Italian Non-governmental Organization Research Articles

Prosthetic valve dysfunction in patients with mechanical heart valves: Results from the Emergency Salam Centre cohort

IntroductionMechanical heart valve (MHV) replacement requires long-life anticoagulation due to the risk of Prosthetic Valve Dysfunction (PVD) and cardioembolism. MethodsWe report data from a prospective observational study conducted on MHV patients in the Khartoum Salam Centre for Cardiac Surgery built by ‘Emergency,’ an Italian Non-Governmental Organization, to evaluate the occurrence of PVD and associated risk factors. ResultsWe prospectively followed 3647 patients, and 38 patients (rate 1.04 × 100 pt-years) had PVD during follow-up. The time in therapeutic range (TTR) among patients without PVD was 53 % (IQR 37–67), and it was 43 % (IQR 19–58) among patients with PVD (p = 0.04). Twenty-three over 38 patients (60.5 %) were symptomatic, 18 (47.4 %) had obstructive valvular stenosis, 24 patients (63.2 %) had INR <2.0 at diagnosis, and 21 patients (55.3 %) had been off warfarin for a long time: 3 patients for 1 week, 1 patient for 2 weeks, and 17 patients for >4 weeks (6 patients were off warfarin from 3 to 12 months). Ten were uncompliant to treatment, and 8 were pregnant women. Ten patients (26.3 %) with PVD had had a previous episode of PVD, and 14 patients (36.8 %) had 2 or more associated risk factors. Only in 6 cases were no associate risk factors found. ConclusionsAmong MHV patients on warfarin treatment with a sub-optimal quality of anticoagulation, the rate of PVD is 1.04 % pt-years, and the most frequent associated risk factor for PVD occurrence is warfarin withdrawal lasting more than one week.

Association of sex with major bleeding risks in sub-Saharian anticoagulated patients with mechanical heart valves: A cohort study from the Khartoum Emergency Salam Centre.

BackgroundRheumatic heart disease (RHD) with mechanical heart valve (MHV) replacement is common in Africa. However, MHV requires lifelong anticoagulation that could have a particular impact in women in reproductive age. MethodsWe report data of a prospective observational cohort study conducted between August 2018 and September 2019 in MHV patients in the Salam Centre for Cardiac Surgery built in Khartoum by Emergency, an Italian Non-Governmental Organization, to evaluate bleeding risk, its associated determinants, and the impact of lifelong anticoagulation in fertile women. ResultsWe studied 3647 patients (median age 25.1 years; 53.9% female). During follow-up [median time 1.1 (0.1–1.2) years], we recorded 85 major bleedings (rate 2.16 × 100 pt-years), Major bleedings occurred more frequently among women (64/85 cases, 75.3%; rate 3.0 × 100 pt-years), compared to men (21/85 cases, 24.7%; rate 1.16 × 100 pt-years) (RR 2.6; 95% CI 1.6–4.5; p = 0.0001). Multivariate analysis was performed to identify variables associated with major bleeding, and female sex was the only risk factor significantly associated, whereas aspirin treatment and higher INR target showed a non-significant trend for higher bleeding risk. Thirty-two/85 (37.6%) of major bleedings were metrorrhagias. When we calculate the incidence of major bleedings after the exclusion of gynecological events, no sex differences in the bleeding risk were found (HR 1.3, 95% CI 0.8–2.3; p = 0.3). ConclusionsBleeding risk of young MHV patients on oral anticoagulant therapy is higher among women, mainly due to metrorrhagia. Women in the reproductive life are at high risk for gynecological bleeding when treated with anticoagulants.

Oral anticoagulant management of patients with mechanical heart valves at the Salam Centre of Khartoum: Observations on quality of anticoagulation and thrombotic risk

IntroductionRheumatic heart disease with mechanical heart valve (MHV) replacement is common in Africa. However, MHV requires long-life anticoagulation and managing this can be challenging. Methods and resultsWe report data of a prospective observational study conducted between August 2018 and September 2019 in MHV patients in the Salam Centre for Cardiac Surgery built in Khartoum, by Emergency, an Italian Non-Governmental Organization, to evaluate the quality of anticoagulation control and the risk of thrombotic complications. ResultsWe studied 3647 patients (median age 25.1 years; 53.9 % female). Median Time in Therapeutic Range (TTR) was 53 % (interquartile range 37 % to 67 %) and 70 thrombotic events (rate 1.8 × 100 pt-years [95 % CI 1.38–2.23]) were recorded. Among patients in the first quartile of TTR (≤37 %), we recorded 34/70 (48.6 %) of all thrombotic events (rate 3.7 × 100 pt-years [95 % CI 2.5–5.1]), with a high mortality rate (2.2 × 100 pt-years [95 % CI 1.3–3.3]). In patients with guideline-recommended TTR (≥65 %) the event rate was 0.8 × 100 pt-years for thrombotic events [95 % CI 0.3–1.5] and 0.4 × 100 pt-years for mortality [95 % CI 0.1–0.9].Multivariable analysis showed that having a TTR in the lowest quartile (≤37 %) and being noncompliant are significantly associated with increased thrombotic risk. Aspirin use or different valve type did not influence the thrombotic risk. Almost 40 % of all thromboembolic complications could have been potentially prevented by further improving VKA management to obtain a TTR > 37 %. ConclusionThe thrombotic risk of MHV patients on VKAs living in a low-income country like Sudan is associated with low quality of anticoagulation control. Efforts should be made to decrease the number of non-compliant patients and to reach a guideline-recommended TTR of ≥65 %.

Distribution of HbS Allele and Haplotypes in a Multi-Ethnic Population of Guinea Bissau, West Africa: Implications for Public Health Screening.

BackgroundSickle Cell Disease (SCD) is an inherited condition that is widespread globally and especially in malaria-endemic West African countries. Limited epidemiological data on SCD are available for Guinea Bissau, where newborn screening is not yet implemented, routine diagnosis is not available, and care is case directed.MethodsDried blood spots were collected from children accessing two hospitals managed by Italian Non-Governmental Organizations in the capital city of Bissau and sent to Padova for Hemoglobin (Hb) quantification through HPLC and molecular analysis. Beta globin gene analysis was performed in all; and Hb haplotype of the HbSS and HbSA patients was performed in South Africa. One hundred samples belonging to the most frequent ethnic groups were randomly selected for detection of G6PD mutations.ResultsSamples from 848 consecutive children (498 males and 350 females, mean age 6.8 years) accessing the two hospitals were analyzed: 6.95% AS (4.42% allelic frequency), 0.94% SS, and 0.23% AC. 376G G6PD allelic frequency was 24%; 14.8% in AS individuals. The Senegal haplotype was the most prevalent (31%), and the proposition of chromosomes with the atypical haplotype was surprisingly high (56%).ConclusionOur study demonstrates a significant frequency of the HbS allele in the population of Guinea Bissau supporting the implementation of screening strategies. The differences among ethnic groups can help guide targeted interventions for SCD awareness campaigns and determine priority areas for public health interventions. The pilot analysis on haplotypes reveals a large proportion of the atypical haplotype, which may be indicative of a genetically heterogeneous population.

Project management in the international aid sector: the perspective of Italian NGOs

In recent years, the project management field has received increasing attention, in terms of both practical implementation and research. However, unlike other sectors, project management practice in the field of international humanitarian aids seems to be neglected. In this context, the current paper illustrates an empirical study on international development projects performed by Italian non-governmental organizations. The aim of the paper is to investigate the use of PM tools in humanitarian aid projects and the relationship between critical success factors and project success. The necessary data were gathered through a questionnaire and statistical methods were subsequently implemented for the data analysis.

Multiple interventions to strengthen immunization services in an Angolan district

Abstract Background Immunization represents one of the most effective intervention in public health. In the Sustainable Development Goals era, adequate vaccination services are still crucial for the prevention of infectious diseases and the reduction of under-5 mortality. However, in 2017 WHO estimated that children &amp;lt;1 year who did not receive the third dose of Diphtheria-Tetanus-Pertussis (DTP3) vaccine were 19.2 million globally, and 600000 of these were located in Angola, a Sub-Saharan country with an estimated DTP3 coverage of 52%. Since 2000, Italian Non-Governmental Organization (NGO) Doctors with Africa CUAMM supports the activity of the hospital of Chiulo in the commune of Mucope (district of Ombadja, south of Angola). Aim of the study is to describe the interventions implemented to strengthen the immunization services performed by the hospital Public Health Staff (PHS). Methods In May 2018 the NGO started to implement multiple interventions to enhance the number of vaccine doses administered. Firstly, outreach immunization sessions were reorganized and reinforced, for example involving local Community Health Workers in the identification of villages with a high burden of unvaccinated children. Other actions were the continuous training of the PHS in data collection and the increased collaboration with the Ombadja District Health Department in order to develop a more efficient vaccine supply chain at local level. Results In 2018, among children &amp;lt;1 year the PHS administered 19746 doses, with a 22.3% growth compared to 2017 (15349 doses). Doses administered during outreach sessions increased by 35.4% (6597 versus 4259 doses). Estimated DTP3 coverage in Mucope commune was 71% (2017, 59%). Conclusions The WHO “Reaching Every Community” strategy emphasizes the importance of high quality immunization services in hard-to-reach areas. The organisation of well-functioning immunization services requires a multifaceted approach by the involved stakeholders. Key messages In 2017, globally 19.2 million of children &amp;lt;1 year did not receive the recommended three DTP doses. Six-hundred thousand were located in Angola. To obtain and sustain an adequate vaccination coverage, especially in hard-to-reach areas, multiple and well-coordinated actions should be implemented by all the involved stakeholders.

One-year activity of a “Casa de Espera” (Maternity Waiting Home) in the south of Angola

Abstract Background Maternity Waiting Homes (MWHs) are structures usually located close to health facilities able to provide emergency obstetric care. Women can decide to be hosted in MWHs and when labour begins they move to the health facility for the delivery. Although the effectiveness of MWHs is debated, literature shows increasing findings about their importance. Aim of the study is to describe a one-year activity of a MWH located in Angola. Methods Since 2000, Italian Non-Governmental Organization (NGO) Doctors with Africa CUAMM supports the activities of the hospital of Chiulo in the district of Ombadja (Cunene province). Among the implemented projects, the NGO supports the local MWH (in Portuguese, “casa de espera”), providing dedicated staff and food for all the women hosted in the MWH. The MWH team routinely performs antenatal care visits and brief talks regarding maternal health. In case of pregnancy complications, the staff promptly refers women to the nearby hospital. The MHW team is also involved in routine data collection. Results In 2018, 703 women were admitted in the MWH. Three-hundred and forty-two (48.6%) were between 18 and 24 years of age. Four-hundred and eighty-two (68.6%) were invited to join the MWH by personnel of local health facilities, while 160 (22.8%) by family members and 61 (8.7%) by community health workers/traditional birth attendants. Age less than 18, previous abortion and/or caesarean were the most assessed factors for high risk pregnancy. In 2018, 1364 deliveries were performed in the hospital, and 593 (43.5%) concerned women hosted in the MWH. Conclusions To achieve the 2030 Sustainable Development Goals targets regarding maternal and neonatal mortality, the implementation of MHWs could represent an effective tool, especially in countries such as Angola where these indicators show a weak annual reduction. Regarding Chiulo’s MWH, an improvement of data collection could lead to a better comprehension of the efficacy of the facility. Key messages In the SDGs era, countries with a high burden of maternal and neonatal mortality should implement various and integrated approaches to achieve significant reductions of these indicators. Although the effectiveness of maternity waiting homes is still debated, increasing findings suggest that they could represent an effective tool to contain mother and child mortality.

Finding alternative roles for Traditional Birth Attendants: an experience from the south of Angola

Abstract Background Reduction of maternal mortality ratio (MMR), a key indicator contained in the Sustainable Development Goals (SDGs), is strictly related to maternal empowerment and to an increasing access to skilled care in pregnancy, childbirth and postpartum. The WHO recommends to define alternative roles for Traditional Birth Attendants (TBAs) in the transition from birth with TBAs to birth with Skilled Birth Attendants (SBAs), in particular in countries where maternal care services still do not meet recommended standards. Objectives In 2018, the Italian Non-Governmental Organization Doctors with Africa CUAMM and the District Health Department of Ombadja (a 350000 inhabitants district in Cunene province, south of Angola) started a three-year multifaceted project to support and strengthen local health services. Aim of this work is to describe the first six months of an implemented activity involving 120 local TBAs, identified and trained to perform basic educational talks in the district territory regarding topical issues of mother and child health. TBAs were also engaged in the referral of pregnant women to health facilities with SBAs. Results From June to November 2018, TBAs performed 2272 talks about maternal and child health issues: healthy pregnancy (551 talks, 24.3%), nutrition (404, 17.8%) and malaria (370, 16.3%) were the most debated topics. The total of women’s presences during these educational talks was 57504, and 15379 of them (26.7%) were pregnant. TBAs referred to health facilities 226 pregnant women for a delivery assisted by SBAs. Conclusions Angolan estimated MMR in 2015 was 477/100000 live births: therefore, more efforts should be made to contribute to the achievement of 2030 SDGs target of 70/100000 globally. Moreover, the country percentage of deliveries assisted by SBAs is less than 50%. Promoting alternative roles for TBAs into the mother and child health framework could represent an effective way to improve maternal and neonatal outcomes. Key messages According to the World Health Organization, defining alternative roles for traditional birth attendants could represent an effective way to support the health of women and children. Traditional Birth Attendants can play an important role in providing basic health education and in the “referral chain” of pregnant women to health facilities with skilled birth attendants.

The SOS Pesca Project: A Multinational and Intersectoral Collaboration for Sustainable Fisheries, Marine Conservation and Improved Quality of Life in Coastal Communities.

Healthy fisheries, particularly small-scale fisheries, are closely linked to prosperous and healthy coastal communities and resilient marine environments. Cuba's marine and coastal ecosystems are highly biodiverse and support fisheries vital to food security and the national economy. Cuban government and state institutions, scientists, managers and fishers-along with colleagues from other countries-have expressed growing concern about the decline of fishing resources. In 2012, under the aegis of the National Center for Protected Areas, Cuban institutions from the Ministry of Science, Technology and Environment and the Ministry of Foreign Investment partnered with the Italian nongovernmental organization, COSPE Onlus, to launch SOS Pesca, a four-year project to achieve sustainable fisheries management, conserve marine habitats and improve quality of life in two Cuban fishing communities (Guayabal in Las Tunas Province and Playa Florida in Camagüey Province). SOS Pesca involved the municipal governments of Amancio Rodríguez (in Las Tunas Province) and Florida (in Camagüey Province), delegates to the Municipal Assembly of People's Power (municipal government) from Guayabal (Amancio Rodríguez Municipality) and Playa Florida (Florida Municipality), the state-owned fishing industry, private fishers, local families, protected area officials and staff scientists, municipal governments and international nongovernmental organizations. By the end of 2012, a new US-Cuban collaboration emerged when COSPE recruited Environmental Defense Fund to provide scientific and technical support, trainings and exchanges focused on fisheries. SOS Pesca succeeded at community, regional fishing zone and national levels. Outcomes included: an assessment of finfish identifying species most vulnerable to fishing (methods and capacities), a proposed management plan for finfish, a National Plan of Action for sharks and rays, two marine protected areas established, increased employment through socioeconomic alternatives, revitalization of community environmental brigades, and greater capacity to use fishery assessment methods and develop management strategies. Perhaps the greatest achievement was communities' and fishers' changed perceptions of their marine environment, the need for conservation and sustainable resource management, and their active role in this objective. SOS Pesca spurred a more participatory form of integrated marine and coastal management in Cuba-one that integrates fisheries and spatial management, links fishing families and coastal communities with scientists and administrators to find solutions that support sustainability, and connects economic alternatives to community-based conservation and improved food security. This innovative multinational collaboration benefited coastal communities, marine and coastal ecosystems and international cooperation.

Nutrition Education Cell, a Community Based Approach to Fight against Child Undernutrition and Strength Community Resilience, in Rural Area in Burkina Faso.

In Burkina Faso, western Africa country, malnutrition is an underlying cause of 35% of deaths among children under 5 years of age. In the health district of Dano, south-west region where the prevalence of chronic malnutrition among children under five exceeds the WHO threshold (30%), ProgettoMondo Mlal, an Italian non-governmental organization, has put in place a mechanism to strengthen the Community system in order to carry out actions for promoting good practices in infant and young child feeding (IYCF) and community management of acute malnutrition at village level. Nutrition Educational Cells (NEC) supported by village nutrition committees (VNCs) were set up in 99 villages of the district. The one-year results show improved knowledge of good IYCF practices at mothers level, an increase in the number of acute malnutrition cases detected and referred to health centers and better participation of local communities in the implementation and financing nutrition actions. In view of the results achieved, the NEC strategy could be an opportunity to strengthen the resilience of communities to the under-nutrition of children under 5 years of age.

Rainbow for Africa Field Hospital

In 2013, the World Health Organization defined the standards for the medical teams involved in the setting of a sudden onset disaster. Rainbow for Africa is an Italian nongovernmental organization operating in a network of organizations with the aim of providing medical care in disaster response and through humanitarian assistance. It has been recently involved in the European migrants crisis in Greece and in the Mediterranean Sea, with the deployment of medical containers for the stabilization of critical patients. Moreover, Rainbow for Africa has developed a mobile and self-sufficient field hospital, incorporating a logistic structure, a two-beds intensive care unit, a surgical operating theatre, and a pneumatic tent for the inpatient care. Keywords:Disaster Medicine; Emergency Medical Team; Foreign Field Hospital;Foreign Medical Team; Rainbow for Africa; Sudden Onset Disaster.

Reduced neonatal mortality in a regional hospital in Mozambique linked to a Quality Improvement intervention

BackgroundNeonatal mortality remains a serious health issue especially in low resource countries, where 99% of neonatal deaths occur. Doctors with Africa CUAMM is an Italian non-governmental organization in the field of healthcare that has been working in Africa since 1955. In Mozambique, at the Central Beira Hospital (CBH), it has a project with the aim of supporting the neonatal intensive care unit (NICU) and the Obstetrical Department of the CBH through a multi-level intervention. Our aim was to evaluate the effectiveness of CUAMM continuous Quality Improvement intervention in terms of reduction of the overall neonatal mortality rate in the NICU of CBH.MethodsA baseline analysis was performed in order to assess the actual standard of neonatal care. Subsequently, the intervention was focused on three main areas: infrastructure, equipment and clinical protocols improvement. A retrospective pre- (2013)/post- (2014) implementation analysis of clinical outcomes was performed.ResultsTotal population included 4,276 newborns, 2,118 (50%) born in 2013 and 2158 (50%) born after implementation. Baseline characteristics of the two groups were similar apart from a higher incidence of outborn neonates (33% vs 30%, p = 0.02) and a lower incidence of Apgar score < 7 at 5 min (37% vs 43%, p < 0.01). The rates of admissions for asphyxia (22% vs 30%), sepsis (4% vs 7%) and prematurity (18% vs 28%) increased between the two study period. Mortality rate for each of these causes decreased from before to after the implementation: asphyxia (34% vs 19%, p < 0.01), sepsis (39% vs 28%, p = 0.06) and prematurity (43% vs 33%, p < 0.01).ConclusionWe found a reduction in mortality rate among newborns admitted to CBH’s NICU after the first year of CUAMM intervention. Most of this reduction can be attributed to the decrease in deaths for asphyxia, sepsis and prematurity. A Quality Improvement intervention based on infrastructural, equipment and clinical objectives was associated with a reduction of neonatal mortality rate in a low-resource NICU.

More efficient project execution and evaluation with logical framework and project cycle management: evidence from international development projects

The importance of international development projects in the field of international aid is growing. Given the characteristics of these projects, some specific methodologies have been developed, such as project cycle management (PCM) and the logical framework (LF) to efficiently carry out social impact assessment and project execution. However, few studies have analyzed the diffusion of these methodologies, especially in the context of non-governmental organizations (NGOs). With a survey of 109 Project Managers working for Italian NGOs, we show that PCM and LF are extensively adopted by NGOs compared with other standard methodologies (e.g. PMBOK Guide, IPMA). Moreover, we show how the adoption of PCM and LF is related to the level of knowledge of such tools by project managers, thus highlighting the importance of training. Finally, in line with previous studies, we find that project managers in NGOs believe that such tools are not easy to use but optimize the (social) impacts of the projects.

The Cardiac Centre Shisong organizes an open door day in Hilton Hotel Yaounde

Initiated in 2002, the Cardiac Centre whose overall objective is to reduce the incidence of cardiovascular diseases (CVD) by providing quality low cost treatment to patients was inaugurated in November 19, 2009 by the Minister of Public Health, André MAMA FOUDA. As personal representative of H.E. Paul Biya, the Minister of Public Health on that same day declared the Cardiac Centre (CC) a National Referral Centre for Cardiovascular Disease [1]. Today, it remains the lone cardio-surgical centre in the Central African Sub-regions. It covers a surface area of 35,000 meters square, having a capacity of 79 beds, two intensive care units, 2 theatres, a catheterization laboratory and competent technical department which permanently takes care of all the equipment on the site. The Centre is the fruit of the collaboration amongst the Tertiary Sisters of St. Francis Cameroon and two Italian non-governmental organizations, namely, Associazione Cuore Fratello and Associazione Bambini Cardiopatici nel Mondo [2].

Ebola seen up-close

EMERGENCY is an Italian non-governmental organization founded in 1994 in order to provide free-of-charge health care to civilians victims of wars and poverty. Since its foundation EMERGENCY provided assistance to more than 6 million people in 16 countries. I chose to go to Sierra Leone after I became involved with EMERGENCY (together with the Spallanzani Infectious Disease Institute in Rome and the Reggio Emilia Hospital) in the planning of a clinical trial for the treatment of Ebola with amiodarone.

On Active Citizenship: Discourses and Language about Youth and Migrants in Italy

The civic and political participation of young people and especially young migrants, who have limited rights of citizenship, is still a significant problem in Italy. Young people struggle to find opportunities and feel excluded from politics: the political agenda tends to see them more as a problem than as a resource. In this article, we illustrate the results of research to understand the dynamics of political and civic participation of young people and what the policy does in their favour. A content analysis of a corpus of European and Italian legislation, policy and planning documents has been undertaken. We also conducted six in-depth interviews with politicians and representatives of Italian nongovernmental organizations in order to investigate (a) policy priorities and institutional points of view, (b) consistency between these priorities and European programmes, and (c) European Union support for the policy actions and projects promoted in Italy about youth. The results showed a general difficulty for young people to ‘engage’ and be engaged in civic and political activities. There is also a gap between the political level and an effective investment which will recognize young people as a real resource.

International Cooperation for the Cure and Prevention of Severe Hemoglobinopathies

Thalassemia major (TM) is the most frequent life-threatening noninfectious disease of childhood in the Middle East, South Asia, and Pacific Islands where it accounts for a significant proportion of childhood mortality, morbidity, and related health care expenses. In spite of major advances in supportive care during the last decade, many patients in low-income and middle-income countries still fare poorly because of high treatment costs and lack of accessible multidisciplinary teams, not to consider the risk of blood-borne infections, primarily hepatitis C. In selected low-risk patients with a compatible sibling, TM is highly curable by bone marrow transplantation (BMT), which also improves the quality of life and is cost-effective. Starting in 2008, the Cure2Children Foundation (C2C), an Italian Non-Governmental Organization, has supported a BMT network in Pakistan, which during 2012 was extended to India. The primary aim of this project was to assess feasibility, outcomes, and costs of matched-related BMT for thalassemia in young low-risk children using a well-established and tolerable strategy. A total of 100 matched-related BMTs have been performed to date by partner institutions within this C2C-supported network; in the 50 low-risk cases with TM, over 90% disease-free survival was obtained with procedure expenses within 10,000 USD/BMT, that is, an outcome comparable to that obtained in affluent countries but with a fraction of the expenses. This cure rate was also obtained in start-up BMT centers (1 in Pakistan and 1 in India) within a structured and intensive cooperation program. Twinning and other international cooperation strategies based on shared principles and a common vision may substantially facilitate access to BMT.

Setting up low-risk bone marrow transplantation for children with thalassemia may facilitate pediatric cancer care

Background:In many South Asian countries there is shortage of centers providing care for pediatric malignancies. This report describes the experience of the Cure2Children Foundation (C2C) in supporting, both financially and professionally, the startup of two bone marrow transplant (BMT) centers, one in Pakistan and one in India, for the cure of transfusion-dependent thalassemia. Even though transplantation is generally considered as a more complex and advanced step relatively to basic pediatric cancer care, the authors argue that BMT for low-risk thalassemia patients with a matched sibling is a relatively simple procedure amenable to focused training.Materials and Methods:Since 2008 the C2C, an Italian Nongovernmental Organization (NGO), has supported a BMT network in Pakistan. The primary aim of this project was to assess feasibility, outcomes, and costs of matched-related BMT for thalassemia in young low-risk children employing a well established and quite tolerable strategy employed in Italy. This initiative relied primarily on focused training and task-shift strategies within a structured cooperation program. The initial success of that strategy led to its replication in India with 100 total BMTs performed over the past 4 years, 91 of which were for thalassemia major.Results:Low-risk matched-related BMT in children younger than 5 years could deliver a 92% thalassemia-free survival with 100% performance score and no extensive chronic graft versus host disease (GVHD), for an average cost of 10,000 USD per BMT. Within an existing hospital facility, 50,000 USD were sufficient to renovate and fully equip a 2-3 bedded start up BMT unit capable of performing safe low-risk compatible marrow transplantation.Conclusions:In low resource settings matched-related low-risk BMT for thalassemia can be performed with outcomes comparable to richer countries and with a fraction of the costs. Within structured and intensive cooperation, good outcomes can be obtained from the very beginning. This observation may have important implications to increase access to cure for both nonmalignant and malignant.

Corrosive oesophageal strictures in children: Outcomes after timely or delayed dilatation

Among benign oesophageal lesions, caustic strictures are the most difficult to dilate. In low-income countries, children suffering caustic oesophageal injury are frequently referred to the hospitals late, sometimes weeks after ingestion. Therefore, dilatation may be performed late and in highly fibrotic strictures. Reports about endoscopic and clinical outcome of such delayed dilatations are scanty. The aim of this study was to evaluate the safety and efficacy of late caustic stricture dilatations in children, comparing it with the results of timely dilatations, both performed at the Hospital of the Italian Non-Governmental Organization "Emergency" at Goderich, Sierra Leone. From December 2005 to May 2007, 78 children (<15 years) complaining alkaline caustic ingestion were submitted to oesophageal dilatation, mainly (97%) using Savary dilators. Two groups were identified: children (group 1) with a late treatment (>6 weeks, 37+/-12 weeks), having arrived to the hospital late after ingestion, and children (group 2) dilated timely, i.e. at <6 weeks (4+/-1.4 weeks) after injury. Strictures were severe in all patients. Twenty-five children were dilated late after injury (6.4 dilatations/patient) with a follow-up of 11+/-2.5 months. A successful clinical outcome was observed in 91.6%. Four perforations (2.6% procedure-related) and one death (4.0%) were observed. Strictures recurred once in 72% of patients, twice in 31.8%. Thirty-one children were dilated timely (4.5 dilatations/patient) with a follow-up of 10+/-2.1 months and a clinical success rate of 96.7%. Procedure-related perforation rate was 0.7% with one death (3.2%). Stricture recurred once in 30% and twice in 3.3%. Delayed dilatation of caustic oesophageal strictures in children carries a higher risk of perforation and a higher recurrence rate.

Candidate HIV-1 Tat vaccine development: from basic science to clinical trials

Over the past 20 years most of the efforts in HIV vaccinedevelopment have focused on sterilizing immunity bytargeting the Envelope protein (Env). However, resultsfrom preclinical and clinical trials have been largelydisappointing [1–11]. Therefore, current vaccine strat-egies are not only aimed at preventing virus infection butalso at blocking virus replication and disease onset. Inparticular, the control of virus replication should provideprotection from disease development and reduce virustransmission, halting the HIV epidemic. This objectivemay be achieved by targeting virus regulatory genes,which are expressed early after infection, are essential forvirus replication and pathogenesis, and are moreconserved among HIV clades. This approach may beeffective for both preventive and therapeutic vaccinestrategies [12–68]. In this article we review thecharacteristics of Tat and why it was selected for use in avaccine.Wealsocitethelessonlearnedinthedevelopmentof this anti-Tat vaccine for use in human clinical trials.