The importance of self-management for better treatment outcomes for HIV patients in a low-income setting: perspectives of HIV experts and service providers.

BACKGROUND: Self-management is the most important strategy to improve quality of life in patients with a chronic disease. Despite the increasing number of people living with HIV (PLWH) in low-income countries, very little research on self-management is conducted in this setting. The aim of this research is to understand the perspectives of service providers and experts on the importance of self-management for PLWH. METHODS: A systematizing expert interview type of qualitative methodology was used to gain the perspectives of experts and service providers. The study participants had experience in researching, managing, or providing HIV service in east and southern African (ESA) countries. All the interviews were audio recorded, transcribed, and translated to English. The quality of the transcripts was ensured by randomly checking the texts against the audio record. A thematic analysis approach supported by Atlas TI version 9 software. RESULT: PLWH face a variety of multi-dimensional problems thematized under contextual and process dimensions. The problems identified under the contextual dimension include disease-specific, facility-related, and social environment-related. Problems with individual origin, such as ignorance, outweighing beliefs over scientific issues, low self-esteem, and a lack of social support, were mostly highlighted under the process dimensions. Those problems have a deleterious impact on self-management, treatment outcomes, and the quality of life of PLWH. Low self-management is also a result of professional-centered service delivery in healthcare facilities and health service providers' incapacity to comprehend a patient's need beyond the medical concerns. Participants in the study asserted that patients have a significant stake in enhancing treatment results and quality of life through enhancing self-management. CONCLUSION AND RECOMMENDATION: HIV patients face multifaceted problems beyond their medical issues. The success of medical treatment for HIV is strongly contingent upon patients' self-management practices and the supportive roles of their family, society, and health service providers. The development and integration of self-management practices into clinical care will benefit patients, their families, and the health system.

Prevalence and predictors of low folate levels among stroke survivors in a country without mandatory folate food fortification: Analysis of a Ghanaian sample.

BACKGROUND: While additional folic acid (FA) treatment has a neutral effect on lowering overall vascular risk in countries that mandate FA fortification of food, meta-analytic data suggest that folate supplementation reduces stroke risk in certain patient subgroups, and among people living in countries without mandatory folate food fortification. However, the burden of folate deficiency among adults with stroke in the world's poorest continent is unknown. PURPOSE: To assess the prevalence and predictors of folate deficiency among recent ischemic stroke survivors. METHODS: We analyzed data among consecutively encountered ischemic stroke patients aged ≥18 years at a tertiary medical center in Kumasi, Ghana between 10/2020 - 08/2021. We identified a modest sample of stroke free adults to serve as a comparator group. Fasting serum folate was measured using a radioimmunoassay and a cut-off of 4ng/mL used to define folate deficiency. Factors associated with serum folate concentration were assessed using a multilinear regression model. RESULTS: Comparing stroke cases (n = 116) with stroke-free comparators (n = 20), mean folate concentration was lower among stroke cases (7 ng/ml vs. 10.2 ng/ml, p = 0.004). Frequency of folate deficiency was higher among stroke cases vs. stroke-free controls (31% vs 5%, p = 0.02). Male sex (beta coefficient of -2.6 (95% CI: -4.2, -0.9) and LDL (ß: -0.76; -1.4, -0.07) were significantly associated with serum folate concentration. CONCLUSION: Almost one in three ischemic stroke survivors have folate deficiency potentially accentuating their risk for further adverse atherosclerotic events in a setting without folate fortification. A clinical trial of folate supplementation among stroke survivors is warranted.

Silent Tears of Midwives: 'I Want Every Mother Who Gives Birth to Have Her Baby Alive'-A Narrative Inquiry of Midwives Experiences of Very Early Neonatal Death from Tanzania.

BACKGROUND: Midwives working in settings with limited clinical resources experience high rates of very early neonatal deaths. Midwives manage the impact of this grief and trauma almost daily, which may affect patient care and their own well-being. RESEARCH AIMS: To explore how midwives are impacted by and cope with high rates of very early neonatal deaths. To document midwives' insights and local solutions that may reduce very early neonatal deaths in limited resource settings. To document the stories of midwives in order to create awareness and garner support for midwives and their critical work in low resource settings. METHODS: Narrative inquiry utilizing semi structured interviews. Twenty-one midwives with at least six months experience who had experienced or witnessed very early neonatal death were interviewed. Data were audio recorded and transcribed, and reflexive thematic analysis of transcripts was conducted. RESULTS AND DISCUSSION: Three themes were identified: (1) deep sadness resulting from very early neonatal deaths leading to internal struggles; (2) use of spirituality, including prayer and occasional beliefs that unexplainable deaths were 'God's plan'; and (3) development of resilience by seeking solutions, educating themselves, taking accountability and guiding mothers. Participating midwives noted that inadequate staff and high caseloads with limited basic supplies hindered their clinical practice. Participants articulated that they concentrated on active solutions to save babies during labour, such as vigilant foetal rate heart monitoring and partogram. Further, reduction and prevention of very early neonatal death is a complex problem requiring multidisciplinary teams and woman-centred care approaches to address issues contributing to the health of mothers and their new-borns. CONCLUSIONS: Midwives' narratives highlighted ways of coping with grief and deep sadness, through prayer, and further education of both mothers and fellow colleagues to achieve better antenatal and intrapartum care and outcomes. This study gave midwives an opportunity for their voices to be heard and to generate solutions or insights that can be shared with colleagues in similar low-resource settings.

A practical formula for fluid resuscitation in acute paediatric burns in a low resource setting: A pilot study.

BACKGROUND: Appropriate fluid resuscitation of acute burn injury is critical and there are recognized challenges with fluid resuscitation, including those with relevance to low resource settings. We developed a practical protocol that guides burn resuscitation and sought to evaluate the safety of our modified resuscitation formula through a small pilot study that particularly addresses the problems we have experienced in a low resource setting. METHODS: Children with burns more than 15% total body surface area admitted within 24 h of injury to Edendale Hospital between 1 June 2021 and 31 August 2021 were included. The resuscitation formula used was 2 mls of Ringers Lactate per bodyweight in kilograms per% total body surface area (TBSA) given over 24 h and adjusted according to urine output. Data analysed included age, weight, mechanism, TBSA, hours post burn at presentation to hospital, total fluid given in the first 24 h of admission, total urine output in the first 24 h of admission, number of fluid adjustments made during the first 24 h and complications related to fluid resuscitation. RESULTS: Ten children were included. The median age was 3 (IQR 2-5) years old, with a mean weight of 14.9 (SD 5.07) kilograms, a median TBSA of 17.4 (IQR 16-26)%, presenting at a median of 12 (6.5-18) hours post burn injury. Mechanism of burn was scald in all cases, with 9 being hot water and hot food in one. In the first 24 h a mean of 2.05 (SD 0.58) mls/kg of fluid was received with a mean urine output of 1.66 (SD 0.57) mls/kg/hr. CONCLUSION: The results of this pilot study to evaluate the safety of our protocol seem reasonable. It is limited by the lack of larger injuries as well as adult patients and a larger prospective study is pertinent.

Incidence of pulmonary tuberculosis in suburban Bissau, Guinea-Bissau between 2004 and 2020: a prospective cohort study.

OBJECTIVES: Previous studies have found declining incidence of tuberculosis (TB) in Bissau, Guinea-Bissau. This study aimed to report incidence rates of TB for the period 2004-2020, stratifying by sex, smear-status, and HIV-status, as well as describe developments in TB case fatality rate and diagnostic delay. DESIGN AND METHODS: Data from the Bandim Health Project HDSS and the TB registry from Jan 1st, 2004 to Dec 31st, 2020 were used. Incidence rates were calculated for each year and for smear-positive, smear-negative, HIV-positive, HIV-negative, and unknown HIV-status. Incidence rate ratio and test for trend were done using a one-step Newton approximation to the log-linear Poisson regression coefficient. RESULTS: Overall TB incidence declined only slightly over the period from 294 per 100,000 in 2004 to 273 in 2020. TB/HIV coinfection declined from 108 in 2004 to 14 in 2020, as did incidence among females and smear-negative cases. CONCLUSIONS: Incidence of PTB in Bissau, Guinea-Bissau is declining slowly, if at all. TB incidence among females, smear-negative TB, TB case fatality rate, and TB/HIV coinfection and diagnostic delay are declining.

Relationships between walking speed, activities and participation in people with chronic stroke in Burundi.

Background: Reduced walking speed because of a stroke may limit activities of daily living (ADLs) and restrict social participation. Objectives: To describe the level of balance impairment, activity limitations, and participation restrictions and to investigate their relationship with walking speed in Burundians with chronic stroke. Methods: This cross-sectional study involved adult stroke survivors. Walking speed, balance, ADLs and social participation were assessed with the 10-meter walk test (10 mWT), the Berg balance scale (BBS), the activity limitation stroke scale and the participation measurement scale, respectively. In order to determine ambulatory independence status, participants were stratified into three walking speed groups (household ambulation, limited ambulation and full-community ambulation), based on the Perry classification. Results: Fifty-eight adults (mean age 52.1 ± 11.4 years) with chronic stroke were included in our study. Most participants had severe balance impairments (median BBS score, 27). Their mean (± standard deviation [SD]) walking speeds, ADL levels and social participation levels were 0.68 ± 0.34 m/s, 50.8% ± 9.3% and 52.8% ± 8.6%, respectively. Walking speed correlated moderately with balance (rho = 0.5, p < 0.001) and strongly with ADL level (r = 0.7, p < 0.001) but not with participation level (r = 0.2, p = 0.25). Conclusion: Using socio-culturally suitable tools, our study showed that walking speed correlates robustly with balance and ADL ability, but not with social participation, in Burundi, a low-income country. Clinical implications: Exercises targeting walking speed would be very useful for people with chronic stroke living in low-resource countries, in order to promote their functional independence.

Mental health workers' perspectives on peer support in high-, middle- and low income settings: a focus group study.

BACKGROUND: Peer support is increasingly acknowledged as an integral part of mental health services around the world. However, most research on peer support comes from high-income countries, with little attention to similarities and differences between different settings and how these affect implementation. Mental health workers have an important role to play in integrating formal peer support into statutory services, and their attitudes toward peer support can represent either a barrier to or facilitator of successful implementation. Thus, this study investigates mental health workers' attitudes toward peer support across a range of high- (Germany, Israel), middle- (India), and low-income country (Tanzania, Uganda) settings. METHODS: Six focus groups were conducted in Ulm and Hamburg (Germany), Butabika (Uganda), Dar es Salaam (Tanzania), Be'er Sheva (Israel), and Ahmedabad, Gujarat (India) with a total of 35 participants. Transcripts were analyzed using thematic content analysis. RESULTS: Participants across the study sites demonstrated overall positive attitudes towards peer support in mental health care, although some concerns were raised on potentially harmful effects of peer support such as negative role modelling and giving inadequate advice to service users. Notably, mental health workers from low- and middle-income countries described peer support workers as bridge-builders and emphasized the mutual benefits of peer support. Mental health workers' views on peer support workers' roles and role boundaries differed between sites. In some settings, mental health workers strongly agreed on the need for role clarity, whereas in others, mental health workers expressed mixed views, with some preferring blurred role boundaries. Regarding collaboration, mental health workers described peer support workers as supporters and utilizers, equal partners or emphasized a need for trust and commitment. CONCLUSIONS: Mental health workers' attitudes toward peer support workers were positive overall, but they also varied depending on local context, resources and previous experiences with peer support. This affected their conceptions of peer support workers' roles, role clarity, and collaboration. This study demonstrated that reconciling the need for local adaptations and safeguarding the core values of peer support is necessary and possible, especially when the implementation of recovery-oriented interventions such as peer support is accelerating worldwide.

Feasibility and acceptability of using the novel urine-based FujiLAM test to detect tuberculosis: A multi-country mixed-methods study.

Background: The novel urine-based FujiLAM test identifies tuberculosis in HIV-positive patients but may be challenging to use at point-of-care (POC). Objectives: We assessed the feasibility and acceptability of using the FujiLAM test at point of care in outpatient settings. Methods: We conducted a mixed methods study in four outpatient settings in Kenya, Mozambique, South Africa, and Uganda between November 2020 and September 2021. The test was performed at POC in existing clinic laboratories and consultation spaces. We performed direct observations in the four health facilities, individual questionnaires, proficiency testing evaluations, and individual interviews among healthcare workers performing the FujiLAM test (healthcare workers), and group discussions with programme managers. Results: Overall, 18/19 (95%) healthcare workers and 14/14 (100%) managers agreed to participate in the study. Most assessed healthcare workers, including lay health workers (10/11; 91%), met the minimum required theoretical knowledge and practical skill in performing the FujiLAM test. Most healthcare workers (17/18; 94%) found the FujiLAM test overall "Easy/Very easy" to perform. Some challenges were mentioned: many timed steps (5/18; 28%); ensuring correct incubation period (5/18; 28%); test result readability (4/18; 22%); and difficulties with cartridge buttons (3/18; 17%). Half of the healthcare workers regularly performing the test (4/7; 57%) found it "Easy" to integrate into routine activities. Most healthcare workers and managers believed that any healthcare worker could perform the test after adequate training. Conclusions: Implementing the FujiLAM test in outpatient POC settings is feasible and acceptable to healthcare workers and managers. This test can be performed in various clinic locations by any healthcare worker. The timed, multi-step test procedure is challenging and may affect the workload in resource-constrained health facilities.

Segmenting Clinicians' Usage Patterns of a Digital Health Tool in Resource-Limited Settings: Clickstream Data Analysis and Survey Study.

BACKGROUND: Evidence-based digital health tools allow clinicians to keep up with the expanding medical literature and provide safer and more accurate care. Understanding users' online behavior in low-resource settings can inform programs that encourage the use of such tools. Our program collaborates with digital tool providers, including UpToDate, to facilitate free subscriptions for clinicians serving in low-resource settings globally. OBJECTIVE: We aimed to define segments of clinicians based on their usage patterns of UpToDate, describe the demographics of those segments, and relate the segments to self-reported professional climate measures. METHODS: We collected 12 months of clickstream data (a record of users' clicks within the tool) as well as repeated surveys. We calculated the total number of sessions, time spent online, type of activity (navigating, reading, or account management), calendar period of use, percentage of days active online, and minutes of use per active day. We defined behavioral segments based on the distributions of these statistics and related them to survey data. RESULTS: We enrolled 1681 clinicians from 75 countries over a 9-week period. We based the following five behavioral segments on the length and intensity of use: short-term, light users (420/1681, 25%); short-term, heavy users (252/1681, 15%); long-term, heavy users (403/1681, 24%); long-term, light users (370/1681, 22%); and never-users (252/1681, 15%). Users spent a median of 5 hours using the tool over the year. On days when users logged on, they spent a median of 4.4 minutes online and an average of 71% of their time reading medical content as opposed to navigating or managing their account. Over half (773/1432, 54%) of the users actively used the tool for 48 weeks or more during the 52-week study period. The distribution of segments varied by age, with lighter and less use among those aged 35 years or older compared to that among younger users. The speciality of medicine had the heaviest use, and emergency medicine had the lightest use. Segments varied strongly by geographic region. As for professional climate, most respondents (1429/1681, 85%) reported that clinicians in their area would view the use of a online tool positively, and compared to those who reported other views, these respondents were less likely to be never-users (286/1681, 17% vs 387/1681, 23%) and more likely to be long-term users (655/1681, 39% vs 370/1681, 22%). CONCLUSIONS: We believe that these behavioral segments can help inform the implementation of digital health tools, identify users who may need assistance, tailor training and messaging for users, and support research on digital health efforts. Methods for combining clickstream data with demographic and survey data have the potential to inform global health implementation. Our forthcoming analysis will use these methods to better elucidate what drives digital health tool use.

Application of the anatomical chemical system/defined daily doses: Challenges and way forward for resource-limited countries.

WHAT IS KNOWN AND OBJECTIVE: The Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) methodology is a WHO gold standard for ensuring systematic Drug Utilization Research (DUR) and has been mainly used in the developed world. This article examines the challenges and way forward for using this methodology in resource-limited countries. CONTENT: The ATC/DDD is superior over other methods employed in DUR as it offers a unified medicines regulation and management system at all care levels. The ATC/DDD allows access to standardized and validated information on DUR by: assessing patterns of utilization, defining optimal use levels, identification of gaps, aggregating and analysing statistics for reporting adverse drug reactions, as well as assisting in developing rational medicines use interventions and monitoring their outcomes. WHAT IS NEW AND CONCLUSION: Application of the ATC/DDD methodology is crucial for improved patient management, optimal consumption of national pharmaceutical budgets and policy formulation in resource-limited countries.

Effectiveness of a technology-assisted, family volunteers delivered, brief, multicomponent parents' skills training intervention for children with developmental disorders in rural Pakistan: a cluster randomized controlled trial.

BACKGROUND: Globally, there is a large documented gap between needs of families and children with developmental disorders and available services. We adapted the World Health Organization's mental health Gap-Intervention Guidelines (mhGAP-IG) developmental disorders module into a tablet-based android application to train caregivers of children with developmental disorders. We aimed to evaluate the effectiveness of this technology-assisted, family volunteers delivered, parents' skills training intervention to improve functioning in children with developmental disorders in a rural community of Rawalpindi, Pakistan. METHODS: In a single-blinded, cluster randomized controlled trial, 30 clusters were randomised (1:1 ratio) to intervention (n = 15) or enhanced treatment as usual (ETAU) arm (n = 15). After screening, 540 children (18 participants per cluster) aged 2-12 years, with developmental disorders and their primary caregivers were recruited into the trial. Primary outcome was child's functioning, measured by Childhood Disability Assessment Schedule for Developmental Disorders (DD-CDAS) at 6-months post-intervention. Secondary outcomes were parents' health related quality of life, caregiver-child joint engagement, socio-emotional well-being of children, family empowerment and stigmatizing experiences. Intention-to-treat analyses were done using mixed-models adjusted for covariates and clusters. RESULTS: At 6-months post-intervention, no statistically significant mean difference was observed on DD-CDAS between intervention and ETAU (mean [SD], 47.65 [26.94] vs. 48.72 [28.37], Adjusted Mean Difference (AMD), - 2.63; 95% CI - 6.50 to 1.24). However, parents in the intervention arm, compared to ETAU reported improved health related quality of life (mean [SD] 65.56 [23.25] vs. 62.17 [22.63], AMD 5.28; 95% CI 0.44 to 10.11). The results were non-significant for other secondary outcomes. CONCLUSIONS: In the relatively short intervention period of 6 months, no improvement in child functioning was observed; but, there were significant improvements in caregivers' health related quality of life. Further trials with a longer follow-up are recommended to evaluate the impact of intervention. Trial registration Clinicaltrials.gov, NCT02792894. Registered April 4, 2016, https://clinicaltrials.gov/ct2/show/NCT02792894.

Come together to promote health: case study and theoretical perspectives from a Kenyan community-based program.

Over the past four decades, group-based microfinance programs have spread rapidly throughout south Asia, sub-Saharan Africa and Latin America. Recent evaluations of the programs have identified social capital as a common byproduct of frequent association by members, increasing trust, belonging and normative influence. Concurrently, social capital is increasingly recognized as an important health determinant. We present an overview of a program intervention operating in Kenya that utilizes a microfinance approach to produce social capital, and seeks to leverage that social capital to promote health at three levels-the village, group, and individual. A theory of change is presented for each of these three levels, demonstrating conceptually and with program examples how social capital can be applied to promote health. Related social theories and approaches, further research and program directions are given for each of the three levels. We identify potential to improve a broad range of health outcomes through this innovative model, which requires engagement with health promotion researchers and planners in low- and middle-income countries for further refinement and validation.

Assessing the performance of the Caregiver Reported Early Development Instruments (CREDI) in rural India.

Although many education and health programs aim to improve early childhood development, it is challenging to assess developmental levels of infants and small children through large household surveys. The Caregiver Reported Early Development Instruments (CREDI) has been proposed as an adaptable, practical, and low-cost instrument for measuring the developmental status of children under 3 years of age at scale, as it is relatively short and collected by caregiver report. This study employed the CREDI to measure the development of a sample of 994 children ages 22-35 months in rural India and compared the results to those obtained using the Bayley Scales of Infant and Toddler Development (Bayley-III), a reliable and widely used instrument, albeit one not always suited to large-scale data collection efforts given its length, cost, and complexity of administration. The CREDI validation exercise showed that caregivers can provide assessments in keeping with the more interactive (hence more time-consuming and training-intensive) Bayley-III instrument. Noteworthy, there was no indication that concordance of the instruments differed by education of the caregiver. This is important as it points to alternate feasible tools to measure child development outcomes through large-scale surveys.

Improving the use of focus group discussions in low income settings.

BACKGROUND: The quality of data obtained through Focus Group Discussions (FGDs) is highly dependent on appropriate design and facilitation. In low-income settings steep power gradients between researcher and participants, as well as conversational norms, could reduce the ability of participants to voice personal opinions. Activity-oriented exercises have been suggested as a way overcoming these challenges, however little evidence exists - to date - on their use in low-income settings. We selected six exercises for use in Ethiopia and Nigeria and report our experiences. METHODS: The six exercises (picture sorting, associative pictures, picture ranking, decision trees, predictive story-telling and provocative statements) were used in 32 maternal and new-born care themed FGDs conducted in Amhara and Southern Nations Nationalities and People's Regions (Ethiopia) and Gombe State (Nigeria). Six facilitators and two supervisors who used these exercises were interviewed about their experiences. FGD verbatim transcripts and interview notes were analysed to explore methodological effectiveness and respondents' experience. All data were coded in NVIVO using a deductive coding frame. RESULTS: Facilitators and participants described the methods as 'fun' and 'enjoyable'. The exercises yielded more in-depth and complete information than 'normal' FGDs, but facilitator's probing skills and overall FGD group dynamics proved crucial in this success. Explaining and conducting the exercises increased FGD length. Data richness, participant reaction and understanding, and ease of facilitation varied by study site, exercise, and participant group. Overall, the exercises worked better in Nigeria than in Ethiopia. The provocative statement exercise was most difficult for participants to understand, the decision-tree most difficult to facilitate and the picture exercises most enjoyable. The story telling exercise took relatively little time, was well understood, yielded rich data and reduced social desirability bias. DISCUSSION: The majority of the exercises proved successful tools in yielding richer and less biased information from FGDs and were experienced as fun and engaging. Tailoring of the exercises, as well as thorough training and selection of the facilitators, were pivotal in this success. The difference in the two countries shows that adequate piloting and adaptation is crucial, and that some exercises may not be adaptable to all settings.

Operationalizing the One Health Approach in Uganda: Challenges and Opportunities.

Uganda is considered as a 'hot spot' for emerging and re-emerging infectious disease epidemics. The country has experienced several epidemics including; Ebola, Marburg, plague, Rift Valley fever, yellow fever and Crimean Congo haemorrhagic fever. Epidemics overwhelm health systems, devastate economies and cause global health insecurity. These public health challenges arising from the interaction of humans-animals-environment link require a holistic approach referred to as One Health (OH). OH is the collaborative effort of multiple disciplines working locally, nationally, and globally, to attain optimal health for people, animals, and the environment. Given its situation, Uganda has embraced the OH approach in order to be able to predict, prepare and respond to these public health challenges effectively, though still in infancy stages. In this paper, we present major achievements and challenges of OH implementation, and make recommendations for systematic and sustainable OH implementation. Achievements include: formation of the National One Health (NOH) platform with a Memorandum of Understanding between sectors; a national priority list of zoonotic diseases, the NOH Strategic Plan and a One Health communication strategy to strengthen engagement across sectors and stakeholders. There have also been efforts to integrate OH in academia. The challenges are related to inadequate; coordination across sectors, government commitment, advocacy and awareness creation and research. For systematic and sustainable OH engagements, urgent efforts should be made through government support to address current and related future challenges.

Perceptions and Acceptability of Digital Interventions Among Tuberculosis Patients in Cambodia: Qualitative Study of Video-Based Directly Observed Therapy.

BACKGROUND: Despite the development of effective drugs for treatment, tuberculosis remains one of the leading causes of death from an infectious disease worldwide. One of the greatest challenges to tuberculosis control is patient adherence to treatment. Recent research has shown that video-based directly observed therapy is a feasible and effective approach to supporting treatment adherence in high-income settings. However, few studies have explored the potential for such a solution in a low- or middle-income country setting. Globally, these countries' rapidly rising rate of mobile penetration suggests that the potential for translation of these results may be high. OBJECTIVE: We sought to examine patient perceptions related to the use of mobile health, and specifically video-based directly observed therapy, in a previously unstudied patient demographic: patients with tuberculosis in a low-income country setting (Cambodia). METHODS: We conducted a cross-sectional qualitative study in urban and periurban areas in Cambodia, consisting of 6 focus groups with tuberculosis patients who were receiving treatment (standard directly observed therapy) through a nongovernmental organization. RESULTS: Familiarity with mobile technology and apps was widespread in this population, and overall willingness to consider a mobile app for video-based directly observed therapy was high. However, we identified potential challenges. First, patients very much valued their frequent in-person interactions with their health care provider, which may be reduced with the video-based directly observed therapy intervention. Second, there may be technical issues to address, including how to make the app suitable for illiterate participants. CONCLUSIONS: While video-based directly observed therapy is a promising technology, even in country settings where mobile penetration is reportedly almost universal, it should be introduced with caution. However, the results were generally promising and yielded important insights that not only will be translated into the further adaptation of key features of video-based directly observed therapy for tuberculosis patients in Cambodia, but also can inform the future design and successful implementation of video-based directly observed therapy interventions in low- and middle-income settings more generally.

Conservative management of Cantrell syndrome: a case report.

Cantrell syndrome (CS) is defined as congenital combination of five anomalies: defects at the lower part of the sternum, anterior diaphragm, midline supraumbilical abdominal wall, diaphragmatic pericardium and ectopia cordis. Antenatal screening should be performed to make an accurate prenatal diagnosis. The prognosis is usually poor with a high mortality early in life. The gold standard management is surgery but its prognosis remains poor. In many low-income settings prenatal examinations and surgery treatment are not possible. In the present case, we report a not surgery managed baby affected by CS, with good clinical conditions after 5 months.

An Increased Risk of Stunting among Newborns in Poorer Rural Settings: A Cross-Sectional Pilot Study among Pregnant Women at Selected Sites in Rural Cambodia.

We conducted an observational study of 194 pregnant women from two different study sites in rural Cambodia. Socioeconomic and anthropometric data was obtained from the women and their newborns. In addition, we collected blood and urine samples from the women for further analyses in planned papers. There were significant differences between the two study groups for clinical outcomes. The mothers from the poorer area were shorter and weighed less at the time of inclusion. Their babies had significantly smaller head circumferences and a lower ponderal index. Conclusion: There are significant anthropometric differences between women and their newborns from two separate study sites in Cambodia. Possible associations between stunting and exposure to Persistent Toxic Substances (PTS) as organochlorines and toxic trace elements will be investigated in future studies.

Successful Surgery Management of Giant Periorbital Malignant Schwannoma in a Low-Income Setting.

Schwannoma can arise from any cranial, peripheral or autonomic nerve, except the olfactory and optic. About 25-45% of extracranial schwannomas lie in the head and neck. Data on malignant schwannoma from low-income settings are inconsistent. We reported a case of giant periorbital malignant schwannoma successfully treated in a low-income setting. The strength of our case is given not only by the rarity and the size of the disease but also for highlighting the weakness of health system in low-resource settings. It is mandatory to strengthen the health system with particular attention to physical, psychologic and social aspects and to promote comprehensive programs including all these aspects.

Feasibility of using Determine TB-LAM to diagnose tuberculosis in HIV-positive patients in programmatic conditions: a multisite study.

Background: Determine TB-LAM is a urine-based point-of-care assay for diagnosis of tuberculosis (TB). Objective: To assess the feasibility of using LAM to diagnose TB in adult HIV-positive patients in resource-limited settings. Methods: We performed a multi-centric mixed-methods cross-sectional descriptive study in the Democratic Republic of Congo, Malawi, and Mozambique. We used the study and program monitoring tools to estimate user workload, turn-around time (TAT), and proportion of patients with LAM and sputum-based results. We conducted semi-structured interviews to assess the user acceptability of the LAM. Results: The duration of the LAM testing activity per patient was 27 min (IQR 26-29); staff continued with other duties whilst waiting for the result. More patients had a LAM versus a sputum-based result: 168/213 (78.9%) vs 77/213 (36.1%), p < 0.001 in DRC; 691/695 (99.4%) vs 429/695 (61.7%), p < 0.001 in Malawi; and 646/647 (99.8%) vs 262/647 (40.5%), p < 0.001 in Mozambique. The median TAT in minutes when LAM was performed in the consultation room was 75 (IQR 45-188) in DRC, 29 (IQR 27-39) in Malawi, and 36 (IQR 35-41) in Mozambique. In comparison, the overall median TAT for sputum-based tests (smear or GeneXpert) was 2 (IQR 1-3) days. The median time to the first anti-TB drug dose for LAM-positive patients was 155 (IQR 90-504) minutes in DRC and 90 (IQR 60-117) minutes in Mozambique. The overall inter-reader agreement for the interpretation of the LAM result as positive or negative was 98.9%, kappa 0.97 (95%CI 0.96-0.99). Overall, LAM users found the test easy to perform. Major concerns were use of the reading card and the prior requirement of CD4 results before LAM testing. Conclusion: It is feasible to implement the LAM test in low resource settings. The short TAT permitted same day initiation of TB treatment for LAM-positive patients.