile processing unit to address these deficiencies. The sterile processing unit, dubbed "the sterile box," is a full suite capable of handling instruments from the moment they leave the operating room to the point they are sterile and ready to be reused for the next surgery. The sterile processing unit is self-sufficient in power and water and features an intake for contaminated instruments, decontamination, sterilization via non-electric steam sterilizers, and secure inventory storage. To validate efficacy, we ran tests of decontamination and sterilization performance. Results of 61 trials validate convincingly that our sterile processing unit achieves satisfactory outcomes for decontamination and sterilization and as such holds promise to support healthcare facilities in low resources settings.

  10. Behavioral management in children with intellectual disabilities in a resource-poor setting in Barwani, India

    PubMed Central

    Lakhan, Ram

    2014-01-01

    Background: Management of behavioral problems in children with intellectual disabilities (ID) is a great concern in resource-poor areas in India. This study attempted to analyze the efficacy of behavioral intervention provided in resource-poor settings. Objective: This study was aimed to examine the outcome of behavioral management provided to children with ID in a poor rural region in India. Materials and Methods: We analyzed data from 104 children between 3 and 18 years old who received interventions for behavioral problems in a clinical or a community setting. The behavioral assessment scale for Indian children with mental retardation (BASIC-MR) was used to quantify the study subjects’ behavioral problems before and after we applied behavioral management techniques (baseline and post-intervention, respectively). The baseline and post-intervention scores were analyzed using the following statistical techniques: Wilcoxon matched-pairs signed-rank test for the efficacy of intervention; χ2 for group differences. Results: The study demonstrated behavioral improvements across all behavior domains (P < 0.05). Levels of improvement varied for children with different severities of ID (P = 0.001), between children who did and did not have multiple disabilities (P = 0.011). Conclusion: The outcome of this behavioral management study suggests that behavioral intervention can be effectively provided to children with ID in poor areas. PMID:24574557

  11. A Shipping Container-Based Sterile Processing Unit for Low Resources Settings.

    PubMed

    Boubour, Jean; Jenson, Katherine; Richter, Hannah; Yarbrough, Josiah; Oden, Z Maria; Schuler, Douglas A

    2016-01-01

    Deficiencies in the sterile processing of medical instruments contribute to poor outcomes for patients, such as surgical site infections, longer hospital stays, and deaths. In low resources settings, such as some rural and semi-rural areas and secondary and tertiary cities of developing countries, deficiencies in sterile processing are accentuated due to the lack of access to sterilization equipment, improperly maintained and malfunctioning equipment, lack of power to operate equipment, poor protocols, and inadequate quality control over inventory. Inspired by our sterile processing fieldwork at a district hospital in Sierra Leone in 2013, we built an autonomous, shipping-container-based sterile processing unit to address these deficiencies. The sterile processing unit, dubbed "the sterile box," is a full suite capable of handling instruments from the moment they leave the operating room to the point they are sterile and ready to be reused for the next surgery. The sterile processing unit is self-sufficient in power and water and features an intake for contaminated instruments, decontamination, sterilization via non-electric steam sterilizers, and secure inventory storage. To validate efficacy, we ran tests of decontamination and sterilization performance. Results of 61 trials validate convincingly that our sterile processing unit achieves satisfactory outcomes for decontamination and sterilization and as such holds promise to support healthcare facilities in low resources settings. PMID:27007568

  12. Access and management of HIV-related diseases in resource-constrained settings: a workshop report.

    PubMed

    Dimba, Eao; Yengopal, V; Joshua, E; Thavarajah, R; Balasundaram, S

    2016-04-01

    With advancement of medical interventions, the lifespan of people living with HIV has increased globally. However, low- and middle-income countries (LMICs) which bear the greatest burden of the HIV pandemic face a constant challenge in addressing the treatment needs of immune-suppressed patients. An analysis of the current management protocols and access to medication in resource-poor settings was conducted at this workshop, with emphasis on the situation in resource-poor settings. The participants developed a consensus document based on the need to respond to the constantly changing HIV pandemic. Provision of oral health care must be guided by interconnecting principles based on population based strategies that address upstream determinants of health. Basic oral health coverage in developing countries can only be realized with a strong foundation at the primary health level. Early diagnosis of HIV-related comorbidities including the adverse effects of ARVs is essential for the improvement of treatment outcomes. Standardization of oral health care delivery mechanisms will facilitate evaluation at national and regional levels. Oral health care workers have a moral obligation to participate in sustained campaigns to reduce the social stigma associated with HIV/AIDS in their work places at every stage of the referral chain. Future research also needs to realign itself towards prevention using the common risk factor approach, which has a broader impact on non-communicable diseases, which are increasingly affecting patients with HIV/AIDS as their life expectancies increase. PMID:27109288

  13. A Shipping Container-Based Sterile Processing Unit for Low Resources Settings

    PubMed Central

    2016-01-01

    Deficiencies in the sterile processing of medical instruments contribute to poor outcomes for patients, such as surgical site infections, longer hospital stays, and deaths. In low resources settings, such as some rural and semi-rural areas and secondary and tertiary cities of developing countries, deficiencies in sterile processing are accentuated due to the lack of access to sterilization equipment, improperly maintained and malfunctioning equipment, lack of power to operate equipment, poor protocols, and inadequate quality control over inventory. Inspired by our sterile processing fieldwork at a district hospital in Sierra Leone in 2013, we built an autonomous, shipping-container-based sterile processing unit to address these deficiencies. The sterile processing unit, dubbed “the sterile box,” is a full suite capable of handling instruments from the moment they leave the operating room to the point they are sterile and ready to be reused for the next surgery. The sterile processing unit is self-sufficient in power and water and features an intake for contaminated instruments, decontamination, sterilization via non-electric steam sterilizers, and secure inventory storage. To validate efficacy, we ran tests of decontamination and sterilization performance. Results of 61 trials validate convincingly that our sterile processing unit achieves satisfactory outcomes for decontamination and sterilization and as such holds promise to support healthcare facilities in low resources settings. PMID:27007568

  14. Establishing and Delivering Quality Radiation Therapy in Resource-Constrained Settings: The Story of Botswana

    PubMed Central

    Heunis, Magda; Karumekayi, Talkmore; Makufa, Remigio; Bvochora-Nsingo, Memory; Gierga, David P.; Suneja, Gita; Grover, Surbhi; Kasese, Joseph; Mmalane, Mompati; Moffat, Howard; von Paleske, Alexander; Makhema, Joseph; Dryden-Peterson, Scott

    2016-01-01

    There is a global cancer crisis, and it is disproportionately affecting resource-constrained settings, especially in low- and middle-income countries (LMICs). Radiotherapy is a critical and cost-effective component of a comprehensive cancer control plan that offers the potential for cure, control, and palliation of disease in greater than 50% of patients with cancer. Globally, LMICs do not have adequate access to quality radiation therapy and this gap is particularly pronounced in sub-Saharan Africa. Although there are numerous challenges in implementing a radiation therapy program in a low-resource setting, providing more equitable global access to radiotherapy is a responsibility and investment worth prioritizing. We outline a systems approach and a series of key questions to direct strategy toward establishing quality radiation services in LMICs, and highlight the story of private-public investment in Botswana from the late 1990s to the present. After assessing the need and defining the value of radiation, we explore core investments required, barriers that need to be overcome, and assets that can be leveraged to establish a radiation program. Considerations addressed include infrastructure; machine choice; quality assurance and patient safety; acquisition, development, and retention of human capital; governmental engagement; public–private partnerships; international collaborations; and the need to critically evaluate the program to foster further growth and sustainability. PMID:26578607

  15. Simplified Negative Pressure Wound Therapy Device for Application in Low-Resource Settings.

    PubMed

    Zurovcik, Danielle R; Mody, Gita N; Riviello, Robert; Slocum, Alex

    2015-10-01

    Negative pressure wound therapy (NPWT) provides proven wound healing benefits and is often a desirable wound treatment methodology. Unfortunately, NPWT devices are not widely available in low-resource settings. To overcome the identified NPWT barriers, a simplified NPWT (sNPWT) system was designed and iteratively improved during field-based testing. The sNPWT technology, our device design iterations, and the design-based results of our field tests are described in this article. The sNPWT system includes a bellows hand pump, an occlusive drape, and a tube with tube connectors, connecting the drape to the pump. The most critical property of an sNPWT system is that it must be airtight. The details of the design iterations, which are needed to achieve an occlusive system, are explained. During the design process, the sNPWT system was tested during the earthquake relief in Haiti. This testing found that a liquid sealant was necessary to seal the drape to the periwound skin. A study conducted in Rwanda verified that a liquid latex sealant was safe to use, and that the tube connector must be connected to the drape with an airtight method during the manufacturing process. This work has shown that sNPWT is feasible in low-resource settings. Since the completion of the clinical testing, the design has been further evolved, and the developers are working with contract manufacturers to produce the final design and preparing for regulatory approval applications. PMID:26356213

  16. 44 CFR 352.25 - Limitation on committing Federal facilities and resources for emergency preparedness.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... COMMERCIAL NUCLEAR POWER PLANTS: EMERGENCY PREPAREDNESS PLANNING Federal Participation § 352.25 Limitation on... implementing a determination under subpart A (44 CFR 352.6(d)), that Federal facilities and resources are... assumption that, in the event of an actual radiological emergency or disaster, State and local...

  17. 44 CFR 352.25 - Limitation on committing Federal facilities and resources for emergency preparedness.

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... COMMERCIAL NUCLEAR POWER PLANTS: EMERGENCY PREPAREDNESS PLANNING Federal Participation § 352.25 Limitation on... implementing a determination under subpart A (44 CFR 352.6(d)), that Federal facilities and resources are... assumption that, in the event of an actual radiological emergency or disaster, State and local...

  18. Bringing Savings Opportunities to Public Elementary School Children in Resource-Limited, Rural Communities

    ERIC Educational Resources Information Center

    Cheang, Michael; Kawamura, Laura

    2014-01-01

    This article describes the community organizing role of an Extension educator and a research faculty to enable young children in a resource-limited community to start savings accounts and to save regularly through a school-based savings effort. The study explored whether children from low-income communities are capable of saving money regularly…

  19. Children's Cooperative and Competitive Interactions in Limited Resource Situations: A Literature Review

    ERIC Educational Resources Information Center

    Green, Vanessa A.; Rechis, Ruth

    2006-01-01

    The ability to balance cooperative and competitive behaviors has important implications for a child's overall development. While socially competent children appear to learn highly successful strategies for entering peer groups and negotiating access to limited resources, the development of this level of social competence can be challenging for…

  20. Nutrition Education Brings Behavior and Knowledge Change in Limited-Resource Older Adults

    ERIC Educational Resources Information Center

    McClelland, Jacquelyn W.; Jayaratne, K.S.U.; Bird, Carolyn L.

    2013-01-01

    A prospective, controlled, randomized, crossover design was used to examine a nutrition education curriculum's effects on knowledge and behavior of 463 limited-resource older adults in 13 counties. Counties were randomized to begin with the treatment or control curriculum and then the remaining curriculum. Participants completed a pre-test…

  1. 44 CFR 352.25 - Limitation on committing Federal facilities and resources for emergency preparedness.

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... Federal facilities and resources for emergency preparedness. 352.25 Section 352.25 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY PREPAREDNESS COMMERCIAL NUCLEAR POWER PLANTS: EMERGENCY PREPAREDNESS PLANNING Federal Participation § 352.25 Limitation...

  2. 44 CFR 352.25 - Limitation on committing Federal facilities and resources for emergency preparedness.

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... Federal facilities and resources for emergency preparedness. 352.25 Section 352.25 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY PREPAREDNESS COMMERCIAL NUCLEAR POWER PLANTS: EMERGENCY PREPAREDNESS PLANNING Federal Participation § 352.25 Limitation...

  3. 44 CFR 352.25 - Limitation on committing Federal facilities and resources for emergency preparedness.

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... Federal facilities and resources for emergency preparedness. 352.25 Section 352.25 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF HOMELAND SECURITY PREPAREDNESS COMMERCIAL NUCLEAR POWER PLANTS: EMERGENCY PREPAREDNESS PLANNING Federal Participation § 352.25 Limitation...

  4. Analytical models for well-mixed populations of cooperators and defectors under limiting resources

    NASA Astrophysics Data System (ADS)

    Requejo, R. J.; Camacho, J.

    2012-06-01

    In the study of the evolution of cooperation, resource limitations are usually assumed just to provide a finite population size. Recently, however, agent-based models have pointed out that resource limitation may modify the original structure of the interactions and allow for the survival of unconditional cooperators in well-mixed populations. Here, we present analytical simplified versions of two types of agent-based models recently published: one in which the limiting resource constrains the ability of reproduction of individuals but not their survival, and a second one where the limiting resource is necessary for both reproduction and survival. One finds that the analytical models display, with a few differences, the same qualitative behavior of the more complex agent-based models. In addition, the analytical models allow us to expand the study and identify the dimensionless parameters governing the final fate of the system, such as coexistence of cooperators and defectors, or dominance of defectors or of cooperators. We provide a detailed analysis of the occurring phase transitions as these parameters are varied.

  5. Herd-Health Programs for Limited-Resource Farmers: Prevention versus Treatment

    ERIC Educational Resources Information Center

    Marshall, Renita W.

    2011-01-01

    In recognition of the changing influences on animal health, Extension professionals are charged with the responsibility of delivering educational programs to our limited resources farmers on the importance of herd health. Herd-health programs must be designed and implemented with the help of an Extension veterinarian to provide routine, planned…

  6. Revising an Extension Education Website for Limited Resource Audiences Using Social Marketing Theory

    ERIC Educational Resources Information Center

    Francis, Sarah L.; Martin, Peggy; Taylor, Kristin

    2011-01-01

    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…

  7. Enhancing Teaching and Learning Wi-Fi Networking Using Limited Resources to Undergraduates

    ERIC Educational Resources Information Center

    Sarkar, Nurul I.

    2013-01-01

    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…

  8. Airborne exposure limits for chemical and biological warfare agents: is everything set and clear?

    PubMed

    Sabelnikov, Alex; Zhukov, Vladimir; Kempf, C Ruth

    2006-08-01

    Emergency response strategies (guidelines) for biological, chemical, nuclear, or radiological terrorist events should be based on scientifically established exposure limits for all the agents or materials involved. In the case of a radiological terrorist event, emergency response guidelines (ERG) have been worked out. In the case of a terrorist event with the use of chemical warfare (CW) agents the situation is not that clear, though the new guidelines and clean-up values are being generated based on re-evaluation of toxicological and risk data. For biological warfare (BW) agents, such guidelines do not yet exist. In this paper the current status of airborne exposure limits (AELs) for chemical and biological warfare (CBW) agents are reviewed. Particular emphasis is put on BW agents that lack such data. An efficient, temporary solution to bridge the gap in experimental infectious data and to set provisional AELs for BW agents is suggested. It is based on mathematically generated risks of infection for BW agents grouped by their alleged ID50 values in three categories: with low, intermediate and high ID50 values.

  9. Setting occupational exposure limits for sensory irritants: the approach in the European Union.

    PubMed

    Meldrum, M

    2001-01-01

    Beginning in 1990, the European Commission initiated a program to establish European Union (EU)-wide occupational exposure limits (OELs). As in the United States and other countries, a panel of experts known as the Scientific Committee on Occupational Exposure Limits (SCOEL) was identified and brought together to identify the proper values. This article describes the approach used by SCOEL to identify appropriate values for sensory irritants. The EU panel believes that irritant effects in the eyes and respiratory tract can produce symptoms that range from trivial to serious, and that responses to irritants may be viewed as belonging to a continuum. One of the interesting differences between the approach used by the ACGIH TLV committee and the SCOEL is the use of five grades of irritation to evaluate this class of chemicals. For purposes of setting an OEL, the SCOEL makes no distinction between irritation or nuisance and related somatic effects such as headache. How the committee established an OEL for ethyl acetate is offered as an illustrative example.

  10. Approaches and considerations for setting occupational exposure limits for sensory irritants: report of recent symposia.

    PubMed

    Paustenbach, D

    2001-01-01

    Over the past 50 years significant strides have been made in reducing occupational exposure to airborne chemicals. To a large extent, the impetus behind the reductions has been the identification of presumably safe levels of exposure, or occupational exposure limits (OELs). Most of the reduction in exposure has been to chemicals such as hepatotoxins, neurotoxins, nephrotoxins, and carcinogens that cause frank toxic effects. Recently, however, a number of industrial hygiene and occupational medicine initiatives have sought to identify acceptable levels of exposure to sensory irritants and reduce exposure to this class of chemicals. This article presents an overview of the field with emphasis on the work presented at two symposia sponsored by the Chemical Manufacturers Association: "How Do We Set an Occupational Exposure Limit (OEL) for Irritation?" (1998) at the American Industrial Hygiene Conference and Exposition and "Respiratory Tract Irritation and Olfaction Conference" (1997). The two symposia reviewed clinical and experimental methods used to assess odor and sensory irritation, to increase understanding of the research needed to establish OELs for sensory irritants, and to discuss how to use this information to identify appropriate values. The symposia illustrated that research in this area is evolving quickly and that there is already sufficient understanding to permit scientists to identify chemicals likely to be sensory irritants. Further, there appears to be an ample number of research methods for identification of airborne concentrations that should protect most workers. This article summarizes some of the key points raised at these symposia and suggests areas deserving of future study.

  11. The Scientific Basis of Uncertainty Factors Used in Setting Occupational Exposure Limits.

    PubMed

    Dankovic, D A; Naumann, B D; Maier, A; Dourson, M L; Levy, L S

    2015-01-01

    The uncertainty factor concept is integrated into health risk assessments for all aspects of public health practice, including by most organizations that derive occupational exposure limits. The use of uncertainty factors is predicated on the assumption that a sufficient reduction in exposure from those at the boundary for the onset of adverse effects will yield a safe exposure level for at least the great majority of the exposed population, including vulnerable subgroups. There are differences in the application of the uncertainty factor approach among groups that conduct occupational assessments; however, there are common areas of uncertainty which are considered by all or nearly all occupational exposure limit-setting organizations. Five key uncertainties that are often examined include interspecies variability in response when extrapolating from animal studies to humans, response variability in humans, uncertainty in estimating a no-effect level from a dose where effects were observed, extrapolation from shorter duration studies to a full life-time exposure, and other insufficiencies in the overall health effects database indicating that the most sensitive adverse effect may not have been evaluated. In addition, a modifying factor is used by some organizations to account for other remaining uncertainties-typically related to exposure scenarios or accounting for the interplay among the five areas noted above. Consideration of uncertainties in occupational exposure limit derivation is a systematic process whereby the factors applied are not arbitrary, although they are mathematically imprecise. As the scientific basis for uncertainty factor application has improved, default uncertainty factors are now used only in the absence of chemical-specific data, and the trend is to replace them with chemical-specific adjustment factors whenever possible. The increased application of scientific data in the development of uncertainty factors for individual chemicals also has

  12. The Scientific Basis of Uncertainty Factors Used in Setting Occupational Exposure Limits

    PubMed Central

    Dankovic, D. A.; Naumann, B. D.; Maier, A.; Dourson, M. L.; Levy, L. S.

    2015-01-01

    The uncertainty factor concept is integrated into health risk assessments for all aspects of public health practice, including by most organizations that derive occupational exposure limits. The use of uncertainty factors is predicated on the assumption that a sufficient reduction in exposure from those at the boundary for the onset of adverse effects will yield a safe exposure level for at least the great majority of the exposed population, including vulnerable subgroups. There are differences in the application of the uncertainty factor approach among groups that conduct occupational assessments; however, there are common areas of uncertainty which are considered by all or nearly all occupational exposure limit-setting organizations. Five key uncertainties that are often examined include interspecies variability in response when extrapolating from animal studies to humans, response variability in humans, uncertainty in estimating a no-effect level from a dose where effects were observed, extrapolation from shorter duration studies to a full life-time exposure, and other insufficiencies in the overall health effects database indicating that the most sensitive adverse effect may not have been evaluated. In addition, a modifying factor is used by some organizations to account for other remaining uncertainties—typically related to exposure scenarios or accounting for the interplay among the five areas noted above. Consideration of uncertainties in occupational exposure limit derivation is a systematic process whereby the factors applied are not arbitrary, although they are mathematically imprecise. As the scientific basis for uncertainty factor application has improved, default uncertainty factors are now used only in the absence of chemical-specific data, and the trend is to replace them with chemical-specific adjustment factors whenever possible. The increased application of scientific data in the development of uncertainty factors for individual chemicals also

  13. The Scientific Basis of Uncertainty Factors Used in Setting Occupational Exposure Limits.

    PubMed

    Dankovic, D A; Naumann, B D; Maier, A; Dourson, M L; Levy, L S

    2015-01-01

    The uncertainty factor concept is integrated into health risk assessments for all aspects of public health practice, including by most organizations that derive occupational exposure limits. The use of uncertainty factors is predicated on the assumption that a sufficient reduction in exposure from those at the boundary for the onset of adverse effects will yield a safe exposure level for at least the great majority of the exposed population, including vulnerable subgroups. There are differences in the application of the uncertainty factor approach among groups that conduct occupational assessments; however, there are common areas of uncertainty which are considered by all or nearly all occupational exposure limit-setting organizations. Five key uncertainties that are often examined include interspecies variability in response when extrapolating from animal studies to humans, response variability in humans, uncertainty in estimating a no-effect level from a dose where effects were observed, extrapolation from shorter duration studies to a full life-time exposure, and other insufficiencies in the overall health effects database indicating that the most sensitive adverse effect may not have been evaluated. In addition, a modifying factor is used by some organizations to account for other remaining uncertainties-typically related to exposure scenarios or accounting for the interplay among the five areas noted above. Consideration of uncertainties in occupational exposure limit derivation is a systematic process whereby the factors applied are not arbitrary, although they are mathematically imprecise. As the scientific basis for uncertainty factor application has improved, default uncertainty factors are now used only in the absence of chemical-specific data, and the trend is to replace them with chemical-specific adjustment factors whenever possible. The increased application of scientific data in the development of uncertainty factors for individual chemicals also has

  14. Tele-cytology: An innovative approach for cervical cancer screening in resource-poor settings.

    PubMed

    Singh, Sandeep; Badaya, Sorabh

    2016-01-01

    Carcinoma cervix remains a leading cause of cancer mortality among women in countries lacking any screening program. The existing screening policy and approach via conventional cytology centered mainly in Tertiary Care Center, is totally unaffordable to Indian women, especially in the remote areas. This suggests the need of depolarizing the resources via generating the near real time modalities which could be used at the door step of the needy ones. For any screening modality to be effective it should be adequately sensitive, specific, reproducible, cheap, simple, affordable, and the most important is should be real time to ensure wide coverage and curtail loss to follow-up. Incorporating telecytology as a screening tool could make the dream come true. Telecytology is the interpretation of cytology material at a distance using digital images. Use of mobile telecytology unit housed in a van carrying satellite equipment and the automated image capturing systems is the central theme behind this idea. The imaging equipment would be carrying out the imaging of Papanicolaou smears prepared at the screening site and sending the images to the central laboratories situated at some tertiary care level. This concept could overcome the hindrance of trained cytology infrastructure in the resource poor settings and could provide an efficient and economical way of screening patients. There is possibility that the designed approach may not detect the entire women positive for the disease but if the desired objective was to diagnose as many cases as possible in resource poor setting, then this process offers an advantage over no screening at all. PMID:27461597

  15. Use of traditional medicines to cope with climate-sensitive diseases in a resource poor setting in Bangladesh

    PubMed Central

    2014-01-01

    Background This study aims to explore the use of traditional medicines to cope with climate sensitive diseases in areas vulnerable to climate change. We assessed the extent to which traditional or alternative medicines were used for the treatment of the climate sensitive diseases by villagers as part of their health-coping strategies. Methods The study deployed a mixed-method research design to know the health-coping strategies of the people in a resource-poor setting. A cross sectional study was conducted from September 2010 to March 2011 among 450 households selected randomly in the districts of Rajshahi and Khulna, Bangladesh. The elder males or females of each household were interviewed. For qualitative methods, twelve focus group discussions (six with females and six with males) and fifteen key informant interviews were conducted by the research team, using interview guidelines on the use of traditional medicine. Results Univariate analysis showed that the use of traditional medicines has increased among community members of all socio-economic and demographic backgrounds. Due to the increased incidence of disease and sickness respondents had to increase the use of their cultural means to cope with adverse health situations. Conclusions A systematic collection of knowledge on the use of traditional medicines to cope with climate-sensitive diseases can help the adaptation of communities vulnerable to climate change. In addition it can be instrumental in creating a directory of traditional medicine components used for specific diseases and highlight the effectiveness and relevance of traditional medicines as health-coping strategies. This may be useful for policymakers, researchers, and development partners to adapt existing health care policy in resource-limited contexts. It may also encourage WHO, national and international institutions, such as pharmaceutical companies, to carry out research investigating the effectiveness of these traditional medicines and

  16. Safety and Benefit of Discontinuing Statin Therapy in the Setting of Advanced, Life-Limiting Illness

    PubMed Central

    Kutner, Jean S.; Blatchford, Patrick J.; Taylor, Don H.; Ritchie, Christine S.; Bull, Janet H.; Fairclough, Diane L.; Hanson, Laura C.; LeBlanc, Thomas W.; Samsa, Greg P.; Wolf, Steven; Aziz, Noreen M.; Currow, David C.; Ferrell, Betty; Wagner-Johnston, Nina; Zafar, S. Yousuf; Cleary, James F.; Dev, Sandesh; Goode, Patricia S.; Kamal, Arif H.; Kassner, Cordt; Kvale, Elizabeth A.; McCallum, Janelle G.; Ogunseitan, Adeboye B.; Pantilat, Steven Z.; Portenoy, Russell K.; Prince-Paul, Maryjo; Sloan, Jeff A.; Swetz, Keith M.; Von Gunten, Charles F.; Abernethy, Amy P.

    2015-01-01

    IMPORTANCE For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, −3.5% to 10.5%; P = .36) and did not meet the noninferiority end point. Total QOL was better for the group

  17. Do Subjective Measures Improve the Ability to Identify Limited Health Literacy in a Clinical Setting?

    PubMed Central

    Goodman, Melody S.; Griffey, Richard T.; Carpenter, Christopher R.; Blanchard, Melvin; Kaphingst, Kimberly A.

    2016-01-01

    Background Existing health literacy assessments developed for research purposes have constraints that limit their utility for clinical practice, including time requirements and administration protocols. The Brief Health Literacy Screen (BHLS) consists of 3 self-administered Single-Item Literacy Screener (SILS) questions and obviates these clinical barriers. We assessed whether the addition of SILS items or the BHLS to patient demographics readily available in ambulatory clinical settings reaching underserved patients improves the ability to identify limited health literacy. Methods We analyzed data from 2 cross-sectional convenience samples of patients from an urban academic emergency department (n = 425) and a primary care clinic (n = 486) in St. Louis, Missouri. Across samples, health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R), Newest Vital Sign (NVS), and the BHLS. Our analytic sample consisted of 911 adult patients, who were primarily female (62%), black (66%), and had at least a high school education (82%); 456 were randomly assigned to the estimation sample and 455 to the validation sample. Results The analysis showed that the best REALM-R estimation model contained age, sex, education, race, and 1 SILS item (difficulty understanding written information). In validation analysis this model had a sensitivity of 62%, specificity of 81%, a positive likelihood ratio (LR+) of 3.26, and a negative likelihood ratio (LR−) of 0.47; there was a 28% misclassification rate. The best NVS estimation model contained the BHLS, age, sex, education and race; this model had a sensitivity of 77%, specificity of 72%, LR+ of 2.75, LR− of 0.32, and a misclassification rate of 25%. Conclusions Findings suggest that the BHLS and SILS items improve the ability to identify patients with limited health literacy compared with demographic predictors alone. However, despite being easier to administer in clinical settings, subjective

  18. Evolution of metabolic rate in a parasitic wasp: the role of limitation in intrinsic resources.

    PubMed

    Moiroux, Joffrey; Giron, David; Vernon, Philippe; van Baaren, Joan; van Alphen, Jacques J M

    2012-07-01

    Metabolic rate, a physiological trait closely related to fitness traits, is expected to evolve in response to two main environmental variables: (1) climate, low metabolic rates being found in dry and hot regions when comparing populations originating from different climates in a common garden experiment and (2) resource limitations, low metabolic rates being selected when resources are limited. The main goal of this study was to investigate if differences in intrinsic resource limitations may have disrupted the expected evolution of metabolic rate in response to climate in a parasitic wasp. We compared CO(2) production of females from 4 populations of a Drosophila parasitoid, Leptopilina boulardi, as an estimate of their metabolic rate. Two populations from a hot and dry area able to synthesise lipids de novo at adult stage were compared with two populations originating from a mild and humid climate where no lipid accumulation during adult life was observed. These last females are thus more limited in lipids than the first ones. We observed that a high metabolic rate has been selected in hot and dry environments, contrarily to the results of a great majority of studies. We suggest that lipogenesis occurring there may have allowed the selection of a higher metabolic rate, as females are less limited in energetic resources than females from the mild environment. A high metabolic rate may have been selected there as it partly compensates for the long distances that females have to cross to find laying opportunities in distant orchards. We suggest that intrinsic resources should be integrated when investigating geographical variations in metabolism as this factor may disrupt evolution in response to climate.

  19. Misclassification of First–Line Antiretroviral Treatment Failure Based on Immunological Monitoring of HIV Infection in Resource–limited Settings

    PubMed Central

    Kantor, Rami; Diero, Lameck; DeLong, Allison; Kamle, Lydia; Muyonga, Sarah; Mambo, Fidelis; Walumbe, Eunice; Emonyi, Wilfred; Chan, Philip; Carter, E. Jane; Hogan, Joseph; Buziba, Nathan

    2016-01-01

    Background The monitoring of patients with human immunodeficiency virus (HIV) infection who are treated with antiretroviral medications in resource-limited settings is typically performed by use of clinical and immunological criteria. The early identification of first-line antiretroviral treatment failure is critical to prevent morbidity, mortality, and drug resistance. Misclassification of failure may result in premature switching to second-line therapy. Methods Adult patients in western Kenya had their viral loads (VLs) determined if they had adhered to first-line therapy for >6 months and were suspected of experiencing immunological failure (ie, their CD4 cell count decreased by ⩾25% in 6 months). Misclassification of treatment failure was defined as a ⩾25% decrease in CD4 cell count with a VL of <400 copies/mL. Logistic and tree regressions examined relationships between VL and 4 variables: CD4 T cell count (hereafter CD4 cell count), percentage of T cells expressing CD4 (hereafter CD4 cell percentage), percentage decrease in the CD4 T cell count (hereafter CD4 cell count percent decrease), and percentage decrease in the percentage of T cells expressing CD4 (hereafter CD4% percent decrease). Results There were 149 patients who were treated for 23 months; they were identified as having a ⩾25% decrease in CD4 cell count (from 375 to 216 cells/μL) and a CD4% percent decrease (from 19% to 15%); of these 149 patients, 86 (58%) were misclassified as having experienced treatment failure. Of 42 patients who had a ⩾50% decrease in CD4 cell count, 18 (43%) were misclassified. In multivariate logistic regression, misclassification odds were associated with a higher CD4 cell count, a shorter duration of therapy, and a smaller CD4% percent decrease. By combining these variables, we may be able to improve our ability to predict treatment failure. Conclusions Immunological monitoring as a sole indicator of virological failure would lead to a premature switch to

  20. Adapting an evidence-based intervention for autism spectrum disorder for scaling up in resource-constrained settings: the development of the PASS intervention in South Asia

    PubMed Central

    Divan, Gauri; Hamdani, Syed Usman; Vajartkar, Vivek; Minhas, Ayesha; Taylor, Carol; Aldred, Catherine; Leadbitter, Kathy; Rahman, Atif; Green, Jonathan; Patel, Vikram

    2015-01-01

    Background Evidence-based interventions for autism spectrum disorders evaluated in high-income countries typically require highly specialised manpower, which is a scarce resource in most low- and middle-income settings. This resource limitation results in most children not having access to evidence-based interventions. Objective This paper reports on the systematic adaptation of an evidence-based intervention, the Preschool Autism Communication Therapy (PACT) evaluated in a large trial in the United Kingdom for delivery in a low-resource setting through the process of task-shifting. Design The adaptation process used the Medical Research Council framework for the development and adaptation of complex interventions, focusing on qualitative methods and case series and was conducted simultaneously in India and Pakistan. Results The original intervention delivered by speech and language therapists in a high-resource setting required adaptation in some aspects of its content and delivery to enhance contextual acceptability and to enable the intervention to be delivered by non-specialists. Conclusions The resulting intervention, the Parent-mediated intervention for Autism Spectrum Disorder in South Asia (PASS), shares the core theoretical foundations of the original PACT but is adapted in several respects to enhance its acceptability, feasibility, and scalability in low-resource settings. PMID:26243710

  1. The implications of reduced metabolic rate in resource-limited corals.

    PubMed

    Jacobson, Lianne M; Edmunds, Peter J; Muller, Erik B; Nisbet, Roger M

    2016-03-01

    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. PMID:26823098

  2. Pathways of care-seeking during fatal infant illnesses in under-resourced South African settings

    PubMed Central

    Sharkey, Alyssa B; Chopra, Mickey; Jackson, Debra; Winch, Peter J; Minkovitz, Cynthia S

    2011-01-01

    Summary The purpose of this study was to examine care-seeking during fatal infant illnesses in under-resourced South African settings to inform potential strategies for reducing infant mortality. We interviewed 22 caregivers of deceased infants in a rural community and 28 in an urban township. We also interviewed seven local leaders and 12 health providers to ascertain opinions about factors contributing to infant death. Despite the availability of free public health services in these settings, many caregivers utilised multiple sources of care including allopathic, indigenous and home treatments. Urban caregivers reported up to eight points of care while rural caregivers reported up to four points of care. The specific pathways taken and combinations of care varied, but many caregivers used other types of care shortly after presenting at public services, indicating dissatisfaction with the care they received. Many infants died despite caregivers’ considerable efforts, pointing to critical deficiencies in the system of care serving these families. Initiatives that aim to improve assessment, management and referral practices by both allopathic and traditional providers (for example, through training and improved collaboration), and caregiver recognition of infant danger signs may reduce the high rate of infant death in these settings. PMID:22136954

  3. New Compound Sets Identified from High Throughput Phenotypic Screening Against Three Kinetoplastid Parasites: An Open Resource

    PubMed Central

    Peña, Imanol; Pilar Manzano, M.; Cantizani, Juan; Kessler, Albane; Alonso-Padilla, Julio; Bardera, Ana I.; Alvarez, Emilio; Colmenarejo, Gonzalo; Cotillo, Ignacio; Roquero, Irene; de Dios-Anton, Francisco; Barroso, Vanessa; Rodriguez, Ana; Gray, David W.; Navarro, Miguel; Kumar, Vinod; Sherstnev, Alexander; Drewry, David H.; Brown, James R.; Fiandor, Jose M.; Julio Martin, J.

    2015-01-01

    Using whole-cell phenotypic assays, the GlaxoSmithKline high-throughput screening (HTS) diversity set of 1.8 million compounds was screened against the three kinetoplastids most relevant to human disease, i.e. Leishmania donovani, Trypanosoma cruzi and Trypanosoma brucei. Secondary confirmatory and orthogonal intracellular anti-parasiticidal assays were conducted, and the potential for non-specific cytotoxicity determined. Hit compounds were chemically clustered and triaged for desirable physicochemical properties. The hypothetical biological target space covered by these diversity sets was investigated through bioinformatics methodologies. Consequently, three anti-kinetoplastid chemical boxes of ~200 compounds each were assembled. Functional analyses of these compounds suggest a wide array of potential modes of action against kinetoplastid kinases, proteases and cytochromes as well as potential host–pathogen targets. This is the first published parallel high throughput screening of a pharma compound collection against kinetoplastids. The compound sets are provided as an open resource for future lead discovery programs, and to address important research questions. PMID:25740547

  4. Physiological and life history strategies of a fossil large mammal in a resource-limited environment.

    PubMed

    Köhler, Meike; Moyà-Solà, Salvador

    2009-12-01

    Because of their physiological and life history characteristics, mammals exploit adaptive zones unavailable to ectothermic reptiles. Yet, they perform best in energy-rich environments because their high and constant growth rates and their sustained levels of resting metabolism require continuous resource supply. In resource-limited ecosystems such as islands, therefore, reptiles frequently displace mammals because their slow and flexible growth rates and low metabolic rates permit them to operate effectively with low energy flow. An apparent contradiction of this general principle is the long-term persistence of certain fossil large mammals on energy-poor Mediterranean islands. The purpose of the present study is to uncover the developmental and physiological strategies that allowed fossil large mammals to cope with the low levels of resource supply that characterize insular ecosystems. Long-bone histology of Myotragus, a Plio-Pleistocene bovid from the Balearic Islands, reveals lamellar-zonal tissue throughout the cortex, a trait exclusive to ectothermic reptiles. The bone microstructure indicates that Myotragus grew unlike any other mammal but similar to crocodiles at slow and flexible rates, ceased growth periodically, and attained somatic maturity extremely late by approximately 12 years. This developmental pattern denotes that Myotragus, much like extant reptiles, synchronized its metabolic requirements with fluctuating resource levels. Our results suggest that developmental and physiological plasticity was crucial to the survival of this and, perhaps, other large mammals on resource-limited Mediterranean Islands, yet it eventually led to their extinction through a major predator, Homo sapiens.

  5. The common property resource problem and the creation of limited property rights

    SciTech Connect

    Berkes, F.

    1985-06-01

    Fish resources are generally considered common property and open to any user. This, the assumption goes, makes them susceptible to the ''tragedy of the commons'' in which selfish users are both the villians and the victims. While it is true that wild fish populations cannot readily be privatized, it hardly follows that they are completely open-access. In addition to social controls found in many traditional fishing communities, amply documented by anthropologists, many administrative controls in contemporary fisheries management also create limited property rights over fishery resources. This study focuses on Great Lakes fisheries of Ontario in Lakes Erie and St. Clair, and the kinds and diversity of limited property rights instituted in these areas: the formal and informal allocation of fishing areas, and the allocation of quantitative fishing rights (quotas), all of which serve as mechanisms to solve the common property resource problem. The Great Lakes fisheries suggest certain generalizations about the management of common property resources. The paper offers a ''life-cycle'' model of living resources use.

  6. National Laboratory Planning: Developing Sustainable Biocontainment Laboratories in Limited Resource Areas.

    PubMed

    Yeh, Kenneth B; Adams, Martin; Stamper, Paul D; Dasgupta, Debanjana; Hewson, Roger; Buck, Charles D; Richards, Allen L; Hay, John

    2016-01-01

    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. PMID:27559843

  7. National Laboratory Planning: Developing Sustainable Biocontainment Laboratories in Limited Resource Areas.

    PubMed

    Yeh, Kenneth B; Adams, Martin; Stamper, Paul D; Dasgupta, Debanjana; Hewson, Roger; Buck, Charles D; Richards, Allen L; Hay, John

    2016-01-01

    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.

  8. Evidence-based approach to the maintenance of laboratory and medical equipment in resource-poor settings.

    PubMed

    Malkin, Robert; Keane, Allison

    2010-07-01

    Much of the laboratory and medical equipment in resource-poor settings is out-of-service. The most commonly cited reasons are (1) a lack of spare parts and (2) a lack of highly trained technicians. However, there is little data to support these hypotheses, or to generate evidence-based solutions to the problem. We studied 2,849 equipment-repair requests (of which 2,529 were out-of-service medical equipment) from 60 resource-poor hospitals located in 11 nations in Africa, Europe, Asia, and Central America. Each piece of equipment was analyzed by an engineer or an engineering student and a repair was attempted using only locally available materials. If the piece was placed back into service, we assumed that the engineer's problem analysis was correct. A total of 1,821 pieces of medical equipment were placed back into service, or 72%, without requiring the use of imported spare parts. Of those pieces repaired, 1,704 were sufficiently documented to determine what knowledge was required to place the equipment back into service. We found that six domains of knowledge were required to accomplish 99% of the repairs: electrical (18%), mechanical (18%), power supply (14%), plumbing (19%), motors (5%), and installation or user training (25%). A further analysis of the domains shows that 66% of the out-of-service equipment was placed back into service using only 107 skills covering basic knowledge in each domain; far less knowledge than that required of a biomedical engineer or biomedical engineering technician. We conclude that a great majority of laboratory and medical equipment can be put back into service without importing spare parts and using only basic knowledge. Capacity building in resource-poor settings should first focus on a limited set of knowledge; a body of knowledge that we call the biomedical technician's assistant (BTA). This data set suggests that a supported BTA could place 66% of the out-of-service laboratory and medical equipment in their hospital back

  9. Limiting the Scope of Needs Assessment Studies or (How We Learned to Set Limits--And Feel No Guilt).

    ERIC Educational Resources Information Center

    Eastmond, J. Nicholls, Jr.; And Others

    Needs assessment is an activity undertaken for planning purposes. It is important to define the limits of the study and design it on a scale appropriate to the entire planning process. This paper suggests that a needs assessment be structured into two phases. In the pre-assessment phase, a conceptual framework and well-defined exploratory…

  10. A taxonomy for community-based care programs focused on HIV/AIDS prevention, treatment, and care in resource-poor settings.

    PubMed

    Rachlis, Beth; Sodhi, Sumeet; Burciul, Barry; Orbinski, James; Cheng, Amy H Y; Cole, Donald

    2013-04-16

    Community-based care (CBC) can increase access to key services for people affected by HIV/AIDS through the mobilization of community interests and resources and their integration with formal health structures. Yet, the lack of a systematic framework for analysis of CBC focused on HIV/AIDS impedes our ability to understand and study CBC programs. We sought to develop taxonomy of CBC programs focused on HIV/AIDS in resource-limited settings in an effort to understand their key characteristics, uncover any gaps in programming, and highlight the potential roles they play. Our review aimed to systematically identify key CBC programs focused on HIV/AIDS in resource-limited settings. We used both bibliographic database searches (Medline, CINAHL, and EMBASE) for peer-reviewed literature and internet-based searches for gray literature. Our search terms were 'HIV' or 'AIDS' and 'community-based care' or 'CBC'. Two co-authors developed a descriptive taxonomy through an iterative, inductive process using the retrieved program information. We identified 21 CBC programs useful for developing taxonomy. Extensive variation was observed within each of the nine categories identified: region, vision, characteristics of target populations, program scope, program operations, funding models, human resources, sustainability, and monitoring and evaluation strategies. While additional research may still be needed to identify the conditions that lead to overall program success, our findings can help to inform our understanding of the various aspects of CBC programs and inform potential logic models for CBC programming in the context of HIV/AIDS in resource-limited settings. Importantly, the findings of the present study can be used to develop sustainable HIV/AIDS-service delivery programs in regions with health resource shortages.

  11. A taxonomy for community-based care programs focused on HIV/AIDS prevention, treatment, and care in resource-poor settings

    PubMed Central

    Rachlis, Beth; Sodhi, Sumeet; Burciul, Barry; Orbinski, James; Cheng, Amy H.Y.; Cole, Donald

    2013-01-01

    Community-based care (CBC) can increase access to key services for people affected by HIV/AIDS through the mobilization of community interests and resources and their integration with formal health structures. Yet, the lack of a systematic framework for analysis of CBC focused on HIV/AIDS impedes our ability to understand and study CBC programs. We sought to develop taxonomy of CBC programs focused on HIV/AIDS in resource-limited settings in an effort to understand their key characteristics, uncover any gaps in programming, and highlight the potential roles they play. Our review aimed to systematically identify key CBC programs focused on HIV/AIDS in resource-limited settings. We used both bibliographic database searches (Medline, CINAHL, and EMBASE) for peer-reviewed literature and internet-based searches for gray literature. Our search terms were ‘HIV’ or ‘AIDS’ and ‘community-based care’ or ‘CBC’. Two co-authors developed a descriptive taxonomy through an iterative, inductive process using the retrieved program information. We identified 21 CBC programs useful for developing taxonomy. Extensive variation was observed within each of the nine categories identified: region, vision, characteristics of target populations, program scope, program operations, funding models, human resources, sustainability, and monitoring and evaluation strategies. While additional research may still be needed to identify the conditions that lead to overall program success, our findings can help to inform our understanding of the various aspects of CBC programs and inform potential logic models for CBC programming in the context of HIV/AIDS in resource-limited settings. Importantly, the findings of the present study can be used to develop sustainable HIV/AIDS-service delivery programs in regions with health resource shortages. PMID:23594416

  12. [Soil water resource use limit in semi-arid loess hilly area].

    PubMed

    Guo, Zhong-sheng

    2010-12-01

    Taking Caragana korshinskii as test object, and by using neutron probe, a long term observation was conducted on the soil water and plant growth during the process of vegetation restoration in semi-arid loess hilly area. The results showed that after seeding on waste land, the capability of plant community in conserving soil and water was promoted with time, with the depth of roots to absorb and use soil water increased and the soil water content reduced. Then, the dried soil layer appeared, and its deepness and thickness increased with increasing plant age. Therefore, the plant use of soil water had a limit, soil water resource use limit, i.e., the soil water storage when the deepness of dried soil layer was equal to the largest depth that rain could recharge. In the C. korshinskii woodland in semi-arid loess hilly area, the soil water resource use limit in 0-290 cm layer was 249.4 mm. When the soil water storage in woodland was close or equal to the soil water resource use limit, effective measures should be taken to decrease soil evapotranspiration or increase soil water supply to ensure the sustainable water use of plant roots. PMID:21442986

  13. Mutagenicity assessment strategy for pharmaceutical intermediates to aid limit setting for occupational exposure.

    PubMed

    Araya, Selene; Lovsin-Barle, Ester; Glowienke, Susanne

    2015-11-01

    Pharmaceutical intermediates (IM) are used in the synthesis of active pharmaceutical ingredients. They are not intended for human administration, yet employees may be exposed to IM during the manufacturing process. In the context of occupational health, hazard assessment of IM is needed to identify potential intrinsic hazards which could cause unwanted adverse effects. In particular, a carcinogenic potential influences the protection strategy in the workplace. DNA reactive substances may, even if present at very low levels, lead to mutations and therefore, potentially cause cancer. The use of in silico methods to predict mutagenicity is increasingly acknowledged and implemented in the recently released ICH M7 guideline for the limitation of DNA reactive impurities. In this study we investigate the possibility to apply (quantitative) structure-activity-relationships ((Q)SARs) during hazard identification to reduce the number of Ames tests needed for a hazard assessment of IM while maintaining high standards of protection of employees. Ames test outcomes for 188 substances used in the pharmaceutical production were compared with their in silico predictions using two different (Q)SAR methodologies (knowledge based and statistical) complemented by expert knowledge. The results of the analysis showed that a negative prediction for mutagenicity provides a high confidence that the IM is not mutagenic in the Ames test with the negative predictive value of 97%. On the other hand the positive predictive value was only 57% and therefore considered too low to reliably consider positive predicted IM to be mutagenic. In order to avoid any unnecessary burden for occupational health purposes caused by falsely positive predicted IM, all positive predicted IM and those with insufficient coverage by the in silico systems are submitted to an Ames test to verify or reject the prediction. It is shown that the described in silico prediction approach ensures appropriate protection

  14. Mutagenicity assessment strategy for pharmaceutical intermediates to aid limit setting for occupational exposure.

    PubMed

    Araya, Selene; Lovsin-Barle, Ester; Glowienke, Susanne

    2015-11-01

    Pharmaceutical intermediates (IM) are used in the synthesis of active pharmaceutical ingredients. They are not intended for human administration, yet employees may be exposed to IM during the manufacturing process. In the context of occupational health, hazard assessment of IM is needed to identify potential intrinsic hazards which could cause unwanted adverse effects. In particular, a carcinogenic potential influences the protection strategy in the workplace. DNA reactive substances may, even if present at very low levels, lead to mutations and therefore, potentially cause cancer. The use of in silico methods to predict mutagenicity is increasingly acknowledged and implemented in the recently released ICH M7 guideline for the limitation of DNA reactive impurities. In this study we investigate the possibility to apply (quantitative) structure-activity-relationships ((Q)SARs) during hazard identification to reduce the number of Ames tests needed for a hazard assessment of IM while maintaining high standards of protection of employees. Ames test outcomes for 188 substances used in the pharmaceutical production were compared with their in silico predictions using two different (Q)SAR methodologies (knowledge based and statistical) complemented by expert knowledge. The results of the analysis showed that a negative prediction for mutagenicity provides a high confidence that the IM is not mutagenic in the Ames test with the negative predictive value of 97%. On the other hand the positive predictive value was only 57% and therefore considered too low to reliably consider positive predicted IM to be mutagenic. In order to avoid any unnecessary burden for occupational health purposes caused by falsely positive predicted IM, all positive predicted IM and those with insufficient coverage by the in silico systems are submitted to an Ames test to verify or reject the prediction. It is shown that the described in silico prediction approach ensures appropriate protection

  15. Effective Practices in Providing Online, In-Service Training to Health Professionals in Low-Resource Settings

    ERIC Educational Resources Information Center

    Chio, Karen Sherk

    2012-01-01

    As doctors, nurses and public health professionals are promoted into management and leadership positions in resource-poor countries around the world, they are tasked with leading teams and managing drugs and financial and material resources. These responsibilities require a set of skills and knowledge different from that needed for their clinical…

  16. A new solar-powered blood pressure measuring device for low-resource settings.

    PubMed

    Parati, Gianfranco; Kilama, Michael Ochan; Faini, Andrea; Facelli, Elisa; Ochen, Kenneth; Opira, Cyprian; Mendis, Shanthi; Wang, Jiguang; Atkins, Neil; O'Brien, Eoin

    2010-12-01

    The management of high blood pressure (BP) is particularly inadequate in low-income countries, where the unavailability of a reliable, durable, and affordable BP-measurement device is a major obstacle to accurate diagnosis. Recognizing this, a World Health Organization committee was established to correct this deficiency by influencing manufacturers to produce a device according to predetermined criteria and to demonstrate the suitability of the device for low resource settings. A device, which fulfilled stipulated criteria in being inexpensive, semiautomated, and solar powered, was validated according to the International Protocol of the European Society of Hypertension; it was then subjected to field testing in 716 subjects from 2 centers in Uganda and 1 in Zambia. The Omron HEM-SOLAR having previously fulfilled accuracy criteria of the International Protocol for both systolic blood pressure (SBP) and diastolic blood pressure (DBP), fulfilled criteria for SBP, but not for DBP, when revalidated. In field testing, average SBPs and DBPs were 120.5 ± 21.6/74.6 ± 13.8 mm Hg and 122.3 ± 21.8/71.2 ± 14.0 mm Hg, respectively, with the auscultatory technique and the Omron HEM-SOLAR, respectively. Between-device agreement in defining SBP was 93.7%. The Omron HEM-SOLAR was favored over the mercury sphygmomanometer by both patients and investigators. In summary, considering the accuracy, robustness, relatively low cost, operational simplicity, and advantages such as solar power, the Omron HEM-SOLAR is likely to be a valuable device for improving BP measurement in low-resource settings with nonphysician health workers.

  17. Prostate cancer diagnosis in a resource-poor setting: the changing role of digital rectal examination.

    PubMed

    Ahmed, Muhammed

    2011-07-01

    We undertook this study in order to determine the current role of digital rectal examination (DRE) in the diagnosis of prostate cancer in a resource-poor setting. The diagnosis of prostate cancer has been revolutionized by the introduction of prostate-specific antigen (PSA), transrectal ultrasound (TRUS) for biopsy guidance and more efficient biopsy equipment, but they are not readily available in most developing countries. This is a prospective study of 131 patients with suspected prostate cancer based on clinical presentation, DRE and elevated PSA. The presence or absence of cancer was confirmed by biopsy and histologic examination. Patients with screen- or incidentally-detected prostate cancer were excluded. The most common symptom was the development of lower urinary tract symptoms (LUTS). All patients had abnormal DRE and indurated prostate was the most frequent finding (50%). The mean PSA was 33.9 ng/mL: of the 131 patients, 80 (61.1%) had a malignant histology following biopsy, 47 (35.9%) were benign and four (3.0%) were prostate intraepithelial neoplasia (PIN). The low specificity of DRE in the diagnosis of prostate cancer requires that it should be combined with other diagnostic modalities such as PSA and TRUS-guided prostate biopsy. Thus government and health-care providers in resource-poor countries must strive to make these facilities available in order to improve prostate cancer diagnosis.

  18. The role of breast cancer civil society in different resource settings.

    PubMed

    Azenha, Gustavo; Bass, Loyce Pace; Caleffi, Maira; Smith, Robert; Pretorius, Lauren; Durstine, Alessandra; Perez, Cristina Parsons

    2011-04-01

    Breast cancer civil society, as represented by non-governmental organizations (NGOs) in this study, can play an essential role in breast cancer control. Their breast cancer-related programs often reflect the breast cancer burden and the resources available for cancer control within the country or region they serve. This report reviews organizational features and program activities of 154 NGOs involved in breast cancer control from 35 countries. Breast cancer civil society in low and lower-middle income countries are most often associated with hospitals and medical professionals and focus on direct medical services, providing information, raising community awareness, and early detection campaigns. In upper-middle income countries, NGOs were likely to be survivor-led and there were more breast cancer-specific organizations. NGOs played a lesser role in provision of direct medical services and had a greater program emphasis on other areas of patient services, including emotional support. In high income countries, they were typically survivor-led, breast cancer-specific NGOs were prominent, and NGOs had a more prominent focus on research, advocacy and legal rights compared to other resource settings. PMID:21345677

  19. Setting Occupational Exposure Limits for Chemical Allergens--Understanding the Challenges.

    PubMed

    Dotson, G S; Maier, A; Siegel, P D; Anderson, S E; Green, B J; Stefaniak, A B; Codispoti, C D; Kimber, I

    2015-01-01

    Chemical allergens represent a significant health burden in the workplace. Exposures to such chemicals can cause the onset of a diverse group of adverse health effects triggered by immune-mediated responses. Common responses associated with workplace exposures to low molecular weight (LMW) chemical allergens range from allergic contact dermatitis to life-threatening cases of asthma. Establishing occupational exposure limits (OELs) for chemical allergens presents numerous difficulties for occupational hygiene professionals. Few OELs have been developed for LMW allergens because of the unique biological mechanisms that govern the immune-mediated responses. The purpose of this article is to explore the primary challenges confronting the establishment of OELs for LMW allergens. Specific topics include: (1) understanding the biology of LMW chemical allergies as it applies to setting OELs; (2) selecting the appropriate immune-mediated response (i.e., sensitization versus elicitation); (3) characterizing the dose (concentration)-response relationship of immune-mediated responses; (4) determining the impact of temporal exposure patterns (i.e., cumulative versus acute exposures); and (5) understanding the role of individual susceptibility and exposure route. Additional information is presented on the importance of using alternative exposure recommendations and risk management practices, including medical surveillance, to aid in protecting workers from exposures to LMW allergens when OELs cannot be established.

  20. The role of freezing in setting the latitudinal limits of mangrove forests.

    PubMed

    Stuart, S A; Choat, B; Martin, K C; Holbrook, N M; Ball, M C

    2007-01-01

    Mangrove trees dominate coastal vegetation in tropical regions, but are completely replaced by herbaceous salt marshes at latitudes above 32 degrees N and 40 degrees S. Because water deficit can increase damage caused by freezing, we hypothesized that mangroves, which experience large deficits as a result of saline substrates, would suffer freeze-induced xylem failure. Vulnerability to freeze-induced xylem embolism was examined in the most poleward mangrove species in North America, in an area where freezing is rare but severe, and in Australia, in an area where freezing is frequent but mild. Percentage loss in hydraulic conductivity was measured following manipulations of xylem tension; xylem sap ion concentration was determined using X-ray microanalysis. Species with wider vessels suffered 60-100% loss of hydraulic conductivity after freezing and thawing under tension, while species with narrower vessels lost as little as 13-40% of conductivity. These results indicate that freeze-induced embolism may play a role in setting the latitudinal limits of distribution in mangroves, either through massive embolism following freezing, or through constraints on water transport as a result of vessel size. PMID:17244052

  1. Setting Occupational Exposure Limits for Chemical Allergens—Understanding the Challenges

    PubMed Central

    Dotson, G. S.; Maier, A.; Siegel, P. D.; Anderson, S. E.; Green, B. J.; Stefaniak, A. B.; Codispoti, C. D.; Kimber, I.

    2015-01-01

    Chemical allergens represent a significant health burden in the workplace. Exposures to such chemicals can cause the onset of a diverse group of adverse health effects triggered by immune-mediated responses. Common responses associated with workplace exposures to low molecular weight (LMW) chemical allergens range from allergic contact dermatitis to life-threatening cases of asthma. Establishing occupational exposure limits (OELs) for chemical allergens presents numerous difficulties for occupational hygiene professionals. Few OELs have been developed for LMW allergens because of the unique biological mechanisms that govern the immune-mediated responses. The purpose of this article is to explore the primary challenges confronting the establishment of OELs for LMW allergens. Specific topics include: (1) understanding the biology of LMW chemical allergies as it applies to setting OELs; (2) selecting the appropriate immune-mediated response (i.e., sensitization versus elicitation); (3) characterizing the dose (concentration)-response relationship of immune-mediated responses; (4) determining the impact of temporal exposure patterns (i.e., cumulative versus acute exposures); and (5) understanding the role of individual susceptibility and exposure route. Additional information is presented on the importance of using alternative exposure recommendations and risk management practices, including medical surveillance, to aid in protecting workers from exposures to LMW allergens when OELs cannot be established. PMID:26583909

  2. Within-population spatial variation in pollinator visitation rates, pollen limitation on seed set, and flower longevity in an alpine species

    NASA Astrophysics Data System (ADS)

    Lundemo, Sverre; Totland, Ørjan

    2007-11-01

    Pollen limitation through insufficient pollen deposition on stigmas caused by too infrequent pollinator visitation may influence the reproductive outcome of plants. In this study we investigated how pollinator visitation rate, the degree of pollen limitation, and flower longevity varied spatially among three sites at different altitudes within a population of the dwarf shrub Dryas octopetala L. in alpine southern Norway. Significant pollen limitation on seed set only occurred at the mid-elevation site, while seed set at the other sites appeared to be mainly resource limited, thus indicating a spatial variation in pollen limitation. There was no association between the spatial variation in the extent of pollen limitation and pollinator visitation rate to flowers. However, pollinator visitation rates were related to flower longevity of Dryas; sites with low visitation rates had long-lived flowers and vice versa. Thus, our results suggest within-population spatial co-variation between pollinator visitation rates, pollen limitation, and a developmental response to these factors, flower longevity.

  3. Drug Susceptibility and Resistance Mutations After First-Line Failure in Resource Limited Settings

    PubMed Central

    Wallis, Carole L.; Aga, Evgenia; Ribaudo, Heather; Saravanan, Shanmugam; Norton, Michael; Stevens, Wendy; Kumarasamy, Nagalingeswaran; Bartlett, John; Katzenstein, David

    2014-01-01

    Background. The development of drug resistance to nucleoside reverse transcriptase inhibitors (NRTIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) has been associated with baseline human immunodeficiency virus (HIV)-1 RNA level (VL), CD4 cell counts (CD4), subtype, and treatment failure duration. This study describes drug resistance and levels of susceptibility after first-line virologic failure in individuals from Thailand, South Africa, India, Malawi, Tanzania. Methods. CD4 and VL were captured at AIDs Clinical Trial Group (ACTG) A5230 study entry, a study of lopinavir/ritonavir (LPV/r) monotherapy after first-line virologic failure on an NNRTI regimen. HIV drug-resistance mutation associations with subtype, site, study entry VL, and CD4 were evaluated using Fisher exact and Kruskall–Wallis tests. Results. Of the 207 individuals who were screened for A5230, sequence data were available for 148 individuals. Subtypes observed: subtype C (n = 97, 66%) AE (n = 27, 18%), A1 (n = 12, 8%), and D (n = 10, 7%). Of the 148 individuals, 93% (n = 138) and 96% (n = 142) had at least 1 reverse transcriptase (RT) mutation associated with NRTI and NNRTI resistance, respectively. The number of NRTI mutations was significantly associated with a higher study screening VL and lower study screening CD4 (P < .001). Differences in drug-resistance patterns in both NRTI and NNRTI were observed by site. Conclusions. The degree of NNRTI and NRTI resistance after first-line virologic failure was associated with higher VL at study entry. Thirty-two percent of individuals remained fully susceptible to etravirine and rilpivirine, protease inhibitor resistance was rare. Some level of susceptibility to NRTI remained; however, VL monitoring and earlier virologic failure detection may result in lower NRTI resistance. PMID:24795328

  4. A global health delivery framework approach to epilepsy care in resource-limited settings.

    PubMed

    Cochran, Maggie F; Berkowitz, Aaron L

    2015-11-15

    The Global Health Delivery (GHD) framework (Farmer, Kim, and Porter, Lancet 2013;382:1060-69) allows for the analysis of health care delivery systems along four axes: a care delivery value chain that incorporates prevention, diagnosis, and treatment of a medical condition; shared delivery infrastructure that integrates care within existing healthcare delivery systems; alignment of care delivery with local context; and generation of economic growth and social development through the health care delivery system. Here, we apply the GHD framework to epilepsy care in rural regions of low- and middle-income countries (LMIC) where there are few or no neurologists.

  5. Prevention and treatment of human immunodeficiency virus/acquired immunodeficiency syndrome in resource-limited settings.

    PubMed Central

    Hogan, Daniel R.; Salomon, Joshua A.

    2005-01-01

    Strategies for confronting the epidemic of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have included a range of different approaches that focus on prevention and treatment. However, debate persists over what levels of emphasis are appropriate for the different components of the global response. This paper presents an overview of this debate and briefly summarizes the evidence on a range of interventions designed to prevent the spread of HIV infection, paying particular attention to voluntary counselling and testing, treatment for sexually transmitted infections and prevention of mother-to-child transmission. We also review the experience with antiretroviral therapy to date in terms of response rates and survival rates, adherence, drug resistance, behavioural change and epidemiological impact. Although various studies have identified strategies with proven effectiveness in reducing the risks of HIV infection and AIDS mortality, considerable uncertainties remain. Successful integration of treatment and prevention of HIV/AIDS will require a balanced approach and rigorous monitoring of the impact of programmes in terms of both individual and population outcomes. PMID:15744406

  6. TB screening among people living with HIV/AIDS in resource-limited settings.

    PubMed

    Date, Anand; Modi, Surbhi

    2015-04-15

    Tuberculosis (TB) continues to be the leading cause of morbidity and mortality among people living with HIV (PLHIV), making improved prevention and treatment of HIV-associated TB critical to ensuring long-term survival of PLHIV. TB screening among PLHIV is central to implementation of the World Health Organization's 3 I's interventions for reducing the impact of the TB and HIV syndemics. Effective TB screening will result in the identification of PLHIV with presumptive TB disease (ie, those with a positive symptom screen who require appropriate evaluation, including the use of diagnostic tools such as the Xpert MTB/RIF assay) and those eligible for isoniazid preventive therapy (ie, those who have a negative clinical symptom screen or who have a positive screen but are found not to have TB disease). Identification of PLHIV with presumptive TB also facilitates implementation of basic administrative measures for TB infection control, including fast tracking of coughing patients and separation from noncoughing PLHIV to reduce TB transmission. By contributing to the early diagnosis of TB disease among PLHIV, TB screening is also critical to facilitate early initiation of antiretroviral treatment among PLHIV diagnosed with TB disease who might not otherwise be eligible for antiretroviral treatment based on CD4 count or clinical staging. TB screening thus serves as a gateway for multiple TB/HIV interventions and is an integral part of routine clinical services for PLHIV at each clinic visit.

  7. Paediatric cancer care in a limited-resource setting: Children's Welfare Teaching Hospital, Medical City, Baghdad.

    PubMed

    Al-Hadad, Salma A Naji; Al-Jadiry, Mazin Faisal Farhan; Lefko, Claudia

    2016-01-01

    There has been a lot of news coming out of Iraq in recent decades, but most of it ignores the situation for people on the ground: ordinary men, women and children who continue trying to live their lives in spite of wars, economic sanctions, violence, and social, political and cultural collapse. The challenges of maintaining and sustaining health in an environment where everything-the human spirit, education and health care systems and the health-sustaining infrastructures of housing, water purification and the electric grid-is damaged or broken are enormous. PMID:27350793

  8. Modelling inter-supply chain competition with resource limitation and demand disruption

    NASA Astrophysics Data System (ADS)

    Chen, Zhaobo; Teng, Chunxian; Zhang, Ding; Sun, Jiayi

    2016-05-01

    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.

  9. Voluntary limit setting and player choice in most intense online gamblers: an empirical study of gambling behaviour.

    PubMed

    Auer, Michael; Griffiths, Mark D

    2013-12-01

    Social responsibility in gambling has become a major issue for the gaming industry. The possibility for online gamblers to set voluntary time and money limits are a social responsibility practice that is now widespread among online gaming operators. The main issue concerns whether the voluntary setting of such limits has any positive impact on subsequent gambling behaviour and whether such measures are of help to problem gamblers. In this paper, this issue is examined through data collected from a representative random sample of 100,000 players who gambled on the win2day gambling website. When opening an account at the win2day site, there is a mandatory requirement for all players to set time and cash-in limits (that cannot exceed 800 per week). During a 3-month period, all voluntary time and/or money limit setting behaviour by a subsample of online gamblers (n = 5,000) within this mandatory framework was tracked and recorded for subsequent data analysis. From the 5,000 gamblers, the 10 % most intense players (as measured by theoretical loss) were further investigated. Voluntary spending limits had the highest significant effect on subsequent monetary spending among casino and lottery gamblers. Monetary spending among poker players significantly decreased after setting a voluntary time limit. The highest significant decrease in playing duration was among poker players after setting a voluntary playing duration limit. The results of the study demonstrated that voluntary limit setting had a specific and significant effect on the studied gamblers. Therefore, voluntary limits appear to show an appropriate effect in the desired target group (i.e., the most gaming intense players).

  10. Stressors, coping resources, functioning, and role limitations among older korean immigrants: gender differences.

    PubMed

    Lee, Kyoung Hag; GlenMaye, Linnea Flynn

    2014-01-01

    This study explored the differential impacts of stressors and coping resources on the functioning and roles of 246 older Korean immigrant men and women. Older Korean immigrant women were significantly more likely than men to have acculturation and socioeconomic stressors, physical/social functioning problems, and role limitations. English-language barriers and lack of transportation were significantly related to lower functioning and higher role limitations of older Korean women compared to those of older men. Providing social and health care services with bilingual and transportation services to older Korean immigrant women is recommended to increase their physical/social functioning and role performance. PMID:24483283

  11. Building sustainable organizational capacity to deliver HIV programs in resource-constrained settings: stakeholder perspectives

    PubMed Central

    Sharma, Anjali; Chiliade, Philippe; Reyes, E. Michael; Thomas, Kate K.; Collens, Stephen R.; Morales, José Rafael

    2013-01-01

    Background In 2008, the US government mandated that HIV/AIDS care and treatment programs funded by the US President's Emergency Plan for AIDS Relief (PEPFAR) should shift from US-based international partners (IPs) to registered locally owned organizations (local partners, or LPs). The US Health Resources and Services Administration (HRSA) developed the Clinical Assessment for Systems Strengthening (ClASS) framework for technical assistance in resource-constrained settings. The ClASS framework involves all stakeholders in the identification of LPs’ strengths and needs for technical assistance. Objective This article examines the role of ClASS in building capacity of LPs that can endure and adapt to changing financial and policy environments. Design All stakeholders (n=68) in Kenya, Zambia, and Nigeria who had participated in the ClASS from LPs and IPs, the US Centers for Disease Control and Prevention (CDC), and, in Nigeria, HIV/AIDS treatment facilities (TFs) were interviewed individually or in groups (n=42) using an open-ended interview guide. Thematic analysis revealed stakeholder perspectives on ClASS-initiated changes and their sustainability. Results Local organizations were motivated to make changes in internal operations with the ClASS approach, PEPFAR's competitive funding climate, organizational goals, and desired patient health outcomes. Local organizations drew on internal resources and, if needed, technical assistance from IPs. Reportedly, ClASS-initiated changes and remedial action plans made LPs more competitive for PEPFAR funding. LPs also attributed their successful funding applications to their preexisting systems and reputation. Bureaucracy, complex and competing tasks, and staff attrition impeded progress toward the desired changes. Although CDC continues to provide technical assistance through IPs, declining PEPFAR funds threaten the consolidation of gains, smooth program transition, and continuity of treatment services. Conclusions The well

  12. Reflections on informed choice in resource-poor settings: the case of infant feeding counselling in PMTCT programmes in Tanzania.

    PubMed

    Våga, Bodil Bø; Moland, Karen Marie; Evjen-Olsen, Bjørg; Blystad, Astrid

    2014-03-01

    A growing emphasis on patient involvement in health care has brought 'informed choice' to the core of the debate on provider-patient interaction in global health-care programmes. How the principles of patient involvement and informed choice are implemented and experienced in diverging health systems and cultural contexts are issues of increasing interest. Infant feeding and infant feeding counselling of HIV-positive women have posed particular challenges related to choice. Based on ethnographic research conducted from 5 November 2008 to 5 August 2009 within prevention of mother-to-child transmission of HIV (PMTCT) programmes in two hospitals in rural and semi-urban Tanzania, this study explores nurse counsellors' and HIV-positive women's experiences of infant feeding counselling and patient choice. One of the hospitals (hospital A) promoted exclusive breastfeeding as the only infant feeding option, while the other hospital (hospital B) aimed to follow the Tanzanian PMTCT infant feeding guidelines of 2007 promoting patient choice in infant feeding methods. Women in hospital A expressed trust in the advice given and confidence in their own ability to practice exclusive breastfeeding, while women in hospital B expressed great uncertainty and confusion about how best to feed their infants. This paper reflects on the feasibility of a counselling procedure that promotes choice of infant feeding methods in PMTCT programmes in severely resource-poor settings where HIV-positive women have limited access to resources and to up-to-date knowledge on HIV and infant feeding outside the counselling room. We suggest that a universalistic procedure presenting the same unambiguous message on infant feeding to all women enrolled in the PMTCT programme in this and similar settings is likely to produce more confidence, less confusion and, hence, better results in terms of HIV-free survival of the baby.

  13. Cultural Health Capital on the margins: Cultural resources for navigating healthcare in communities with limited access.

    PubMed

    Madden, Erin Fanning

    2015-05-01

    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.

  14. Implementation Research to Inform the Use of Xpert MTB/RIF in Primary Health Care Facilities in High TB and HIV Settings in Resource Constrained Settings

    PubMed Central

    Muyoyeta, Monde; Moyo, Maureen; Kasese, Nkatya; Ndhlovu, Mapopa; Milimo, Deborah; Mwanza, Winfridah; Kapata, Nathan; Schaap, Albertus; Godfrey Faussett, Peter; Ayles, Helen

    2015-01-01

    Background The current cost of Xpert MTB RIF (Xpert) consumables is such that algorithms are needed to select which patients to prioritise for testing with Xpert. Objective To evaluate two algorithms for prioritisation of Xpert in primary health care settings in a high TB and HIV burden setting. Method Consecutive, presumptive TB patients with a cough of any duration were offered either Xpert or Fluorescence microscopy (FM) test depending on their CXR score or HIV status. In one facility, sputa from patients with an abnormal CXR were tested with Xpert and those with a normal CXR were tested with FM (“CXR algorithm”). CXR was scored automatically using a Computer Aided Diagnosis (CAD) program. In the other facility, patients who were HIV positive were tested using Xpert and those who were HIV negative were tested with FM (“HIV algorithm”). Results Of 9482 individuals pre-screened with CXR, Xpert detected TB in 2090/6568 (31.8%) with an abnormal CXR, and FM was AFB positive in 8/2455 (0.3%) with a normal CXR. Of 4444 pre-screened with HIV, Xpert detected TB in 508/2265 (22.4%) HIV positive and FM was AFB positive in 212/1920 (11.0%) in HIV negative individuals. The notification rate of new bacteriologically confirmed TB increased; from 366 to 620/ 100,000/yr and from 145 to 261/100,000/yr at the CXR and HIV algorithm sites respectively. The median time to starting TB treatment at the CXR site compared to the HIV algorithm site was; 1(IQR 1-3 days) and 3 (2-5 days) (p<0.0001) respectively. Conclusion Use of Xpert in a resource-limited setting at primary care level in conjunction with pre-screening tests reduced the number of Xpert tests performed. The routine use of Xpert resulted in additional cases of confirmed TB patients starting treatment. However, there was no increase in absolute numbers of patients starting TB treatment. Same day diagnosis and treatment commencement was achieved for both bacteriologically confirmed and empirically diagnosed patients

  15. OBSERVED BINARY FRACTION SETS LIMITS ON THE EXTENT OF COLLISIONAL GRINDING IN THE KUIPER BELT

    SciTech Connect

    Nesvorny, David; Vokrouhlicky, David; Bottke, William F.; Levison, Harold F.; Noll, Keith

    2011-05-15

    The size distribution in the cold classical Kuiper Belt (KB) can be approximated by two idealized power laws: one with steep slope for radii R > R* and one with shallow slope for R < R*, where R* {approx} 25-50 km. Previous works suggested that the size frequency distribution (SFD) rollover at R* can be the result of extensive collisional grinding in the KB that led to the catastrophic disruption of most bodies with R < R*. Here, we use a new code to test the effect of collisions in the KB. We find that the observed rollover could indeed be explained by collisional grinding provided that the initial mass in large bodies was much larger than the one in the present KB and was dynamically depleted. In addition to the size distribution changes, our code also tracks the effects of collisions on binary systems. We find that it is generally easier to dissolve wide binary systems, such as the ones existing in the cold KB today, than to catastrophically disrupt objects with R {approx} R*. Thus, the binary survival sets important limits on the extent of collisional grinding in the KB. We find that the extensive collisional grinding required to produce the SFD rollover at R* would imply a strong gradient of the binary fraction with R and separation, because it is generally easier to dissolve binaries with small components and/or those with wide orbits. The expected binary fraction for R {approx}< R* is {approx}<0.1. The present observational data do not show such a gradient. Instead, they suggest a large binary fraction of {approx}0.4 for R = 30-40 km. This may indicate that the rollover was not produced by disruptive collisions, but is instead a fossil remnant of the KB object formation process.

  16. Systems Biology and Biomarkers of Early Effects for Occupational Exposure Limit Setting.

    PubMed

    DeBord, D Gayle; Burgoon, Lyle; Edwards, Stephen W; Haber, Lynne T; Kanitz, M Helen; Kuempel, Eileen; Thomas, Russell S; Yucesoy, Berran

    2015-01-01

    In a recent National Research Council document, new strategies for risk assessment were described to enable more accurate and quicker assessments. This report suggested that evaluating individual responses through increased use of bio-monitoring could improve dose-response estimations. Identification of specific biomarkers may be useful for diagnostics or risk prediction as they have the potential to improve exposure assessments. This paper discusses systems biology, biomarkers of effect, and computational toxicology approaches and their relevance to the occupational exposure limit setting process. The systems biology approach evaluates the integration of biological processes and how disruption of these processes by chemicals or other hazards affects disease outcomes. This type of approach could provide information used in delineating the mode of action of the response or toxicity, and may be useful to define the low adverse and no adverse effect levels. Biomarkers of effect are changes measured in biological systems and are considered to be preclinical in nature. Advances in computational methods and experimental -omics methods that allow the simultaneous measurement of families of macromolecules such as DNA, RNA, and proteins in a single analysis have made these systems approaches feasible for broad application. The utility of the information for risk assessments from -omics approaches has shown promise and can provide information on mode of action and dose-response relationships. As these techniques evolve, estimation of internal dose and response biomarkers will be a critical test of these new technologies for application in risk assessment strategies. While proof of concept studies have been conducted that provide evidence of their value, challenges with standardization and harmonization still need to be overcome before these methods are used routinely.

  17. Kinetics of cold-set diffusion-limited aggregations of denatured whey protein isolate colloids.

    PubMed

    Wu, Hua; Xie, Jianjun; Morbidelli, Massimo

    2005-01-01

    The CaCl2-induced cold-set aggregation kinetics of the denatured whey protein isolate (WPI) colloids has been investigated under dilute diffusion-limited cluster aggregation (DLCA) conditions, using small-angle light scattering. In particular, the structure factor, the scattered intensity at zero angle and the average radius of gyration have been measured for the aggregating system as a function of time. It is found that the fractal dimension of the clusters is df= 1.85, in the range typical of clusters aggregated under DLCA conditions. The aggregation kinetics in this transition region can be described by a power law relation in the initial stage of the aggregation, but the exponent of the power law is equal to 0.7, i.e., significantly larger than 1/df= 0.54, which is the typical value of the DLCA kinetics. Since it is found that the average gyration radius of the clusters has reached a value of 80 microm, leading to a cumulative volume fraction of clusters equal to 0.25, it is legitimate to expect that the process is in the region of transition from aggregation to gelation. This confirmed by the fact that, at the later stage of the aggregation, the growth of the average cluster size further accelerates with time and eventually becomes explosive, leading to gelation. The observed aggregation kinetics has been compared with that reported in the literature from DLCA Monte Carlo simulations, and a good agreement has been found with the data corresponding to the transition region from aggregation to gelation. Numerical simulations using the Smoluchowski kinetic model have also been carried out in order to support the experimental findings.

  18. Systems Biology and Biomarkers of Early Effects for Occupational Exposure Limit Setting

    PubMed Central

    DeBord, D. Gayle; Burgoon, Lyle; Edwards, Stephen W.; Haber, Lynne T.; Kanitz, M. Helen; Kuempel, Eileen; Thomas, Russell S.; Yucesoy, Berran

    2015-01-01

    In a recent National Research Council document, new strategies for risk assessment were described to enable more accurate and quicker assessments.( 1 ) This report suggested that evaluating individual responses through increased use of bio-monitoring could improve dose-response estimations. Identi-fication of specific biomarkers may be useful for diagnostics or risk prediction as they have the potential to improve exposure assessments. This paper discusses systems biology, biomarkers of effect, and computational toxicology approaches and their relevance to the occupational exposure limit setting process. The systems biology approach evaluates the integration of biological processes and how disruption of these processes by chemicals or other hazards affects disease outcomes. This type of approach could provide information used in delineating the mode of action of the response or toxicity, and may be useful to define the low adverse and no adverse effect levels. Biomarkers of effect are changes measured in biological systems and are considered to be preclinical in nature. Advances in computational methods and experimental -omics methods that allow the simultaneous measurement of families of macromolecules such as DNA, RNA, and proteins in a single analysis have made these systems approaches feasible for broad application. The utility of the information for risk assessments from -omics approaches has shown promise and can provide information on mode of action and dose-response relationships. As these techniques evolve, estimation of internal dose and response biomarkers will be a critical test of these new technologies for application in risk assessment strategies. While proof of concept studies have been conducted that provide evidence of their value, challenges with standardization and harmonization still need to be overcome before these methods are used routinely. PMID:26132979

  19. Systems Biology and Biomarkers of Early Effects for Occupational Exposure Limit Setting.

    PubMed

    DeBord, D Gayle; Burgoon, Lyle; Edwards, Stephen W; Haber, Lynne T; Kanitz, M Helen; Kuempel, Eileen; Thomas, Russell S; Yucesoy, Berran

    2015-01-01

    In a recent National Research Council document, new strategies for risk assessment were described to enable more accurate and quicker assessments. This report suggested that evaluating individual responses through increased use of bio-monitoring could improve dose-response estimations. Identification of specific biomarkers may be useful for diagnostics or risk prediction as they have the potential to improve exposure assessments. This paper discusses systems biology, biomarkers of effect, and computational toxicology approaches and their relevance to the occupational exposure limit setting process. The systems biology approach evaluates the integration of biological processes and how disruption of these processes by chemicals or other hazards affects disease outcomes. This type of approach could provide information used in delineating the mode of action of the response or toxicity, and may be useful to define the low adverse and no adverse effect levels. Biomarkers of effect are changes measured in biological systems and are considered to be preclinical in nature. Advances in computational methods and experimental -omics methods that allow the simultaneous measurement of families of macromolecules such as DNA, RNA, and proteins in a single analysis have made these systems approaches feasible for broad application. The utility of the information for risk assessments from -omics approaches has shown promise and can provide information on mode of action and dose-response relationships. As these techniques evolve, estimation of internal dose and response biomarkers will be a critical test of these new technologies for application in risk assessment strategies. While proof of concept studies have been conducted that provide evidence of their value, challenges with standardization and harmonization still need to be overcome before these methods are used routinely. PMID:26132979

  20. On the validity of the basis set superposition error and complete basis set limit extrapolations for the binding energy of the formic acid dimer

    SciTech Connect

    Miliordos, Evangelos; Xantheas, Sotiris S.

    2015-03-07

    We report the variation of the binding energy of the Formic Acid Dimer with the size of the basis set at the Coupled Cluster with iterative Singles, Doubles and perturbatively connected Triple replacements [CCSD(T)] level of theory, estimate the Complete Basis Set (CBS) limit, and examine the validity of the Basis Set Superposition Error (BSSE)-correction for this quantity that was previously challenged by Kalescky, Kraka, and Cremer (KKC) [J. Chem. Phys. 140, 084315 (2014)]. Our results indicate that the BSSE correction, including terms that account for the substantial geometry change of the monomers due to the formation of two strong hydrogen bonds in the dimer, is indeed valid for obtaining accurate estimates for the binding energy of this system as it exhibits the expected decrease with increasing basis set size. We attribute the discrepancy between our current results and those of KKC to their use of a valence basis set in conjunction with the correlation of all electrons (i.e., including the 1s of C and O). We further show that the use of a core-valence set in conjunction with all electron correlation converges faster to the CBS limit as the BSSE correction is less than half than the valence electron/valence basis set case. The uncorrected and BSSE-corrected binding energies were found to produce the same (within 0.1 kcal/mol) CBS limits. We obtain CCSD(T)/CBS best estimates for D{sub e} = − 16.1 ± 0.1 kcal/mol and for D{sub 0} = − 14.3 ± 0.1 kcal/mol, the later in excellent agreement with the experimental value of −14.22 ± 0.12 kcal/mol.

  1. On the validity of the basis set superposition error and complete basis set limit extrapolations for the binding energy of the formic acid dimer.

    PubMed

    Miliordos, Evangelos; Xantheas, Sotiris S

    2015-03-01

    We report the variation of the binding energy of the Formic Acid Dimer with the size of the basis set at the Coupled Cluster with iterative Singles, Doubles and perturbatively connected Triple replacements [CCSD(T)] level of theory, estimate the Complete Basis Set (CBS) limit, and examine the validity of the Basis Set Superposition Error (BSSE)-correction for this quantity that was previously challenged by Kalescky, Kraka, and Cremer (KKC) [J. Chem. Phys. 140, 084315 (2014)]. Our results indicate that the BSSE correction, including terms that account for the substantial geometry change of the monomers due to the formation of two strong hydrogen bonds in the dimer, is indeed valid for obtaining accurate estimates for the binding energy of this system as it exhibits the expected decrease with increasing basis set size. We attribute the discrepancy between our current results and those of KKC to their use of a valence basis set in conjunction with the correlation of all electrons (i.e., including the 1s of C and O). We further show that the use of a core-valence set in conjunction with all electron correlation converges faster to the CBS limit as the BSSE correction is less than half than the valence electron/valence basis set case. The uncorrected and BSSE-corrected binding energies were found to produce the same (within 0.1 kcal/mol) CBS limits. We obtain CCSD(T)/CBS best estimates for De = - 16.1 ± 0.1 kcal/mol and for D0 = - 14.3 ± 0.1 kcal/mol, the later in excellent agreement with the experimental value of -14.22 ± 0.12 kcal/mol.

  2. Geometric Limits of Julia Sets of Maps zn + exp(2πiθ) as n → ∞

    NASA Astrophysics Data System (ADS)

    Kaschner, Scott R.; Romero, Reaper; Simmons, David

    We show that the geometric limit as n → ∞ of the Julia sets J(Pn,c) for the maps Pn,c(z) = zn + c does not exist for almost every c on the unit circle. Furthermore, we show that there is always a subsequence along which the limit does exist and equals the unit circle.

  3. Influences on Healthcare-seeking during Final Illnesses of Infants in Under-resourced South African Settings

    PubMed Central

    Chopra, Mickey; Jackson, Debra; Winch, Peter J.; Minkovitz, Cynthia S

    2011-01-01

    To examine how health caregivers in under-resourced South African settings select from among the healthcare alternatives available to them during the final illness of their infants, qualitative interviews were conducted with 39 caregivers of deceased infants in a rural community and an urban township. Nineteen local health providers and community leaders were also interviewed to ascertain opinions about local healthcare and other factors impacting healthcare-seeking choices. The framework analysis method guided qualitative analysis of data. Limited autonomy of caregivers in decision-making, lack of awareness of infant danger-signs, and identification of an externalizing cause of illness were important influences on healthcare-seeking during illnesses of infants in these settings. Health system factors relating to the performance of health workers and the accessibility and availability of services also influenced healthcare-seeking decisions. Although South African public-health services are free, the findings showed that poor families faced other financial constraints that impacted their access to healthcare. Often there was not one factor but a combination of factors occurring either concurrently or sequentially that determined whether, when, and from where outside healthcare was sought during final illnesses of infants. In addition to reducing health system barriers to healthcare, initiatives to improve timely and appropriate healthcare-seeking for sick infants must take into consideration ways to mitigate contextual problems, such as limited autonomy of caregivers in decision-making, and reconcile local explanatory models of childhood illnesses that may not encourage healthcare-seeking at allopathic services. PMID:21957677

  4. Study participants incentives, compensation and reimbursement in resource-constrained settings

    PubMed Central

    2013-01-01

    Introduction Controversies still exists within the research fraternity on the form and level of incentives, compensation and reimbursement to study participants in resource-constrained settings. While most research activities contribute significantly to advancement of mankind, little has been considered in rewarding directly the research participants from resource-constrained areas. Methods A study was conducted in Zimbabwe to investigate views and expectations of various stakeholders on study participation incentives, compensation and reimbursement issues. Data was collected using various methods including a survey of about 1,008 parents/guardians of school children participating in various immunological cohort studies and parasitology surveys. Community advisory boards (CABs) at 9 of the sites were also consulted. Further, information was gathered during discussions held at a basic research ethics training workshop. The workshop had 45 participants that including 40 seasoned Zimbabwean researchers and 5 international research collaborators. Results About 90% (907) of the study participants and guardians expected compensation of reasonable value, in view of the researchers' value and comparison to other sites regardless of economic status of the community. During discussion with researchers at a basic ethics training workshop, about 80% (32) believed that decisions on level of compensation should be determined by the local research ethics committees. While, the few international research collaborators were of the opinion that compensation should be in accordance with local guidelines, and incentives should be in line with funding. Both the CAB members and study participants expressed that there should be a clear distinction between study incentive and compensation accorded to individual and community expectations on benefits from studies. However, CABs expressed that their suggestions on incentives and compensation are often moderated by the regulatory authorities

  5. A Rapid and Low-Cost PCR Thermal Cycler for Low Resource Settings

    PubMed Central

    Wong, Grace; Wong, Isaac; Chan, Kamfai; Hsieh, Yicheng; Wong, Season

    2015-01-01

    Background Many modern molecular diagnostic assays targeting nucleic acids are typically confined to developed countries or to the national reference laboratories of developing-world countries. The ability to make technologies for the rapid diagnosis of infectious diseases broadly available in a portable, low-cost format would mark a revolutionary step forward in global health. Many molecular assays are also developed based on polymerase chain reactions (PCR), which require thermal cyclers that are relatively heavy (>20 pounds) and need continuous electrical power. The temperature ramping speed of most economical thermal cyclers are relatively slow (2 to 3°C/s) so a polymerase chain reaction can take 1 to 2 hours. Most of all, these thermal cyclers are still too expensive ($2k to $4k) for low-resource setting uses. Methodology/Principal Findings In this article, we demonstrate the development of a low-cost and rapid water bath based thermal cycler that does not require active temperature control or continuous power supply during PCR. This unit costs $130 to build using commercial off-the-shelf items. The use of two or three vacuum-insulated stainless-steel Thermos food jars containing heated water (for denaturation and annealing/extension steps) and a layer of oil on top of the water allow for significantly stabilized temperatures for PCR to take place. Using an Arduino-based microcontroller, we automate the “archaic” method of hand-transferring PCR tubes between water baths. Conclusions/Significance We demonstrate that this innovative unit can deliver high speed PCR (17 s per PCR cycle) with the potential to go beyond the 1,522 bp long amplicons tested in this study and can amplify from templates down to at least 20 copies per reaction. The unit also accepts regular PCR tubes and glass capillary tubes. The PCR efficiency of our thermal cycler is not different from other commercial thermal cyclers. When combined with a rapid nucleic acid detection approach

  6. Benefits and challenges of starting a new therapeutic apheresis service in a resource-constrained setting.

    PubMed

    Arogundade, Fatiu A; Sanusi, Abubakr A; Oguntola, Stephen O; Omotoso, Bolanle A; Abdel-Rahman, Emaad M; Akinsola, Adewale; Balogun, Rasheed A

    2014-08-01

    Therapeutic apheresis (TA) refers to a group of extracorporeal blood treatment modalities with clinical indications for which the clinicians' knowledge, availability and applicability vary widely worldwide. Therapeutic plasma exchange (TPE), the most common TA technique, is neither readily available nor affordable in many parts of Africa. This article focuses on the challenges of starting a TPE program in a resource-constrained economy and the result of a survey of Nigerian nephrology professionals on TPE. A critical appraisal of published manuscripts from Nigeria on TA was undertaken to assess uses, methods, and challenges encountered followed by a survey of the perceptions of Nigerian nephrology professionals on TPE. Survey results: 56.7% of respondents had very little or no knowledge of TPE; 40.5% moderate and only 2.7% admitting to having a good knowledge. Only 18.9% of respondents have ever participated or observed a TPE procedure with the remaining 81.1% not having any exposure to the procedure. A vast majority of the respondents 97.3% felt they needed better exposure and training in TPE and its applications. Among consultants, 56% had little knowledge, 88% had never participated or observed the TPE procedure, and 94% felt they needed better exposure and training. There is significant limitation in accessibility, availability, and use of TPE in Nigeria; knowledge of TPE and its applications is minimal among nephrology professionals. Efforts should be concentrated on improving the knowledge and availability of TPE in resource-constrained economy like Nigeria. Centers that would be able to manage cases requiring TA should be developed. PMID:24832211

  7. Intelligent self-organization methods for wireless ad hoc sensor networks based on limited resources

    NASA Astrophysics Data System (ADS)

    Hortos, William S.

    2006-05-01

    A wireless ad hoc sensor network (WSN) is a configuration for area surveillance that affords rapid, flexible deployment in arbitrary threat environments. There is no infrastructure support and sensor nodes communicate with each other only when they are in transmission range. To a greater degree than the terminals found in mobile ad hoc networks (MANETs) for communications, sensor nodes are resource-constrained, with limited computational processing, bandwidth, memory, and power, and are typically unattended once in operation. Consequently, the level of information exchange among nodes, to support any complex adaptive algorithms to establish network connectivity and optimize throughput, not only deplete those limited resources and creates high overhead in narrowband communications, but also increase network vulnerability to eavesdropping by malicious nodes. Cooperation among nodes, critical to the mission of sensor networks, can thus be disrupted by the inappropriate choice of the method for self-organization. Recent published contributions to the self-configuration of ad hoc sensor networks, e.g., self-organizing mapping and swarm intelligence techniques, have been based on the adaptive control of the cross-layer interactions found in MANET protocols to achieve one or more performance objectives: connectivity, intrusion resistance, power control, throughput, and delay. However, few studies have examined the performance of these algorithms when implemented with the limited resources of WSNs. In this paper, self-organization algorithms for the initiation, operation and maintenance of a network topology from a collection of wireless sensor nodes are proposed that improve the performance metrics significant to WSNs. The intelligent algorithm approach emphasizes low computational complexity, energy efficiency and robust adaptation to change, allowing distributed implementation with the actual limited resources of the cooperative nodes of the network. Extensions of the

  8. Resource limitation of phytoplankton growth in the Crozet Basin, Subantarctic Southern Ocean

    NASA Astrophysics Data System (ADS)

    Sedwick, P. N.; Blain, S.; Quéguiner, B.; Griffiths, F. B.; Fiala, M.; Bucciarelli, E.; Denis, M.

    In January-February 1999, we performed shipboard iron- and macronutrient-addition experiments in the Crozet Basin, Indian sector of the Subantarctic Southern Ocean, to evaluate the sufficiency of ambient iron and macronutrient concentrations for algal growth. Experiments were conducted with near-surface seawater collected from three locations in a narrow latitudinal band characterized by relatively low algal biomass (<0.7 μg l -1 chlorophyll a), low dissolved iron concentrations (<0.33 nM), and strong meridional gradients in temperature, salinity and macronutrient concentrations: (1) the Polar Frontal Zone (PFZ) near 46°S, 65°E (˜19 μM nitrate and 1.2 μM silicic acid); (2) the confluence of the Subantarctic and Subtropical Fronts (SAF/STF) near 44°12'S, 63°23'E (˜5.4 μM nitrate and 0.5 μM silicic acid); and (3) the southern Subtropical Zone (STZ) near 43°18'S, 62°31'E (<0.1 μM nitrate and ˜1.4 μM silicic acid). Our experimental results reveal three distinct regimes of resource limitation of phytoplankton growth. In the PFZ, iron availability exerted the primary limitation on nitrate drawdown and biomass accumulation, thus community growth, with silicic acid availability exerting a secondary limitation on diatom growth and biogenic silica production. Within the SAF/STF, iron deficiency was also the primary limitation on algal community growth; however, here we observed evidence of secondary limitation of nitrate drawdown and biomass accumulation by silicic acid deficiency, via control of algal community structure—such that iron addition preferentially stimulated the growth of non-diatom nanoplankton—suggesting that the algal community was poised close to co-limitation by iron and silicic acid. As expected, our experimental results indicate that macronutrients (nitrate/phosphate) were the primary limitation on community growth in the STZ waters; however, our results also suggest that iron deficiency imposed a significant secondary limitation on

  9. A new method to estimate mortality in crisis-affected and resource-poor settings: validation study

    PubMed Central

    Roberts, Bayard; Morgan, Oliver W; Sultani, Mohammed Ghaus; Nyasulu, Peter; Rwebangila, Sunday; Myatt, Mark; Sondorp, Egbert; Chandramohan, Daniel; Checchi, Francesco

    2010-01-01

    Background Data on mortality rates are crucial to guide health interventions in crisis-affected and resource-poor settings. The methods currently available to collect mortality data in such settings feature important methodological limitations. We developed and validated a new method to provide near real-time mortality estimates in such settings. Methods We selected four study sites: Kabul, Afghanistan; Mae La refugee camp, Thailand; Chiradzulu District, Malawi; and Lugufu and Mtabila refugee camps, Tanzania. We recorded information about all deaths in a 60-day period by asking key community informants and decedents’ next of kin to refer interviewers to bereaved households. We used the total number of deaths and population estimates to calculate mortality rates for 60- and 30-day periods. For validation we compared these rates with a best estimate of mortality using capture–recapture analysis with two further independent lists of deaths. Results The population covered by the new method was 76 476 persons in Kabul, 43 794 in Mae La camp, 54 418 in Chiradzulu District and 80 136 in the Tanzania camps. The informant method showed moderate sensitivity (55.0% in Kabul, 64.0% in Mae La, 72.5% in Chiradzulu and 67.7% in Tanzania), but performed better than the active surveillance system in the Tanzania refugee camps. Conclusions The informant method currently features moderate sensitivity for accurately assessing mortality, but warrants further development, particularly considering its advantages over current options (ease of implementation and analysis and near-real estimates of mortality rates). Strategies should be tested to improve the performance of the informant method. PMID:21044978

  10. Spatial distribution of limited resources and local density regulation in juvenile Atlantic salmon.

    PubMed

    Finstad, Anders G; Einum, Sigurd; Ugedal, Ola; Forseth, Torbjørn

    2009-01-01

    1. Spatial heterogeneity of resources may influence competition among individuals and thus have a fundamental role in shaping population dynamics and carrying capacity. In the present study, we identify shelter opportunities as a limiting resource for juvenile Atlantic salmon (Salmo salar L.). Experimental and field studies are combined in order to demonstrate how the spatial distribution of shelters may influence population dynamics on both within and among population scales. 2. In closed experimental streams, fish performance scaled negatively with decreasing shelter availability and increasing densities. In contrast, the fish in open stream channels dispersed according to shelter availability and performance of fish remaining in the streams did not depend on initial density or shelters. 3. The field study confirmed that spatial variation in densities of 1-year-old juveniles was governed both by initial recruit density and shelter availability. Strength of density-dependent population regulation, measured as carrying capacity, increased with decreasing number of shelters. 4. Nine rivers were surveyed for spatial variation in shelter availability and increased shelter heterogeneity tended to decrease maximum observed population size (measured using catch statistics of adult salmon as a proxy). 5. Our studies highlight the importance of small-scale within-population spatial structure in population dynamics and demonstrate that not only the absolute amount of limiting resources but also their spatial arrangement can be an important factor influencing population carrying capacity. PMID:18808436

  11. Oculomotor responses and visuospatial perceptual judgments compete for common limited resources

    PubMed Central

    Tibber, Marc S.; Grant, Simon; Morgan, Michael J.

    2010-01-01

    While there is evidence for multiple spatial and attentional maps in the brain it is not clear to what extent visuoperceptual and oculomotor tasks rely on common neural representations and attentional mechanisms. Using a dual-task interference paradigm we tested the hypothesis that eye movements and perceptual judgments made to simultaneously presented visuospatial information compete for shared limited resources. Observers undertook judgments of stimulus collinearity (perceptual extrapolation) using a pointer and Gabor patch and/or performed saccades to a peripheral dot target while their eye movements were recorded. In addition, observers performed a non-spatial control task (contrast discrimination), matched for task difficulty and stimulus structure, which on the basis of previous studies was expected to represent a lesser load on putative shared resources. Greater mutual interference was indeed found between the saccade and extrapolation task pair than between the saccade and contrast discrimination task pair. These data are consistent with visuoperceptual and oculomotor responses competing for common limited resources as well as spatial tasks incurring a relatively high attentional cost. PMID:20053112

  12. Setting limits: Using air pollution thresholds to protect and restore U.S. ecosystems

    USGS Publications Warehouse

    Fenn, M.E.; Lambert, K.F.; Blett, T.F.; Burns, Douglas A.; Pardo, L.H.; Lovett, Gary M.; Haeuber, R. A.; Evers, D.C.; Driscoll, C.T.; Jeffries, D.S.

    2011-01-01

    More than four decades of research provide unequivocal evidence that sulfur, nitrogen, and mercury pollution have altered, and will continue to alter, our nation's lands and waters. The emission and deposition of air pollutants harm native plants and animals, degrade water quality, affect forest productivity, and are damaging to human health. Many air quality policies limit emissions at the source but these control measures do not always consider ecosystem impacts. Air pollution thresholds at which ecological effects are observed, such as critical loads, are effective tools for assessing the impacts of air pollution on essential ecosystem services and for informing public policy. U.S. ecosystems can be more effectively protected and restored by using a combination of emissions-based approaches and science-based thresholds of ecosystem damage. Based on the results of a comprehensive review of air pollution thresholds, we conclude: ??? Ecosystem services such as air and water purification, decomposition and detoxification of waste materials, climate regulation, regeneration of soil fertility, production and biodiversity maintenance, as well as crop, timber and fish supplies are impacted by deposition of nitrogen, sulfur, mercury and other pollutants. The consequences of these changes may be difficult or impossible to reverse as impacts cascade throughout affected ecosystems. ??? The effects of too much nitrogen are common across the U.S. and include altered plant and lichen communities, enhanced growth of invasive species, eutrophication and acidification of lands and waters, and habitat deterioration for native species, including endangered species. ??? Lake, stream and soil acidification is widespread across the eastern United States. Up to 65% of lakes within sensitive areas receive acid deposition that exceeds critical loads. ??? Mercury contamination adversely affects fish in many inland and coastal waters. Fish consumption advisories for mercury exist in all 50

  13. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting.

    PubMed Central

    Molyneux, Elizabeth; Ahmad, Shafique; Robertson, Ann

    2006-01-01

    PROBLEM: Early assessment, prioritization for treatment and management of sick children attending a health service are critical to achieving good outcomes. Many hospitals in developing countries see large numbers of patients and have few staff, so patients often have to wait before being assessed and treated. APPROACH: We present the example of a busy Under-Fives Clinic that provided outpatient services, immunizations and treatment for medical emergencies. The clinic was providing an inadequate service resulting in some inappropriate admissions and a high case-fatality rate. We assessed the deficiencies and sought resources to improve services. LOCAL SETTING: A busy paediatric outpatient clinic in a public tertiary care hospital in Blantyre, Malawi. RELEVANT CHANGES: The main changes we made were to train staff in emergency care and triage, improve patient flow through the department and to develop close cooperation between inpatient and outpatient services. Training coincided with a restructuring of the physical layout of the department. The changes were put in place when the department reopened in January 2001. LESSONS LEARNED: Improvements in the process and delivery of care and the ability to prioritize clinical management are essential to good practice. Making the changes described above has streamlined the delivery of care and led to a reduction in inpatient mortality from 10-18% before the changes were made (before 2001) to 6-8% after. PMID:16628305

  14. Using behavior change to reduce child lead exposure in resource-poor settings: a formative study.

    PubMed

    Feit, M N; Mathee, A; Harpham, T; Barnes, B R

    2014-12-01

    The objective of this formative research was to explore the acceptability and feasibility of changing housekeeping behaviors as a low-cost approach that may reduce childhood lead exposure in Johannesburg, South Africa. Using the Trials of Improved Practices (TIPs) methodology, modified housekeeping behaviors were negotiated with participants who chose the behaviors they wanted to try and then performed them in their homes over 4 weeks. Researchers interviewed them at the end of the month to understand their experience of trying out the behaviors. The modified behaviors offered to each participant were as follows: cleaning window sills with detergent and water, cleaning window sills more frequently, mopping floors with two buckets (one with soapy water for washing and one with clean water for rinsing), mopping floors more frequently, dusting surfaces with detergent and water and dusting surfaces more frequently. Participants found cleaning window sills with soap and water and cleaning them more often the most acceptable and feasible of behavior modifications. Environmental samples showed a significant reduction in lead dust on window sills. These findings can assist in the development of acceptable and feasible medium-term interventions to reduce childhood lead exposure in resource-poor settings until more robust health policies are implemented. PMID:25214512

  15. Evaluating the impact of pulse oximetry on childhood pneumonia mortality in resource-poor settings.

    PubMed

    Floyd, Jessica; Wu, Lindsey; Hay Burgess, Deborah; Izadnegahdar, Rasa; Mukanga, David; Ghani, Azra C

    2015-12-01

    It is estimated that pneumonia is responsible for 15% of childhood deaths worldwide. Recent research has shown that hypoxia and malnutrition are strong predictors of mortality in children hospitalized for pneumonia. It is estimated that 15% of children under 5 who are hospitalized for pneumonia have hypoxaemia and that around 1.5 million children with severe pneumonia require oxygen treatment each year. We developed a deterministic compartmental model that links the care pathway to disease progression to assess the impact of introducing pulse oximetry as a prognostic tool to distinguish severe from non-severe pneumonia in under-5 year olds across 15 countries with the highest burden worldwide. We estimate that, assuming access to supplemental oxygen, pulse oximetry has the potential to avert up to 148,000 deaths if implemented across the 15 countries. By contrast, integrated management of childhood illness alone has a relatively small impact on mortality owing to its low sensitivity. Pulse oximetry can significantly increase the incidence of correctly treated severe cases as well as reduce the incidence of incorrect treatment with antibiotics. We also found that the combination of pulse oximetry with integrated management of childhood illness is highly cost-effective, with median estimates ranging from US$2.97 to $52.92 per disability-adjusted life year averted in the 15 countries analysed. This combination of substantial burden reduction and favourable cost-effectiveness makes pulse oximetry a promising candidate for improving the prognosis for children with pneumonia in resource-poor settings.

  16. Low-cost tools for diagnosing and monitoring HIV infection in low-resource settings

    PubMed Central

    Wu, Grace

    2012-01-01

    Abstract Low-cost technologies to diagnose and monitor human immunodeficiency virus (HIV) infection in developing countries are a major subject of current research and health care in the developing world. With the great need to increase access to affordable HIV monitoring services in rural areas of developing countries, much work has been focus on the development of point-of-care technologies that are affordable, robust, easy to use, portable and of sufficient quantitative accuracy to enable clinical decision-making. For diagnosis of HIV infection, some low-cost tests, such as lateral flow tests and enzyme-linked immunosorbent assays, are already in place and well established. However, portable quantitative tests for rapid HIV monitoring at the point of care have only recently been introduced to the market. In this review, we discuss low-cost tests for HIV diagnosis and monitoring in low-resource settings, including promising technologies for use at the point of care, that are available or close to market. PMID:23284197

  17. Distributed event-triggered consensus strategy for multi-agent systems under limited resources

    NASA Astrophysics Data System (ADS)

    Noorbakhsh, S. Mohammad; Ghaisari, Jafar

    2016-01-01

    The paper proposes a distributed structure to address an event-triggered consensus problem for multi-agent systems which aims at concurrent reduction in inter-agent communication, control input actuation and energy consumption. Following the proposed approach, asymptotic convergence of all agents to consensus requires that each agent broadcasts its sampled-state to the neighbours and updates its control input only at its own triggering instants, unlike the existing related works. Obviously, it decreases the network bandwidth usage, sensor energy consumption, computation resources usage and actuator wears. As a result, it facilitates the implementation of the proposed consensus protocol in the real-world applications with limited resources. The stability of the closed-loop system under an event-based protocol is proved analytically. Some numerical results are presented which confirm the analytical discussion on the effectiveness of the proposed design.

  18. Staff development sessions. A strategy to facilitate nursing staff education with limited teaching resources.

    PubMed

    Kirsivali-Farmer, K

    1994-01-01

    A reduction in clinical nursing educator positions resulted in the need for the Department of Nursing to continue to facilitate the professional development of nursing staff members with limited resources. In this article, the author describes a program, developed by the central Nursing Education Department at The Toronto Hospital, that was offered to clinical resource nurses, nurse managers, patient care coordinators, and preceptors. These individuals could use the information to promote the development of nursing staff members at the unit level. Several topics were presented: self-directed learning, needs assessment, behavioral objectives, lesson plans, teaching strategies, educational program evaluation, and clinical evaluation. Program evaluations were positive, and 45% of the respondents indicated they had the opportunity to apply what they learned. PMID:7807245

  19. Global women's health is more than maternal health: a review of gynecology care needs in low-resource settings.

    PubMed

    Robinson, Nuriya; Stoffel, Cynthia; Haider, Sadia

    2015-03-01

    Women's health care efforts in low-resource settings are often focused primarily on prenatal and obstetric care. However, women all over the world experience significant morbidity and mortality related to cervical cancer, sexually transmitted infections, and urogynecologic conditions as well as gynecologic care provision including insufficient and ineffective family planning services. Health care providers with an interest in clinical care in low-resource settings should be aware of the scope of the burden of gynecologic issues and strategies in place to combat the problems. This review article discusses the important concerns both in the developing world as well as highlights similar disparities that exist in the United States by women's age, race and ethnicity, and socioeconomic status. Ultimately, this review article aims to inform and update health care providers on critical gynecologic issues in low-resource settings. PMID:25769435

  20. Pollen limitation and its influence on natural selection through seed set.

    PubMed

    Bartkowska, M P; Johnston, M O

    2015-11-01

    Stronger pollen limitation should increase competition among plants, leading to stronger selection on traits important for pollen receipt. The few explicit tests of this hypothesis, however, have provided conflicting support. Using the arithmetic relationship between these two quantities, we show that increased pollen limitation will automatically result in stronger selection (all else equal) although other factors can alter selection independently of pollen limitation. We then tested the hypothesis using two approaches. First, we analysed the published studies containing information on both pollen limitation and selection. Second, we explored how natural selection measured in one Ontario population of Lobelia cardinalis over 3 years and two Michigan populations in 1 year relates to pollen limitation. For the Ontario population, we also explored whether pollinator-mediated selection is related to pollen limitation. Consistent with the hypothesis, we found an overall positive relationship between selection strength and pollen limitation both among species and within L. cardinalis. Unexpectedly, this relationship was found even for vegetative traits among species, and was not found in L. cardinalis for pollinator-mediated selection on nearly all trait types.

  1. Quality of Life Among Individuals with HIV Starting Antiretroviral Therapy in Diverse Resource-Limited Areas of the World

    PubMed Central

    Hendriksen, Ellen S.; Smeaton, Laura; Celentano, David D.; Hosseinipour, Mina C.; Barnett, Ronald; Guanira, Juan; Flanigan, Timothy; Kumarasamy, N.; Klingman, Karin; Campbell, Thomas

    2011-01-01

    As Antiretroviral Therapy (ART) is scaled up in low- and middle-income countries, it is important to understand Quality of Life (QOL) correlates including disease severity and person characteristics and to determine the extent of between-country differences among those with HIV. QOL and medical data were collected from 1,563 of the 1,571 participants at entry into a randomized clinical trial of ART conducted in the U.S. (n = 203) and 8 resource-limited countries (n = 1,360) in the Caribbean, South America, Asia, and Africa. Participants were interviewed prior to initiation of ART using a modified version of the ACTG SF-21, a health-related QOL measure including 8 subscales: general health perception, physical functioning, role functioning, social functioning, cognitive functioning, pain, mental health, and energy/fatigue. Other measures included demographics, CD4+ lymphocyte count, plasma HIV-1 RNA viral load. Higher quality of life in each of the 8 QOL subscales was associated with higher CD4+ lymphocyte category. General health perception, physical functioning, role functioning, and energy/fatigue varied by plasma HIV-1 RNA viral load categories. Each QOL subscale included significant variation by country. Only the social functioning subscale varied by sex, with men having greater impairments than women, and only the physical functioning subscale varied by age category. This was the first large-scale international ART trial to conduct a standardized assessment of QOL in diverse international settings, thus demonstrating that implementation of the behavioral assessment was feasible. QOL indicators at study entry varied with disease severity, demographics, and country. The relationship of these measures to treatment outcomes can and should be examined in clinical trials of ART in resource-limited settings using similar methodologies. PMID:21499794

  2. Quality of life among individuals with HIV starting antiretroviral therapy in diverse resource-limited areas of the world.

    PubMed

    Safren, Steven A; Hendriksen, Ellen S; Smeaton, Laura; Celentano, David D; Hosseinipour, Mina C; Barnett, Ronald; Guanira, Juan; Flanigan, Timothy; Kumarasamy, N; Klingman, Karin; Campbell, Thomas

    2012-02-01

    As Antiretroviral Therapy (ART) is scaled up in low- and middle-income countries, it is important to understand Quality of Life (QOL) correlates including disease severity and person characteristics and to determine the extent of between-country differences among those with HIV. QOL and medical data were collected from 1,563 of the 1,571 participants at entry into a randomized clinical trial of ART conducted in the U.S. (n = 203) and 8 resource-limited countries (n = 1,360) in the Caribbean, South America, Asia, and Africa. Participants were interviewed prior to initiation of ART using a modified version of the ACTG SF-21, a health-related QOL measure including 8 subscales: general health perception, physical functioning, role functioning, social functioning, cognitive functioning, pain, mental health, and energy/fatigue. Other measures included demographics, CD4+ lymphocyte count, plasma HIV-1 RNA viral load. Higher quality of life in each of the 8 QOL subscales was associated with higher CD4+ lymphocyte category. General health perception, physical functioning, role functioning, and energy/fatigue varied by plasma HIV-1 RNA viral load categories. Each QOL subscale included significant variation by country. Only the social functioning subscale varied by sex, with men having greater impairments than women, and only the physical functioning subscale varied by age category. This was the first large-scale international ART trial to conduct a standardized assessment of QOL in diverse international settings, thus demonstrating that implementation of the behavioral assessment was feasible. QOL indicators at study entry varied with disease severity, demographics, and country. The relationship of these measures to treatment outcomes can and should be examined in clinical trials of ART in resource-limited settings using similar methodologies. PMID:21499794

  3. A comparison of limit setting methods for the on-off problem

    NASA Astrophysics Data System (ADS)

    Rolke, Wolfgang A.

    2016-01-01

    We study the frequentist properties of confidence intervals found with various methods previously proposed for the On-Off problem. We derive explicit formulas for the limits and calculate the true coverage and the expected lengths of these methods.

  4. Multidisciplinary predialysis programs: quantification and limitations of their impact on patient outcomes in two Canadian settings.

    PubMed

    Levin, A; Lewis, M; Mortiboy, P; Faber, S; Hare, I; Porter, E C; Mendelssohn, D C

    1997-04-01

    A 1993 National Institutes of Health Consensus statement stressed the importance of early medical intervention in predialysis populations. Given the need for evidence-based practice, we report the outcomes of predialysis programs in two major Canadian cities. The purpose of this report was to determine whether the institution of a multidisciplinary predialysis program is of benefit to patients, and to analyze those factors that are important in actualizing those benefits. Data from two different studies is presented: (1) a prospective, nonrandomized cohort study comparing patients who were or were not exposed to an ongoing multidisciplinary predialysis team (St Paul's Hospital) and (2) a retrospective review of outcomes before and after the institution of a predialysis program (The Toronto Hospital). Although created independently in major academic centers in Canada, the programs both aimed to reduce urgent dialysis starts, improve preparedness for dialysis, and improve resource utilization. The Vancouver study was able to demonstrate significantly fewer urgent dialysis starts (13% v 35%; P < 0.05), more outpatient training (76% v 43%; P < 0.05), and less hospital days in the first month of dialysis (6.5 days v 13.5 days; P < 0.05). Cost savings of the program patients in 1993 are conservatively estimated to be $173,000 (Canadian dollars) or over $4,000 per patient. The Toronto study demonstrated success in predialysis access creation (86.3% of patients), but could not realize any benefit in terms of elective dialysis initiation due to well-documented hemodialysis resource constraints. We conclude that an approach to predialysis patients involving a multidisciplinary team can have a positive impact on quantitative outcomes, but essential elements for success include (1) early referral to a nephrology center, (2) adequate resources for dedicated predialysis program staff and infrastructure, and (3) available resources for patients with end-stage renal disease (ESRD

  5. Evaluating the impact of pulse oximetry on childhood pneumonia mortality in resource-poor settings.

    PubMed

    Floyd, Jessica; Wu, Lindsey; Hay Burgess, Deborah; Izadnegahdar, Rasa; Mukanga, David; Ghani, Azra C

    2015-12-01

    It is estimated that pneumonia is responsible for 15% of childhood deaths worldwide. Recent research has shown that hypoxia and malnutrition are strong predictors of mortality in children hospitalized for pneumonia. It is estimated that 15% of children under 5 who are hospitalized for pneumonia have hypoxaemia and that around 1.5 million children with severe pneumonia require oxygen treatment each year. We developed a deterministic compartmental model that links the care pathway to disease progression to assess the impact of introducing pulse oximetry as a prognostic tool to distinguish severe from non-severe pneumonia in under-5 year olds across 15 countries with the highest burden worldwide. We estimate that, assuming access to supplemental oxygen, pulse oximetry has the potential to avert up to 148,000 deaths if implemented across the 15 countries. By contrast, integrated management of childhood illness alone has a relatively small impact on mortality owing to its low sensitivity. Pulse oximetry can significantly increase the incidence of correctly treated severe cases as well as reduce the incidence of incorrect treatment with antibiotics. We also found that the combination of pulse oximetry with integrated management of childhood illness is highly cost-effective, with median estimates ranging from US$2.97 to $52.92 per disability-adjusted life year averted in the 15 countries analysed. This combination of substantial burden reduction and favourable cost-effectiveness makes pulse oximetry a promising candidate for improving the prognosis for children with pneumonia in resource-poor settings. PMID:26633766

  6. Influenza transmission during extreme indoor conditions in a low-resource tropical setting

    NASA Astrophysics Data System (ADS)

    Tamerius, James; Ojeda, Sergio; Uejio, Christopher K.; Shaman, Jeffrey; Lopez, Brenda; Sanchez, Nery; Gordon, Aubree

    2016-08-01

    Influenza transmission occurs throughout the planet across wide-ranging environmental conditions. However, our understanding of the environmental factors mediating transmission is evaluated using outdoor environmental measurements, which may not be representative of the indoor conditions where influenza is transmitted. In this study, we examined the relationship between indoor environment and influenza transmission in a low-resource tropical population. We used a case-based ascertainment design to enroll 34 households with a suspected influenza case and then monitored households for influenza, while recording indoor temperature and humidity data in each household. We show that the indoor environment is not commensurate with outdoor conditions and that the relationship between indoor and outdoor conditions varies significantly across homes. We also show evidence of influenza transmission in extreme indoor environments. Specifically, our data suggests that indoor environments averaged 29 °C, 18 g/kg specific humidity, and 68 % relative humidity across 15 transmission events observed. These indoor settings also exhibited significant temporal variability with temperatures as high as 39 °C and specific and relative humidity increasing to 22 g/kg and 85 %, respectively, during some transmission events. However, we were unable to detect differences in the transmission efficiency by indoor temperature or humidity conditions. Overall, these results indicate that laboratory studies investigating influenza transmission and virus survival should increase the range of environmental conditions that they assess and that observational studies investigating the relationship between environment and influenza activity should use caution using outdoor environmental measurements since they can be imprecise estimates of the conditions that mediate transmission indoors.

  7. Optimizing outpatient serial sputum colony counting for studies of tuberculosis treatment in resource-poor settings.

    PubMed

    Sloan, Derek J; Corbett, Elizabeth L; Butterworth, Anthony E; Mwandumba, Henry C; Khoo, Saye H; Mdolo, Aaron; Shani, Doris; Kamdolozi, Mercy; Allen, Jenny; Mitchison, Denis A; Coleman, David J; Davies, Geraint R

    2012-07-01

    Serial Sputum Colony Counting (SSCC) is an important technique in clinical trials of new treatments for tuberculosis (TB). Quantitative cultures on selective Middlebrook agar are used to calculate the rate of bacillary elimination from sputum collected from patients at different time points during the first 2 months of therapy. However, the procedure can be complicated by high sample contamination rates. This study, conducted in a resource-poor setting in Malawi, assessed the ability of different antifungal drugs in selective agar to reduce contamination. Overall, 229 samples were studied and 15% to 27% were contaminated. Fungal organisms were particularly implicated, and samples collected later in treatment were at particular risk (P < 0.001). Amphotericin B (AmB) is the standard antifungal drug used on SSCC plates at a concentration of 10 mg/ml. On selective Middlebrook 7H10 plates, AmB at 30 mg/ml reduced sample contamination by 17% compared with AmB at 10 mg/ml. The relative risk of contamination using AmB at 10 mg/ml was 1.79 (95% confidence interval [CI], 1.25 to 3.55). On Middlebrook 7H11 plates, a combination of AmB at 10 mg/ml and carbendazim at 50 mg/ml was associated with 10% less contamination than AmB at 30 mg/ml. The relative risk of contamination with AmB at 30 mg/ml was 1.79 (95% CI, 1.01 to 3.17). Improved antifungal activity was accompanied by a small reduction in bacillary counts, but this did not affect modeling of bacillary elimination. In conclusion, a combination of AmB and carbendazim optimized the antifungal activity of selective media for growth of TB. We recommend this method to reduce contamination rates and improve SSCC studies in African countries where the burden of TB is highest.

  8. Scale-up of Routine Viral Load Testing in Resource-Poor Settings: Current and Future Implementation Challenges

    PubMed Central

    Roberts, Teri; Cohn, Jennifer; Bonner, Kimberly; Hargreaves, Sally

    2016-01-01

    Despite immense progress in antiretroviral therapy (ART) scale-up, many people still lack access to basic standards of care, with our ability to meet the Joint United Nations Programme on HIV/AIDS 90-90-90 treatment targets for HIV/AIDS dependent on dramatic improvements in diagnostics. The World Health Organization recommends routine monitoring of ART effectiveness using viral load (VL) testing at 6 months and every 12 months, to monitor treatment adherence and minimize failure, and will publish its VL toolkit later this year. However, the cost and complexity of VL is preventing scale-up beyond developed countries and there is a lack of awareness among clinicians as to the long-term patient benefits and its role in prolonging the longevity of treatment programs. With developments in this diagnostic field rapidly evolving—including the recent improvements for accurately using dried blood spots and the imminent appearance to the market of point-of-care technologies offering decentralized diagnosis—we describe current barriers to VL testing in resource-limited settings. Effective scale-up can be achieved through health system and laboratory system strengthening and test price reductions, as well as tackling multiple programmatic and funding challenges. PMID:26743094

  9. Detection and Management of Diabetes during Pregnancy in Low Resource Settings: Insights into Past and Present Clinical Practices

    PubMed Central

    Delamou, Alexandre; Belaid, Loubna; De Brouwere, Vincent

    2016-01-01

    Background. Timely and adequate treatment is important to limit complications of diabetes affecting pregnancy, but there is a lack of knowledge on how these women are managed in low resource settings. Objective. To identify modalities of gestational diabetes detection and management in low and lower middle income countries. Methods. We conducted a scoping review of published literature and searched the databases PubMed, Web of Science, Embase, and African Index Medicus. We included all articles published until April 24, 2016, containing information on clinical practices of detection and management of gestational diabetes irrespective of publication date or language. Results. We identified 23 articles mainly from Asia and sub-Saharan Africa. The majority of studies were conducted in large tertiary care centers and hospital admission was reported in a third of publications. Ambulatory follow-up was generally done by weekly to fortnightly visits, whereas self-monitoring of blood glucose was not the norm. The cesarean section rate for pregnancies affected by diabetes ranged between 20% and 89%. Referral of newborns to special care units was common. Conclusion. The variety of reported provider practices underlines the importance of promoting latest consensus guidelines on GDM screening and management and the dissemination of information regarding their implementation. PMID:27803934

  10. The Limitation of Species Range: A Consequence of Searching Along Resource Gradients

    PubMed Central

    Rowell, Jonathan T.

    2009-01-01

    Ecological modelers have long puzzled over the spatial distribution of species. The random walk or diffusive approach to dispersal has yielded important results for biology and mathematics, yet it has been inadequate in explaining all phenomenological features. Ranges can terminate non-smoothly absent a complementary shift in the characteristics of the environment. Also unexplained is the absence of a species from nearby areas of adequate, or even abundant, resources. In this paper, I show how local searching behavior - keyed to a density-dependent fitness - can limit the speed and extent of a species’ spread. In contrast to standard diffusive processes, pseudo-rational movement facilitates the clustering of populations. It also can be used to estimate the speed of an expanding population range, explain expansion stall, and provides a mechanism by which a population can colonize seemingly removed regions - biogeographic islands in a continental framework. Finally, I discuss the effect of resource degradation and different resource impact/utilization curves on the model. PMID:19303032

  11. Lethal combat over limited resources: testing the importance of competitors and kin.

    PubMed

    Innocent, Tabitha M; West, Stuart A; Sanderson, Jennifer L; Hyrkkanen, Nita; Reece, Sarah E

    2011-09-01

    Although most animals employ strategies to avoid costly escalation of conflict, the limitation of critical resources may lead to extreme contests and fatal fighting. Evolutionary theories predict that the occurrence and intensity of fights can be explained by resource value and the density and relatedness of competitors. However, the interaction between these factors and their relative importance often remains unclear; moreover, few systems allow all variables to be experimentally investigated, making tests of these theoretical predictions rare. Here, we use the parasitoid wasp Melittobia to test the importance of all these factors. In contrast to predictions, variation in contested resource value (female mates) and the relatedness of competitors do not influence levels of aggression. However, as predicted, fight intensity increased with competitor density and was not influenced by the greater cost of fighting at high density. Our results suggest that in the absence of kin recognition, indirectly altruistic behavior (spite) is unlikely to evolve, and in such circumstances, the scale of competition will strongly influence the amount of kin discrimination in the form of level of aggression as observed in Melittobia species.

  12. Multi sensor fusion framework for indoor-outdoor localization of limited resource mobile robots.

    PubMed

    Marín, Leonardo; Vallés, Marina; Soriano, Ángel; Valera, Ángel; Albertos, Pedro

    2013-10-21

    This paper presents a sensor fusion framework that improves the localization of mobile robots with limited computational resources. It employs an event based Kalman Filter to combine the measurements of a global sensor and an inertial measurement unit (IMU) on an event based schedule, using fewer resources (execution time and bandwidth) but with similar performance when compared to the traditional methods. The event is defined to reflect the necessity of the global information, when the estimation error covariance exceeds a predefined limit. The proposed experimental platforms are based on the LEGO Mindstorm NXT, and consist of a differential wheel mobile robot navigating indoors with a zenithal camera as global sensor, and an Ackermann steering mobile robot navigating outdoors with a SBG Systems GPS accessed through an IGEP board that also serves as datalogger. The IMU in both robots is built using the NXT motor encoders along with one gyroscope, one compass and two accelerometers from Hitecnic, placed according to a particle based dynamic model of the robots. The tests performed reflect the correct performance and low execution time of the proposed framework. The robustness and stability is observed during a long walk test in both indoors and outdoors environments.

  13. Multi sensor fusion framework for indoor-outdoor localization of limited resource mobile robots.

    PubMed

    Marín, Leonardo; Vallés, Marina; Soriano, Ángel; Valera, Ángel; Albertos, Pedro

    2013-01-01

    This paper presents a sensor fusion framework that improves the localization of mobile robots with limited computational resources. It employs an event based Kalman Filter to combine the measurements of a global sensor and an inertial measurement unit (IMU) on an event based schedule, using fewer resources (execution time and bandwidth) but with similar performance when compared to the traditional methods. The event is defined to reflect the necessity of the global information, when the estimation error covariance exceeds a predefined limit. The proposed experimental platforms are based on the LEGO Mindstorm NXT, and consist of a differential wheel mobile robot navigating indoors with a zenithal camera as global sensor, and an Ackermann steering mobile robot navigating outdoors with a SBG Systems GPS accessed through an IGEP board that also serves as datalogger. The IMU in both robots is built using the NXT motor encoders along with one gyroscope, one compass and two accelerometers from Hitecnic, placed according to a particle based dynamic model of the robots. The tests performed reflect the correct performance and low execution time of the proposed framework. The robustness and stability is observed during a long walk test in both indoors and outdoors environments. PMID:24152933

  14. Multi Sensor Fusion Framework for Indoor-Outdoor Localization of Limited Resource Mobile Robots

    PubMed Central

    Marín, Leonardo; Vallés, Marina; Soriano, Ángel; Valera, Ángel; Albertos, Pedro

    2013-01-01

    This paper presents a sensor fusion framework that improves the localization of mobile robots with limited computational resources. It employs an event based Kalman Filter to combine the measurements of a global sensor and an inertial measurement unit (IMU) on an event based schedule, using fewer resources (execution time and bandwidth) but with similar performance when compared to the traditional methods. The event is defined to reflect the necessity of the global information, when the estimation error covariance exceeds a predefined limit. The proposed experimental platforms are based on the LEGO Mindstorm NXT, and consist of a differential wheel mobile robot navigating indoors with a zenithal camera as global sensor, and an Ackermann steering mobile robot navigating outdoors with a SBG Systems GPS accessed through an IGEP board that also serves as datalogger. The IMU in both robots is built using the NXT motor encoders along with one gyroscope, one compass and two accelerometers from Hitecnic, placed according to a particle based dynamic model of the robots. The tests performed reflect the correct performance and low execution time of the proposed framework. The robustness and stability is observed during a long walk test in both indoors and outdoors environments. PMID:24152933

  15. How to Set up Oral Homework: A Case of Limited Technology

    ERIC Educational Resources Information Center

    Mendez, Elba

    2010-01-01

    Homework usually consists of the learners' written account of how they interpreted a task set by the teacher, and is generally defined as out-of-class assignments that are handed in for the instructor to grade. Learners may work individually or with partners to answer simple or challenging linguistic exercises, sketch out a mind map, or develop a…

  16. Space: A non-limiting resource in the niches of some abundant coral reef gastropods

    NASA Astrophysics Data System (ADS)

    Reichelt, R. E.

    1982-06-01

    Given the importance attributed to the occupation of space in benthic coral reef communities, this study asks the question: are any particular microhabitat types limiting resources for an assemblage of worm-eating gastropods on Heron reef (Great Barrier Reef). Microhabitat resource use was measured on three occasions, separated by 12 and 20-month periods. The gastropod populations were typical of those of other Indo-Pacific sites with respect to mean shell size and density. Fluctuations in species' size and density are assumed to have not significantly influenced availability of microhabitat resources. Gastropods occurred mainly in the structurally complex “refuge” microhabitats during the day and showed an increased abundance in smooth, exposed, “foraging” microhabitat nocturnally. Nassarius gaudiosus is the most extreme microhabitat specialist diurnally and the most extreme microhabitat generalist nocturnally. A similar, although less pronounced trend was exhibited by other gastropod species. Microhabitat niche overlap was high for Conus coronatus, C. miliaris, C. flavidus, Vasum turbinellus and N. gaudiosus at night and was also high during the day for all these species except N. gaudiosus, which showed little overlap with other gastropod species diurnally. Using gastropod abundance data from all samples, and independently derived microhabitat abundance data, multiple regression analysis demonstrated: 1) A significant relationship between the abundances of N. gaudiosus, C. coronatus, and C. flavidus and the abundance of microhabitat 2 (sand under rocks=“refuge”). 2) No positive association between gastropod abundance and the abundance of microhabitat 7a (thin layer of algal-bound sand on reef limestone). Only N. gaudiosus is abundant in microhabitat 2. Therefore it is concluded that, with some exceptions, microhabitat abundance does not have a significant influence, directly or indirectly, on gastropod abundance. It is possible that density

  17. ROBUST ESTIMATION OF MEAN AND VARIANCE USING ENVIRONMENTAL DATA SETS WITH BELOW DETECTION LIMIT OBSERVATIONS

    EPA Science Inventory

    Scientists, especially environmental scientists often encounter trace level concentrations that are typically reported as less than a certain limit of detection, L. Type 1, left-censored data arise when certain low values lying below L are ignored or unknown as they cannot be mea...

  18. An Economic Approach to Setting Contribution Limits in Qualified State-Sponsored Tuition Savings Plans.

    ERIC Educational Resources Information Center

    Ma, Jennifer; Warshawsky, Mark J.; Ameriks, John; Blohm, Julia A.

    This study used an expected utility framework with a mean-lower partial moment specification for investor utility to determine the asset allocation and the allowable contribution limits for qualified state-sponsored tuition savings plans. Given the assumptions about state policymakers' perceptions of investor utility, the study determined the…

  19. 12 CFR 714.9 - Are indirect leasing arrangements subject to the purchase of eligible obligation limit set forth...

    Code of Federal Regulations, 2010 CFR

    2010-01-01

    ... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Are indirect leasing arrangements subject to... Banks and Banking NATIONAL CREDIT UNION ADMINISTRATION REGULATIONS AFFECTING CREDIT UNIONS LEASING § 714.9 Are indirect leasing arrangements subject to the purchase of eligible obligation limit set...

  20. The Association of Parenting Style and Child Age with Parental Limit Setting and Adolescent MySpace Behavior

    ERIC Educational Resources Information Center

    Rosen, Larry D.; Cheever, Nancy A.; Carrier, L. Mark

    2008-01-01

    Parent and teen MySpace user pairs completed online surveys administered in June (N = 266) and September 2006 (N = 341) to assess relationships between parenting styles and limit setting and monitoring of online behaviors, the prevalence of Internet dangers and pre-teen and teen MySpace behaviors. Cross-comparison measures of MySpace usage,…

  1. Work-Family Conflict, Resources, and Role Set Density: Assessing Their Effects on Distress among Working Mothers

    ERIC Educational Resources Information Center

    Kulik, Liat; Liberman, Gabriel

    2013-01-01

    We explored the relationships between the experience of work-family conflict and levels of distress in the family and at work among a sample of 227 Israeli working mothers. We also examined how role set density (RSD, the number of roles they perform) and personal and environmental resources are related to the women's experience of distress.…

  2. Determinants and Management Outcomes of Pelvic Organ Prolapse in a Low Resource Setting

    PubMed Central

    Eleje, GU; Udegbunam, OI; Ofojebe, CJ; Adichie, CV

    2014-01-01

    Background: The last decade has seen significant progress in understanding of the pathophysiology, anatomy and management modalities of pelvic organ prolapse. A review of the way we manage this entity in a low resource setting has become necessary. Aim: The aim of the study is to determine the incidence, risk factors and management modalities of pelvic organ prolapse. Materials and Methods: A 5-year cross-sectional study with retrospective data collection of women who attended the gynecologic clinic in Nnamdi Azikiwe University Teaching Hospital, Nnewi, south-east Nigeria and were diagnosed of pelvic organ prolapse was made. Proforma was initially used for data collection before transfer to Epi-info 2008 (v 3.5.1; Epi Info, Centers for Disease Control and Prevention, Atlanta, GA) software. Results: There were 199 cases of pelvic organ prolapse, out of a total gynecologic clinic attendance of 3082, thus giving an incidence of 6.5%. The mean age was 55.5 (15.9) years with a significant association between prolapse and advanced age (P < 0.001). The age range was 22-80 years. The leading determinants were menopause, advanced age, multiparity, chronic increase in intra-abdominal pressure (IAP) and prolonged labor. Out of the 147 patients with uterine prolapse, majority, 60.5% (89/147) had third degree prolapse. Vaginal hysterectomy with pelvic floor repair was the most common surgery performed. The average duration of hospital stay following surgery was 6.8 (2.9) days and the most common complication was urinary tract infection, 13.5% (27/199). The recurrence rate was 13.5% (27/199). Most of the patients who presented initially with pelvic organ prolapse were lost to follow-up. Conclusion: The incidence of pelvic organ prolapse in this study was 6.5% and the leading determinants of pelvic organ prolapse were - multiparity, menopause, chronic increase in IAP and advanced age. Most were lost to follow-up and a lesser proportion was offered conservative management. Early

  3. Social construction and materiality: the limits of indeterminacy in therapeutic settings.

    PubMed

    Lannamann, J W

    1998-01-01

    By drawing parallels between the courtroom testimony of a Christian Science practitioner and an intersession conversation between systemic family therapists, I critique the abstract idealism of language-centered social constructionism. I argue that social constructionist inquiry that highlights the indeterminacy of meaning without a corresponding emphasis on the responsive embodied practices of family members glosses over the material conditions shaping the politics of interaction. The implications of this problem are discussed as they relate to the setting of family therapy, where social construction theory is often used to guide practical interventions.

  4. The Potential for Increasing Net Incomes on Limited-Resource Farms in Eastern Kentucky. Research Report 24.

    ERIC Educational Resources Information Center

    Stewart, Fred J.; And Others

    The study identified possibilities for improving farm incomes on limited-resource farms in eastern Kentucky. Objectives were to describe farm operations of full-time Appalachian farmers who had gross sales of less than $5,000 in 1972, estimate potential increases in net farm incomes from given resources, and identify nonresource constraints on…

  5. Progress in the development of paper-based diagnostics for low-resource point-of-care settings

    PubMed Central

    Byrnes, Samantha; Thiessen, Gregory; Fu, Elain

    2014-01-01

    This Review focuses on recent work in the field of paper microfluidics that specifically addresses the goal of translating the multistep processes that are characteristic of gold-standard laboratory tests to low-resource point-of-care settings. A major challenge is to implement multistep processes with the robust fluid control required to achieve the necessary sensitivity and specificity of a given application in a user-friendly package that minimizes equipment. We review key work in the areas of fluidic controls for automation in paper-based devices, readout methods that minimize dedicated equipment, and power and heating methods that are compatible with low-resource point-of-care settings. We also highlight a focused set of recent applications and discuss future challenges. PMID: