Single center experience of therapeutic plasma exchange in a resource-constrained setting: A study of trends in scope and complications.

BACKGROUND: Therapeutic apheresis procedures are becoming an increasingly integral part of modern medical practice, be it as a part of therapy or pre-conditioning regimes for solid organ transplants. In our center, we follow the American Society for Apheresis (ASFA) guidelines for categorizing these procedures. However, lack of a centralized registry for therapeutic apheresis in India, lack of consolidated data as well as a resource-constrained setting prevent it from being utilized to its full potential. STUDY DESIGN AND METHODS: This study was a retrospective analysis of therapeutic plasma exchange (TPE) procedures performed from January 2015 to October 2022 in the Department of Transfusion Medicine at a large tertiary care hospital in North India. All consecutive TPE procedures were included. Overall and specialty-wise scoring for all patients was performed. Mean scores were calculated. RESULTS: A total of 1434 procedures were performed during the study duration of 7 years. These procedures were performed for 284 different patients. Majority of the procedures were referred from nephrology (895 of 1434, 62.4%), followed by neurology, gastroenterology, and liver transplant teams, hematology, critical care, rheumatology, pediatrics, and internal medicine. Complete response, partial response, and no-response were observed in 1077 (75.1%), 201 (14%), and 156 (10.9%) procedures respectively. Only 14 procedures reported adverse effects. DISCUSSION: Increasing effectiveness of TPE in a number of procedures and a variety of indications has broadened its scope, while the small number of adverse events, when supervised by trained Transfusion Medicine physicians has made TPE a more viable and safer alternative to other treatment modalities.

"We just don't have the resources": Supervisor perspectives on introducing workplace-based assessments into medical specialist training in South Africa.

BACKGROUND: South Africa (SA) is on the brink of implementing workplace-based assessments (WBA) in all medical specialist training programmes in the country. Despite the fact that competency-based medical education (CBME) has been in place for about two decades, WBA offers new and interesting challenges. The literature indicates that WBA has resource, regulatory, educational and social complexities. Implementing WBA would therefore require a careful approach to this complex challenge. To date, insufficient exploration of WBA practices, experiences, perceptions, and aspirations in healthcare have been undertaken in South Africa or Africa. The aim of this study was to identify factors that could impact WBA implementation from the perspectives of medical specialist educators. The outcomes being reported are themes derived from reported potential barriers and enablers to WBA implementation in the SA context. METHODS: This paper reports on the qualitative data generated from a mixed methods study that employed a parallel convergent design, utilising a self-administered online questionnaire to collect data from participants. Data was analysed thematically and inductively. RESULTS: The themes that emerged were: Structural readiness for WBA; staff capacity to implement WBA; quality assurance; and the social dynamics of WBA. CONCLUSIONS: Participants demonstrated impressive levels of insight into their respective working environments, producing an extensive list of barriers and enablers. Despite significant structural and social barriers, this cohort perceives the impending implementation of WBA to be a positive development in registrar training in South Africa. We make recommendations for future research, and to the medical specialist educational leaders in SA.

Shifting gears to differentiation agents in acute promyelocytic leukemia with resource constraints-a cohort study.

BACKGROUND: Treatment of acute promyelocytic leukaemia has emerged as a major success in hemato-oncology. While literature from the developed world boasts of outstanding outcomes, there is a paucity of data from the developing world. This study aimed to assess complications and outcomes of acute promyelocytic leukaemia in a resource-constrained setting. METHODS: We retrospectively collected data from patients diagnosed with APL from January 2016 to December 2020. RESULTS: Sixty-four patients were treated-32 in both the Sanz high and low-risk groups. In the Sanz low-risk group, 12.5% of patients received ATRA with daunorubicin and 81.25% received ATRA with ATO. In the Sanz high-risk group, 18.8% of patients received ATRA with daunorubicin, 34.3% received ATRA with daunorubicin and ATO while 40.6% received ATRA with ATO. 56.25% of patients developed differentiation syndrome. The incidence was higher in Sanz high-risk group as compared to Sanz low-risk group. 57.4% of patients had an infection at the time of presentation. 62.5% of patients developed neutropenic fever during treatment. 17.2% of patients developed pseudotumor cerebri. The 4-year EFS and OS were 71.25 and 73.13%, respectively. Sanz low-risk group had a better 4-year EFS and OS as compared to the Sanz high-risk group. Haemoglobin at presentation and Sanz high-risk group were associated with poorer outcomes with a hazard ratio of 0.8 and 3.1, respectively. Outcomes in high-risk patients were better with the use of ATRA + ATO + daunorubicin. CONCLUSION: In the Indian population, APL patients have a high incidence of differentiation syndrome, pseudotumor cerebri, and infections during induction. CR, EFS, and OS compared to the developed world can be achieved with optimal therapy. Low haemoglobin at presentation and Sanz high-risk group were associated with poorer outcomes. ATRA, ATO, and daunorubicin combination is the preferred protocol for treating high-risk patients.

How have researchers defined and used the concept of 'continuity of care' for chronic conditions in the context of resource-constrained settings? A scoping review of existing literature and a proposed conceptual framework.

BACKGROUND: Within the context of the growing burden of non-communicable diseases (NCDs) globally, there is limited evidence on how researchers have explored the response to chronic health needs in the context of health policy and systems in low- and middle-income countries. Continuity of care (CoC) is one concept that represents several elements of a long-term model of care. This scoping review aims to map and describe the state of knowledge regarding how researchers in resource-constrained settings have defined and used the concept of CoC for chronic conditions in primary healthcare. METHODS: This scoping review adopted the modified framework for interpretive scoping literature reviews. A systematic literature search in PubMed was performed, followed by a study selection process and data extraction, analysis and synthesis. Extracted data regarding the context of using CoC and the definition of CoC were analysed inductively to identify similar patterns; based on this, articles were divided into groups. MaxQDA was then used to re-code each article with themes according to the CoC definition to perform a cross-case synthesis under each identified group. RESULTS: A total of 55 peer-reviewed articles, comprising reviews or commentaries and qualitative or quantitative studies, were included. The number of articles has increased over the years. Five groups were identified as those (1) reflecting a change across stages or systems of care, (2) mentioning continuity or lack of continuity without a detailed definition, (3) researching CoC in HIV/AIDS programmes and its scaling up to support management of NCDs, (4) researching CoC in NCD management, and (5) measuring CoC with validated questionnaires. CONCLUSION: Research or policy documents need to provide an explicit definition of CoC when this terminology is used. A framework for CoC is suggested, acknowledging three components for CoC (i.e. longitudinal care, the nature of the patient-provider relationship and coordinated care) while considering relevant contextual factors, particularly access and quality.

A counsellor-supported 'PTSD Coach' intervention versus enhanced Treatment-as-Usual in a resource-constrained setting: A randomised controlled trial.

To widen treatment access for posttraumatic stress disorder (PTSD) in resource-constrained South Africa, we evaluated the feasibility and effectiveness of a counsellor-supported PTSD Coach mobile application (app) (PTSD Coach-CS) intervention on PTSD and associated sequelae in a community sample. Participants (female = 89%; black = 77%; aged 19-61) with PTSD were randomised to PTSD Coach-CS (n = 32) or enhanced Treatment-as-Usual (n = 30), and assessed with the Clinician-Administered PTSD Scale (CAPS-5), PTSD Checklist (PCL-5) and Depression, Anxiety and Stress Scale-21 items, at pre- to post-treatment and follow-up (1 and 3 months). We also collected data on user experiences of the PTSD Coach app with self-administered surveys. We conducted an intent-to-treat analysis and linear mixed models. A significant (group × time) effect for the CAPS-5 (F3.136 = 3.33, p = 0.02) indicated a greater reduction in PTSD symptom severity over time for the intervention group with a significant between-group effect size detected at 3-month follow-up. Significant between-group effect sizes were detected in self-reported stress symptom reduction in the intervention group at post-treatment and 3-month follow-up. Participants perceived the app as helpful and were satisfied with the app. Findings suggest PTSD Coach-CS as a suitable low-cost intervention and potential treatment alternative for adults with PTSD in a resource-constrained country. Replication in larger samples is needed to fully support effectiveness. Pan African Trial Registry: PACTR202108755066871.

Participants' experiences of a counsellor-supported PTSD Coach intervention in a resource-constrained setting.

We explored participants' experiences of a counsellor-supported PTSD Coach mobile application intervention (PTSD Coach-CS) in a randomised controlled trial. PTSD Coach-CS participants, who received the intervention and self-completed a custom-designed questionnaire at intervention completion were included (n = 25; female = 20; ages 19-59; isiXhosa = 22). This questionnaire comprised questions regarding the feasibility, acceptability and potential impact of the PTSD Coach-CS intervention, and general psychological support in our setting. Data were analysed using Braun and Clarke's thematic analysis. Three main themes emerged. (i) Participants' largely positive experiences of treatment procedures included the safe space created by the counsellor support in combination with the PTSD Coach application, allowing them to learn about and understand their lived experiences, and to accept their PTSD diagnoses. (ii) Positive perceptions of the PTSD Coach application, yet raising important concerns (e.g., lack of family involvement) for future consideration. (iii) Intervention-specific and systemic treatment barriers (e.g., stigma) providing important information to inform and increase the usefulness of the PTSD Coach-CS intervention. The findings suggest that the PTSD Coach-CS intervention may help address the need for access to suitable care for South African adults with PTSD. Some contextual barriers must be considered in further intervention implementation.

Design of a Rheumatology Transition Clinic for a Resource-Constrained Setting.

OBJECTIVES: To describe the design process of a medical care program for adolescents with pediatric onset rheumatic diseases (PRD) during the transition from pediatric to adult care in a resource-constrained hospital. METHODS: The model of attention was developed in three steps: 1) the selection of a multidisciplinary team, 2) the evaluation of the state of readiness of patients and caregivers for the transition, and 3) the design of a strategy of attention according to local needs. The results of the first two steps were used in order to develop the strategy of attention. RESULTS: The transition process was structured in three stages: pretransition (at pediatric rheumatology clinic), Transition Clinic for Adolescents with Rheumatic Diseases (TCARD, the main intervention), and post-transition (at adult rheumatology clinic). Each stage was divided, in turn, into a variable number of phases (8 in total), which included activities and goals that patients and caregivers were to accomplish during the process. A multidisciplinary approach was planned by pediatric and adult rheumatologists, nutritionists, physiatrists, psychiatrist, psychologist, nurse, and social worker. During TCARD, counseling, education, nutritional, physical, and mental health interventions were considered. CONCLUSIONS: The proposed transition model for patients with rheumatic diseases can be a useful tool in developing countries.

A clinician-monitored 'PTSD Coach' intervention: findings from two pilot feasibility and acceptability studies in a resource-constrained setting.

Background: The high prevalence of trauma exposure and consequent post-traumatic stress disorder (PTSD) is well documented in low- and middle-income countries, and most individuals with PTSD have limited access to treatment in these settings. Freely available internet-based interventions, such as PTSD Coach (web-based and mobile application), can help to address this gap and improve access to and efficiency of care. Objective: We conducted two pilot studies to evaluate the feasibility, acceptability, and preliminary effectiveness of PTSD Coach in a South African resource-constrained context. Method: Pilot 1: Participants with PTSD (n = 10) were randomized to counsellor-supported PTSD Coach Online (PCO) or enhanced treatment as usual. Pilot 2: Participants (n = 10) were randomized to counsellor-supported PTSD Coach Mobile App or self-managed PTSD Coach Mobile App. Feasibility and acceptability were assessed by comparing attrition rates (loss to follow-up), reviewing participant and counsellor feedback contained in fieldnotes, and analysing data on the 'Perceived helpfulness of the PTSD Coach App' (Pilot 2). PTSD symptom severity was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5), changes between treatment and control groups were compared, the reliable change index (RCI) was calculated, and clinically significant changes were determined. Results: Three participants in Pilot 1 and two participants in Pilot 2 were lost to follow-up. Fieldnotes indicated that PTSD Coach Mobile App addressed identified computer literacy challenges in Pilot 1 (PCO); and a shorter duration of intervention (from 8 to 4 weeks) was associated with less attrition. The RCI indicated that four participants in Pilot 1 and eight participants in Pilot 2 experienced significant improvement in PTSD symptom severity. Conclusions: The preliminary results suggest that both platforms can alleviate PTSD symptoms, and that the involvement of volunteer counsellors is beneficial. The use of PTSD Coach Mobile App may be more feasible than the online version (PCO) in our setting. HIGHLIGHTS Research on supported PTSD Coach interventions is limited in resource-constrained settings.Both volunteer counsellor-supported PTSD Coach Online and the PTSD Coach Mobile App showed preliminary reliable and clinically significant changes.The use of PTSD Coach Mobile App seems more feasible than the volunteer counsellor-supported PTSD Coach Online.

Antecedentes: La alta prevalencia de exposición a trauma y el consecuente trastorno de estrés postraumático (TEPT) están bien documentadas en países de bajos y medianos ingresos y la mayoría de los individuos con TEPT tiene acceso limitado a los tratamientos necesarios en estos entornos. Las intervenciones basadas en internet de acceso gratuito, como el 'PTSD Coach', nombre de la aplicación en inglés (disponible vía aplicación móvil y a través de la web), pueden ayudar a abordar esta brecha y mejorar el acceso y la eficiencia de la atención. Condujimos dos estudios piloto para evaluar la viabilidad, aceptabilidad y preliminarmente la efectividad del 'PTSD Coach' en un contexto con recursos limitados de Sudáfrica.Metodología: Piloto 1: Los participantes con TEPT (n = 10) fueron asignados al azar al 'PTSD Coach' en modalidad online (PCO en sus siglas en inglés) apoyado por un consejero o al tratamiento habitual mejorado. Piloto 2: Los participantes (n = 10) fueron asignados al azar al 'PTSD Coach' en modalidad de aplicación móvil apoyado por un consejero o a la aplicación móvil 'PTSD Coach' de manera auto-gestionada. La viabilidad y aceptabilidad se evaluaron comparando las tasas de deserción (perdida durante el seguimiento), revisando los comentarios de retroalimentación dados por los participantes y consejeros, los cuales se encontraban contenidos en las notas de campo, y analizando los datos en la 'Utilidad percibida de la aplicación PTSD Coach' (Piloto 2). La gravedad de los síntomas del TEPT se evaluaron con la Escala de TEPT Administrada por el Clínico (CAPS-5), donde se compararon los cambios entre los grupos de tratamiento y control, el índice de cambio confiable fue calculado y el cambio clínicamente significativo fue determinado.Resultados: En el Piloto 1 se perdieron en el seguimiento tres participantes y en el Piloto 2 se perdieron en el seguimiento dos participantes. Las notas de campo indicaron que la aplicación móvil del 'PTSD Coach' abordó los desafíos de la alfabetización informática en el Piloto 1 (PCO); y una intervención de duración más breve (de ocho a cuatro semanas) se asoció con menos deserción. En el Piloto 1 el RCI indicó que cuatro participantes experimentaron una mejoría significativa en la gravedad de los síntomas del TEPT, mientras que ocho indicaron una mejoría significativa en la gravedad de los síntomas del TEPT en el Piloto 2.Conclusiones: Los resultados preliminares sugieren que ambas plataformas pueden aliviar los síntomas de TEPT y que la participación de un consejero voluntario es beneficiosa. La aplicación móvil 'PTSD Coach' puede ser más factible que la versión en línea (PCO) en nuestro medio.

Effects of Modulated Electro-Hyperthermia (mEHT) on Two and Three Year Survival of Locally Advanced Cervical Cancer Patients.

(1) Background: Modulated electro-hyperthermia (mEHT) is a mild to moderate, capacitive-coupled heating technology that uses amplitude modulation to enhance the cell-killing effects of the treatment. We present three year survival results and a cost effectiveness analysis from an ongoing randomised controlled Phase III trial involving 210 participants evaluating chemoradiotherapy (CRT) with/without mEHT, for the management of locally advanced cervical cancer (LACC) in a resource constrained setting (Ethics Approval: M120477/M704133; ClinicalTrials.gov ID: NCT033320690). (2) Methods: We report hazard ratios (HR); odds ratio (OR), and 95% confidence intervals (CI) for overall survival and disease free survival (DFS) at two and three years in the ongoing study. Late toxicity, quality of life (QoL), and a cost effectiveness analysis (CEA) using a Markov model are also reported. (3) Results: Disease recurrence at two and three years was significantly reduced by mEHT (HR: 0.67, 95%CI: 0.48-0.93, p = 0.017; and HR: 0.70, 95%CI: 0.51-0.98, p = 0.035; respectively). There were no significant differences in late toxicity between the groups, and QoL was significantly improved in the mEHT group. In the CEA, mEHT + CRT dominated the model over CRT alone. (4) Conclusions: CRT combined with mEHT improves QoL and DFS rates, and lowers treatment costs, without increasing toxicity in LACC patients, even in resource-constrained settings.

Clinical correlations to distinguish severe from milder forms of obstructive sleep apnoea syndrome using overnight oximetry for prioritising adenotonsillectomy in a limited-resource setting.

BACKGROUND: In resource-poor settings with limited surgical services, it is essential to identify and prioritise children with severe and very severe obstructive sleep apnoea syndrome (OSAS) to expedite surgery. McGill's Oximetry Score (MOS) has been validated against polysomnography for OSAS and is affordable and easy to use. AIMS: The aim of this study was to assess the correlation of tonsillar size and clinical symptoms with MOS grade 3 or 4, to identify who requires overnight oximetry and who to prioritise for adenotonsillectomy. METHODS: Children with suspected OSAS were recruited from the otolaryngology clinic at the Red Cross War Memorial Children's Hospital. Demographics, symptom screening scores (SSS), patient characteristics, overnight oximetry (OO), echocardiography and MOS scores (graded 1-4) were recorded. Multivariate modified-Poisson regression models were used to examine correlations of patient characteristics 'with grade 3 or 4 MOS. RESULTS: One-hundred-and-three children were analysed, 38% were female, and median (IQR) age was 3.8 (2.5-5.3) years. Increased tonsil size was associated with a 60% increased risk of grade 3 or 4 MOS, risk ratio (RR) 1.59, 95% CI 1.10-2.29 (p = 0.014). Children with witnessed apnoeic events during sleep had 1.3 times increased risk of MOS Grade 3 or 4, RR 1.31, 95% CI (p = 0.033). A significant correlation was shown with grade 3 or 4 MOS, RR 1.15, 95% CI 1.03-1.27 (p = 0.010) by combining tonsillar size with the following symptoms: apnoeic events; struggling to breathe during sleep and needing to stimulate the child to breathe. CONCLUSION: Identifying children with suspected OSAS who require overnight oximetry can be performed using a simple 3-question screening tool: witnessed apnoeic events, struggling to breathe and the need to shake them awake to breathe. This is more precise with an additional clinical finding of grade 3 or 4 tonsils. These children should have surgery expedited. Any child with a MOS 3 or 4 score on OO needs to have expedited surgery.

Does more testing in routine preoperative evaluation benefit the orthopedic patient? Case control study from a resource-constrained setting.

BACKGROUND: Routine preoperative tests in healthy patients not only cause extra anxiety, but may delay treatment without influencing surgical plan. This has worse impact in resource-constrained settings where fee for service rather than health insurance is the usual norm. Investigators aim to determine if "routine" pre-operative tests are justified in healthy orthopedic patients. METHODS: We conducted a non-commercialized, non-funded matched case control study in tertiary care university hospital and a level-1 trauma centre for healthy patients (ASA-1&2) admitted from January 2014-December 2016 for elective orthopedic intermediate and major procedures. Cases (patient who had a change in his/her surgical plan after admission) and controls were selected independently of the exposure of interest then matched randomly to cases on age, gender and procedure type. Primary exposure was the routine preoperative lab tests, as defined by the American Society of Anesthesiologist, which included 13 blood tests. Analysis was done using Principle Component Analysis and Conditional logistic regression at univariate and multivariable levels reporting matched adjusted Odds Ratios. The data was reported in line with STROCSS criteria. RESULTS: Overall, 7610 preoperative tests were done for 670 patients with 62% men among cases and 53% men among controls with mean age of 49.9 ± 22.5 years and 41.1 ± 23.0 years, respectively. There were 1076 (14%) abnormal result that influenced surgical plan in 0.96% cases only. Matched adjusted OR with 95% confidence interval of primary exposure was insignificant. CONCLUSION: Routine preoperative tests were superfluous and did not influence the surgical plan when adjusted for other variables in the model as well as after matching on potential confounders. This study would be amongst first steps to move towards an evidence based surgical practice for preoperative evaluation.

Admission factors associated with the in-hospital mortality of burns patients in resource-constrained settings: A two-year retrospective investigation in a South African adult burns centre.

OBJECTIVE: Little is known concerning the factors associated with in-hospital mortality of trauma patients in resource-constrained settings, not least in burns centres. We investigated this question in the adult burns centre at Tygerberg Hospital in Cape Town. We further assessed whether the Abbreviated Burn Severity Index (ABSI) is an accurate predictive score of mortality in this setting. METHODS: Medical records of all patients admitted with fresh burns over a two-year period (2015 and 2016) were scrutinized to obtain data on patient, injury and admission-related characteristics. Association with in-hospital mortality was investigated for flame burns using logistic regressions and expressed as odds ratios (ORs). The mortality prediction of the ABSI score was assessed using sensitivity and specificity analyses. RESULTS: Overall the in-hospital mortality was 20.4%. For the 263 flame burns, while crude ORs suggested gender, burn depth, burn size, inhalation injury, and referral status were all individually significantly associated with mortality, only the association with female gender, not being referred and burn size remained significant after adjustments (adjusted ORs = 3.79, 2.86 and 1.11 (per percentage increase in size) respectively). For the ABSI score, sensitivity and specificity were 84% and 86% respectively. CONCLUSION: In this specialised centre, mortality occurs in one in five patients. It is associated with a few clinical parameters, and can be predicted using the ABSI score.

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

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.

Recombinase polymerase amplification: Emergence as a critical molecular technology for rapid, low-resource diagnostics.

Isothermal molecular diagnostics are bridging the technology gap between traditional diagnostics and polymerase chain reaction-based methods. These new techniques enable timely and accurate testing, especially in settings where there is a lack of infrastructure to support polymerase chain reaction facilities. Despite this, there is a significant lack of uptake of these technologies in developing countries where they are highly needed. Among these novel isothermal technologies, recombinase polymerase amplification (RPA) holds particular potential for use in developing countries. This rapid nucleic acid amplification approach is fast, highly sensitive and specific, and amenable to countries with a high burden of infectious diseases. Implementation of RPA technology in developing countries is critically required to assess limitations and potentials of the diagnosis of infectious disease, and may help identify impediments that prevent adoption of new molecular technologies in low resource- and low skill settings. This review focuses on approaching diagnosis of infectious disease with RPA.

Determinants of variability in motor performance in middle childhood: a cross-sectional study of balance and motor co-ordination skills.

BACKGROUND: Physical activity is a key component of exploration and development. Poor motor proficiency, by limiting participation in physical and social activities, can therefore contribute to poor psychological and social development. The current study examined the correlates of motor performance in a setting where no locally validated measures of motor skills previously existed. The development of an appropriate assessment schedule is important to avoid the potential misclassification of children's motor performance. METHODS: A cross-sectional study was conducted among a predominantly rural population. Boys (N = 148) and girls (N = 160) aged between 8 and 11 years were randomly selected from five schools within Kilifi District in Kenya. Four tests of static and dynamic balance and four tests of motor coordination and manual dexterity were developed through a 4-step systematic adaptation procedure. Independent samples t-tests, correlational, univariate and regression analyses were applied to examine associations between background variables and motor scores. RESULTS: The battery of tests demonstrated acceptable reliability and validity. Variability in motor performance was significantly associated with a number of background characteristics measured at the child, (gender, nutritional status and school exposure) household (household resources) and neighbourhood levels (area of residence). The strongest effect sizes were related to nutritional status and school exposure. CONCLUSIONS: The current study provides preliminary evidence of motor performance from a typically developing rural population within an age range that has not been previously studied. As well as being culturally appropriate, the developed tests were reliable, valid and sensitive to biological and environmental correlates. Further, the use of composite scores seems to strengthen the magnitude of differences seen among groups.

Causes of puerperal and neonatal sepsis in resource-constrained settings and advocacy for an integrated community-based postnatal approach.

BACKGROUND: Puerperal sepsis and neonatal sepsis are important causes of mortality and morbidity in low-income countries. OBJECTIVES: To help improve global guidelines on postpartum care by reviewing existing data on microbiologic causes of sepsis among mothers, newborns, and mother-newborn pairs. SEARCH STRATEGY: An extensive literature review of peer-reviewed publications from resource-constrained settings was conducted using PubMed. SELECTION CRITERIA: Primary research studies containing microbiologic data on puerperal sepsis or combined maternal and neonatal sepsis published since 1980. DATA COLLECTION AND ANALYSIS: Study characteristics and results were analyzed. Data regarding causative microorganisms were tabulated and discussed in the main text. MAIN RESULTS: Diagnostic evaluation of microorganisms causing puerperal sepsis was difficult, with few studies linking microorganisms causing infection in individual mother-newborn pairs. The most frequent microorganisms associated with puerperal sepsis were Neisseria gonorrhoeae and Chlamydia trachomatis. The most frequent microorganisms associated with neonatal sepsis were Escherichia coli, Staphylococcus aureus, and Klebsiella species. CONCLUSIONS: Management tools for community-based care of mothers with puerperal sepsis-including early detection, initiation of broad-spectrum antibiotic treatment, and timely referral-should be added to those currently in use for neonatal sepsis. Further research is required to address acceptability, feasibility, and impact of community-based presumptive treatment.