Resource-constrained Area Research Articles

Enhancing HIV positivity yield in southern Mozambique: The effect of a Ministry of Health training module in targeted provider-initiated testing and counselling.

In Mozambique, targeted provider-initiated HIV testing and counselling (PITC) is recommended where universal PITC is not feasible, but its effectiveness depends on healthcare providers' training. This study aimed to evaluate the effect of a Ministry of Health training module in targeted PITC on the HIV positivity yield, and identify factors associated with a positive HIV test. We conducted a single-group pre-post study between November 2018 and November 2019 in the triage and emergency departments of four healthcare facilities in Manhiça District, a resource-constrained semi-rural area. It consisted of two two-month phases split by a one-week targeted PITC training module ("observation phases"). The HIV positivity yield of targeted PITC was estimated as the proportion of HIV-positive individuals among those recommended for HIV testing by the provider. Additionally, we extracted aggregated health information system data over the four months preceding and following the observation phases to compare yield in real-world conditions ("routine phases"). Logistic regression analysis from observation phase data was conducted to identify factors associated with a positive HIV test. Among the 7,102 participants in the pre- and post-training observation phases (58.5% and 41.5% respectively), 68% were women, and 96% were recruited at triage. In the routine phases with 33,261 individuals (45.8% pre, 54.2% post), 64% were women, and 84% were seen at triage. While HIV positivity yield between pre- and post-training observation phases was similar (10.9% (269/2470) and 11.1% (207/1865), respectively), we observed an increase in yield in the post-training routine phase for women in triage, rising from 4.8% (74/1553) to 7.3% (61/831) (Yield ratio = 1.54; 95%CI: 1.11-2.14). Age (25-49 years) (OR = 2.43; 95%CI: 1.37-4.33), working in industry/mining (OR = 4.94; 95%CI: 2.17-11.23), unawareness of partner's HIV status (OR = 2.50; 95%CI: 1.91-3.27), and visiting a healer (OR = 1.74; 95%CI: 1.03-2.93) were factors associated with a positive HIV test. Including these factors in the targeted PITC algorithm could have increased new HIV diagnoses by 2.6%. In conclusion, providing refresher training and adapting the current targeted PITC algorithm through further research can help reach undiagnosed PLHIV, treat all, and ultimately eliminate HIV, especially in resource-limited rural areas.

The effect of life-design-based counselling on high school learners from resource-constrained communities

In the study reported on here we explored the influence of life-design counselling intervention on high school learners with career indecision who hail from resource-poor contexts in rural South Africa. Purposeful sampling was used to select 17 participants from a resource-constrained area. A mixed-methods group-based intervention embedded in social constructionism was used to address the research questions. The qualitative outcomes for the 17 participants who constituted the intervention group are reported in this article. Data were generated using life-design-based intervention strategies and qualitative (postmodern) techniques. The intervention enhanced the facets of career adaptability of participants and improved their ability to make career decisions. The results show that participants benefited in planning their future and preparing to leave school. The value of the intervention described in this article can be confirmed in longitudinal research with larger samples of diverse participants and contexts as well as different design and assessment measures.

Lessons Learnt from the Management of Severe COVID-19 Disease in a 93-year-old with Chronic Co-Morbidities at a Resource-constrained Centre in Nigeria – A Retrospective Single Case Study

Introduction: Severe COVID-19 infection is associated with significant mortality in the elderly. This is even more so, when the elderly patient with the disease also has multiple chronic co-morbidities, and is resident in a resource-constrained area.
 Aims/ Objectives: To outline management strategies employed, and important lessons learnt from the successful management of a case of severe COVID-19 disease in a 93-year-old with chronic co-morbidities in a resource-limited setting.
 Methods: We utilized a simple COVID-19 severity categorization algorithm on presentation, to assign the index patient to the appropriate COVID-19 disease severity class and subsequently employed patient’s serial, weekly clinical and laboratory parameters to guide a multi-specialty management protocol.
 Results: A 93-year-old man was referred to a tertiary hospital in Enugu during the second wave of the COVID-19 pandemic, with a 5-day-history of high grade fever, severe fatigue, and altered sensorium. He had been living with diabetes for 48years; recently had worsening glycemic control, and was yet to pass urine in the previous 12hours. He was also being managed conservatively for prostate carcinoma. Examination revealed signs of severe pneumonia and he was drowsy, dehydrated, and had asterixis. A diagnosis of acute kidney injury from septicemia, following community acquired pneumonia and possibly urinary tract infection was made, with COVID-19 infection as a differential. Samples were collected for laboratory investigations while he was recommended for intensive care unit admission for further care. Para-enteral broad spectrum antibiotics, intravenous fluid therapy, intranasal oxygen therapy, basal-bolus-insulin-regimen, and anti-coagulation prophylaxis were instituted. Following laboratory investigation results which included a positive COVID-19 test (clinically categorized as severe disease), severe systemic inflammation, evidence of uro-tract infection, intravascular thrombosis and severe renal impairment, the Nephrology, Infectious disease, Urology teams were invited to co-manage the patient alongside the Endocrinologists. After 27days of collaborative care, patient was discharged with resolution of his symptoms and signs.
 Conclusion: Multi-specialty collaborative care improves patients’ outcome even in the face of severe COVID-19 with associated co-morbidities in elderly patients. Severity stratification ensures life-saving timely care for severe COVID-19 disease.

Scale up of implementation of a multidimensional intervention to enhance hypertension and diabetes care at the primary care setting: A protocol for a cluster-randomized study in Brazil

Hypertension and diabetes mellitus (DM) are highly prevalent in low and middle-income countries (LMICs), and the proportion of patients with uncontrolled diseases is higher than in high-income countries. Innovative strategies are required to surpass barriers of low sources, distance and quality of health care. Our aim is to assess the uptake and effectiveness of the implementation of an integrated multidimensional strategy in the primary care setting, for the management of people with hypertension and diabetes mellitus in Brazil. This scale up implementation study called Control of Hypertension and diAbetes in MINas Gerais (CHArMING) Project has mixed-methods, and comprehends 4 steps: (1) needs assessment, including a standardized structured questionnaire and focus groups with health care practitioners; (2) baseline period, 3 months before the implementation of the intervention; (3) cluster randomized controlled trial (RCT) with a 12-months follow-up period; and (4) a qualitative study after the end of follow-up. The cluster RCT will randomize 35 centers to intervention (n=18) or usual care (n=17). Patients ≥18 years old, with diagnosis of hypertension and/or DM, of 5 Brazilian cities in a resource-constrained area will be enrolled. The intervention consists of a multifaceted strategy, with a multidisciplinary approach, including telehealth tools (decision support systems, short message service, telediagnosis), continued education with an approach to issues related to the care of people with hypertension and diabetes in primary care, including pharmacological and non-pharmacological treatment and behavioral change. The project has actions focused on professionals and patients. This study consists of a multidimensional strategy with multidisciplinary approach using digital health to improve the control of hypertension and/or DM in the primary health care setting. We expect to provide the basis for implementing an innovative management program for hypertension and DM in Brazil, aiming to reduce the present and future burden of these diseases in Brazil and other LMICs. This study was registered in ClinicalTrials.gov. (NCT05660928).

Abstract 13465: Digital Health and Multifaceted Interventions to Help Manage Cardiovascular Patients in a Resource-Constrained Area in Brazil Before and During COVID-19 Pandemic

Introduction: During the COVID-19 pandemic, social isolation led to a reduction in the number of consultations of patients with hypertension and diabetes mellitus (DM) , which may cause serious complications. Objective: To assess the effect of the pandemic on the control of hypertension and DM in primary care. Additionally, to develop and assess usability of a digital solution to improve patient monitoring. Methods: Quasi-experimental study. Patients ≽30 years-old with diagnosis of hypertension or DM from 34 primary health care centers from 10 Brazilian municipalities were assessed from Jun/2017 to Dec/2020. Data on the number of consultations, systolic, diastolic blood pressure (SBP, DBP) and glycohemoglobin levels were collected. A decision support system (DSS) was developed, to be used by community health workers (CHW), to identify patients with uncontrolled diseases during household visits. Software usability was assessed by a panel of experts. Results: From 5,070 patients (mean age 56.0 [IQR 48.0-62.0], 66.4% women), 94.9% had hypertension and 27.0% DM. There was a significant reduction in the weekly number of consultations before vs. after social restriction, (107 [IQR 60, 153] vs (20 [IQR 7, 29]), p<0.001). Only 772 patients (15.2%) returned for consultation since the beginning of the pandemic. They had lower SBP (120.0, IQR 120.0-140.0 mmHg) and DBP (80.0, IQR 80.0-80.0 mmHg), comparing to individuals who did not return (SBP: 130.0, IQR 120.0-140.0 mmHg; DBP: 80.0, IQR 80.0-90.0 mmHg; p<0.001). There was no difference in glycohemoglobin levels. The expert panel agreed the DSS may identify patients at risk, and can be incorporated into the CHW routine. Up to March 2021, over 17,000 registries were performed using the app. Conclusion: COVID-19 pandemic caused a significant reduction in the number of consultations of patients with hypertension and DM in PHC. The DSS was considered useful, and it was well accepted by the CHW.

Event-Triggered Adaptive Finite-Time Control for Active Suspension Systems With Prescribed Performance

In this article, we address the event-triggered based adaptive finite-time control problem for active suspension systems (ASSs) over the resource-constrained controller area network (CAN), which is the most extensively employed in-vehicle communication network in automotive systems. The control aim is to develop an event-triggered algorithm to reduce the communication burden from the CAN and meanwhile improve the suspension performances. Specifically, a novel finite-time performance function is presented to guarantee that the tracking error is retained in a small region at any prespecified time. It is shown that under the proposed control framework, ride comfort, suspension space limitation, and handling stability are all ensured. Then, the established event-triggered mechanism based on the relative threshold method can avoid Zeno behavior. Finally, all the signals are bounded for the closed-loop ASSs. The usefulness of the presented adaptive control strategy is demonstrated through the simulation results.

‘NO! We don’t have a joint account’: mobile telephony, mBanking, and gender inequality in the lives of married women in western rural Kenya

ABSTRACT This paper examines how mobile communication and mobile banking is used by women in rural western Kenya (Elgeyo Marakwet), a resource-constrained area where women must carefully monitor the flow of money through their households. Also, women face structural inequality. Among other things, polygyny (one husband and several wives) is legal. Based on the inductive analysis of 25 interviews with women, and using the lens of intersectionality, we examine their use of mobile banking. We examine how mobile technology plays into the management of the household economy, and how it is used in extramarital relationships. We discuss how women use mobile communication in their collective savings groups (chama). We see how the mobile phone can be the locus of tensions within the household and how mBanking both supports the lives of the women but also how this can eventually undercut social support.

Initial Risk Stratification of Liver Injuries Based on Elevated Transaminases in a Medical Resource-Constrained Area

Liver injuries after blunt abdominal trauma vary from mild contusions to life-threatening damage, indicating that initial risk stratification of liver injuries is critical to improve clinical outcomes, especially in a medical resource-constrained area. This study analyzed 148 patients who underwent abdominal and chest computed tomography with elevated transaminases, with suspected liver injury after blunt abdominal trauma, between January 2008 and December 2017. The mean age was 49.6 (standard deviation 17.2) years; most patients were men (69.6%). The most common cause of trauma was motor vehicle accidents (55.4%), followed by falls (27.7%) and assault (11.5%). Patients with no liver injury (n = 63, 42.6%) and those with American Association for the Surgery of Trauma (AAST) grades I (n = 11, 7.4%) and II (n = 15, 10.1%) were treated with non-operative management. However, 2.8% of patients with AAST III (n = 36, 24.3%), 29.4% with AAST IV (n = 17, 11.5%), and 50.0% with AAST V (n = 6, 4.1%) required trans-arterial embolization, and patients with AAST IV and V had 11.8% and 33.3% mortality rates, respectively. Predictors for major liver injury (AAST IV and V) were aspartate aminotransferase ≥ 450 IU/L (p < 0.0005) and international normalized ratio ≥ 1.2 (p = 0.028). In conclusion, these laboratory values enable an initial risk stratification of liver injuries after blunt abdominal trauma that early appropriate treatment and, if not possible, a prompt transfer to a capable facility would be considered in patients who had the predictors of major liver injury.

Development and Implementation of a Decision Support System to Improve Control of Hypertension and Diabetes in a Resource-Constrained Area in Brazil: Mixed Methods Study.

BackgroundThe low levels of control of hypertension and diabetes mellitus are a challenge that requires innovative strategies to surpass barriers of low sources, distance, and quality of health care.ObjectiveThe aim of this study is to develop a clinical decision support system (CDSS) for diabetes and hypertension management in primary care, to implement it in a resource-constrained region, and to evaluate its usability and health care practitioner satisfaction.MethodsThis mixed methods study is a substudy of HealthRise Brazil Project, a multinational study designed to implement pilot programs to improve screening, diagnosis, management, and control of hypertension and diabetes among underserved communities. Following the identification of gaps in usual care, a team of clinicians established the software functional requirements. Recommendations from evidence-based guidelines were reviewed and organized into a decision algorithm, which bases the CDSS reminders and suggestions. Following pretesting and expert panel assessment, pilot testing was conducted in a quasi-experimental study, which included 34 primary care units of 10 municipalities in a resource-constrained area in Brazil. A Likert-scale questionnaire evaluating perceived feasibility, usability, and utility of the application and professionals’ satisfaction was applied after 6 months. In the end-line assessment, 2 focus groups with primary care physicians and nurses were performed.ResultsA total of 159 reminders and suggestions were created and implemented for the CDSS. At the 6-month assessment, there were 1939 patients registered in the application database and 2160 consultations were performed by primary care teams. Of the 96 health care professionals who were invited for the usability assessment, 26% (25/96) were physicians, 46% (44/96) were nurses, and 28% (27/96) were other health professionals. The questionnaire included 24 items on impressions of feasibility, usability, utility, and satisfaction, and presented global Cronbach α of .93. As for feasibility, all professionals agreed (median scores of 4 or 5) that the application could be used in primary care settings and it could be easily incorporated in work routines, but physicians claimed that the application might have caused significant delays in daily routines. As for usability, overall evaluation was good and it was claimed that the application was easy to understand and use. All professionals agreed that the application was useful (score 4 or 5) to promote prevention, assist treatment, and might improve patient care, and they were overall satisfied with the application (median scores between 4 and 5). In the end-line assessment, there were 4211 patients (94.82% [3993/4211] with hypertension and 24.41% [1028/4211] with diabetes) registered in the application’s database and 7960 consultations were performed by primary health care teams. The 17 participants of the focus groups were consistent to affirm they were very satisfied with the CDSS.ConclusionsThe CDSS was applicable in the context of primary health care settings in low-income regions, with good user satisfaction and potential to improve adherence to evidence-based practices.

Unusual way of securing the airway using gastroscope and cystoscope as an alternative to fiberoptic intubation

Difficult airway still is one of the dreaded crises in anesthesia. A well-formulated plan with all the necessary equipment should be ready when such situations are anticipated, but unanticipated difficulties can arise, and managing such cases is a nightmare for the anesthesiologist. Most hospitals in the developing countries are not equipped technically with all the modern equipment and gadgets as far as anesthesia is concerned. In a resource-constrained area, the skill and innovative ideas of the anesthesiologist often emerge as an alternative option in dealing with such cases. Here, we describe two cases of difficult intubation by conventional approach, which were managed successfully using a pediatric gastroscope and a flexible cystoscope as an alternative to fiberoptic bronchoscope.

Dynamic event-triggered scheduling and control for vehicle active suspension over controller area network

This paper addresses the problem of event-triggered scheduling and control for active suspension of uncertain quarter vehicle suspension systems over resource-constrained controller area network (CAN). The central aim is to develop an efficient dynamic event-triggered scheduling and control co-design approach for improving suspension performance, while significantly alleviating the resource occupancy over CAN in the simultaneous presence of transmission delays and data losses. To this end, two new dynamic event-triggered schedulers (DETSs) are first developed to orchestrate the transmissions of sensor data packets at each sampling time. One salient feature of the DETSs is that the dynamic variables employed in the relevant triggering laws can unremittingly adjust their values over time, which greatly favors the dynamic scheduling of data transmissions over CAN. Then, tractable criteria for stability and suspension performance analysis as well as criteria for co-designing the desired controllers and DETSs are derived. It is shown that the co-design criteria enable comprehensive trade-off analysis between network quality of service and control quality of performance and communication efficiency. Finally, simulation results for a two-degree-of-freedom quarter vehicle model demonstrate possible improvements on ride comfort, good road holding, limited suspension stroke and actuator force, meanwhile saving a large portion of communication resource expenditure.

Parental involvement in low-achieving children’s learning: The role of household wealth in rural India

Existing research recognises that while parents often aspire to be involved in their children’s education, some face barriers that prevent this. Studies situated in the Global North recognise economic constraints as a barrier, presenting a steep gradient whereby the richer households are, the higher their parental involvement levels. This paper analyses the influence of household wealth on parental involvement in low-achieving children's education in a resource-constrained area in rural Uttar Pradesh, India. Based on regression models from a sample of 13,558 households, we corroborate evidence from wealthier contexts: wealthier parents are consistently more likely to be involved in low-achieving children’s learning. This suggests that stakeholders should be aware of the potential influence of household wealth on parental involvement in rural India.

Distribution of IL28B rs12979860 and rs8099917 Genotypes in Patients with Chronic Hepatitis C Virus Infection in Tianjin, China.

Two single-nucleotide polymorphisms (SNPs) rs12979860 (C/T) and rs8099917 (T/G), near the interleukin 28B (IL28B, also known as IFN lambda-3, IFNL3) gene, have a strong association with both spontaneous and treatment-induced hepatitis C virus (HCV) clearance. IL28B polymorphisms have shown a marked differential distribution with regional and ethnic variation. The study aimed to investigate the distribution of IL28B rs12979860 and rs8099917 genotypes in patients with chronic hepatitis C (CHC) in Tianjin, China. A total of 1,600 patients with chronic HCV infection were enrolled, including 762 males and 838 females. The IL28B rs12979860 and rs8099917 polymorphisms were genotyped via a DNA microarray-based assay. The distribution of IL28B rs12979860 CC, CT, and TT genotypes was 93.94%, 5.94%, and 0.12%, and that of rs8099917 TT, TG, and GG genotypes was 88.75%, 11.06%, and 0.19%, respectively. The allele frequencies for rs12979860 C and T were 96.91% and 3.09%, and those for rs8099917 T and G were 94.28% and 5.72%, respectively. The combined assessment of the two SNPs showed that rs12979860 CC/rs8099917 TT was more prevalent with a frequency of 85.94% (1375/1600). When stratified with gender, the genotype and allele distribution of the two SNPs did not significantly differ between male and female subjects. When compared with the data derived from previously reported studies and the 1000 Genomes Project, there was a relatively higher distribution of favorable genotypes rs12979860 CC and rs8099917 TT in the present study. IL28B rs12979860 CC and rs8099917 TT genotypes were predominant in patients with chronic HCV infection in Tianjin, China. These data provided new insight into the geographical frequency distribution of IL28B variants. The higher distribution of the favorable genotypes in Tianjin might be suggestive of better response to antiviral therapy for interferon-eligible CHC patients in this resource-constrained area.

Low cost, low tech SNP genotyping tools for resource-limited areas: Plague in Madagascar as a model.

BackgroundGenetic analysis of pathogenic organisms is a useful tool for linking human cases together and/or to potential environmental sources. The resulting data can also provide information on evolutionary patterns within a targeted species and phenotypic traits. However, the instruments often used to generate genotyping data, such as single nucleotide polymorphisms (SNPs), can be expensive and sometimes require advanced technologies to implement. This places many genotyping tools out of reach for laboratories that do not specialize in genetic studies and/or lack the requisite financial and technological resources. To address this issue, we developed a low cost and low tech genotyping system, termed agarose-MAMA, which combines traditional PCR and agarose gel electrophoresis to target phylogenetically informative SNPs.Methodology/Principal findingsTo demonstrate the utility of this approach for generating genotype data in a resource-constrained area (Madagascar), we designed an agarose-MAMA system targeting previously characterized SNPs within Yersinia pestis, the causative agent of plague. We then used this system to genetically type pathogenic strains of Y. pestis in a Malagasy laboratory not specialized in genetic studies, the Institut Pasteur de Madagascar (IPM). We conducted rigorous assay performance validations to assess potential variation introduced by differing research facilities, reagents, and personnel and found no difference in SNP genotyping results. These agarose-MAMA PCR assays are currently employed as an investigative tool at IPM, providing Malagasy researchers a means to improve the value of their plague epidemiological investigations by linking outbreaks to potential sources through genetic characterization of isolates and to improve understanding of disease ecology that may contribute to a long-term control effort.ConclusionsThe success of our study demonstrates that the SNP-based genotyping capacity of laboratories in developing countries can be expanded with manageable financial cost for resource constraint laboratories. This is a practical formula that reduces resource-driven limitations to genetic research and promises to advance global collective knowledge of infectious diseases emanating from resource limited regions of the world.

Block sparsity-based joint compressed sensing recovery of multi-channel ECG signals.

In recent years, compressed sensing (CS) has emerged as an effective alternative to conventional wavelet based data compression techniques. This is due to its simple and energy-efficient data reduction procedure, which makes it suitable for resource-constrained wireless body area network (WBAN)-enabled electrocardiogram (ECG) telemonitoring applications. Both spatial and temporal correlations exist simultaneously in multi-channel ECG (MECG) signals. Exploitation of both types of correlations is very important in CS-based ECG telemonitoring systems for better performance. However, most of the existing CS-based works exploit either of the correlations, which results in a suboptimal performance. In this work, within a CS framework, the authors propose to exploit both types of correlations simultaneously using a sparse Bayesian learning-based approach. A spatiotemporal sparse model is employed for joint compression/reconstruction of MECG signals. Discrete wavelets transform domain block sparsity of MECG signals is exploited for simultaneous reconstruction of all the channels. Performance evaluations using Physikalisch-Technische Bundesanstalt MECG diagnostic database show a significant gain in the diagnostic reconstruction quality of the MECG signals compared with the state-of-the art techniques at reduced number of measurements. Low measurement requirement may lead to significant savings in the energy-cost of the existing CS-based WBAN systems.

The Development of Lyophilized Loop-mediated Isothermal Amplification Reagents for the Detection of Coxiella burnetii.

Coxiella burnetii, the agent causing Q fever, is an obligate intracellular bacterium. PCR based diagnostic assays have been developed for detecting C. burnetii DNA in cell cultures and clinical samples. PCR requires specialized equipment and extensive end user training, and therefore, it is not suitable for routine work especially in a resource-constrained area. We have developed a loop-mediated isothermal amplification (LAMP) assay to detect the presence of C. burnetii in patient samples. This method is performed at a single temperature around 60 °C in a water bath or heating block. The sensitivity of this LAMP assay is very similar to PCR with a detection limit of about 25 copies per reaction. This report describes the preparation of the reaction using lyophilized reagents and visualization of results using hydroxynaphthol blue (HNB) or a UV lamp with fluorescent intercalating dye in the reaction. The LAMP reagents were lyophilized and stored at room temperature (RT) for one month without loss of detection sensitivity. This LAMP assay is particularly robust because the reaction mixture preparation does not involve complex steps. This method is ideal for use in resource-limited settings where Q fever is endemic.

A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa

Resource-constrained countries are in extreme need of pre-hospital emergency care systems. However, current popular strategies to provide pre-hospital emergency care are inappropriate for and beyond the means of a resource-constrained country, and so new ones are needed—ones that can both function in an under-developed area’s particular context and be done with the area’s limited resources. In this study, we used a two-location pilot and then consensus approach to develop a strategy to implement and support pre-hospital emergency care in one such developing, resource-constrained area: the Western Cape province of South Africa. Local community members are trained to be emergency first aid responders who can provide immediate, on-scene care until a Transporter can take the patient to the hospital. Management of the system is done through local Community Based Organizations, which can adapt the model to their communities as needed to ensure local appropriateness and feasibility. Within a community, the system is implemented in a graduated manner based on available resources, is designed to not rely on the whole system being implemented first to provide partial function, and can also be implemented to integrate with and support an already existing ambulance system/EMS. The University of Cape Town’s Division of Emergency Medicine and the Western Cape’s provincial METRO EMS intend to follow this model, along with sharing it with other South African provinces.

Diagnosing linear immunoglobulin - A dermatosis of childhood in a resource-constrained area: Case report and review of literature

Linear immunoglobulin A (IgA) dermatosis (LAD) of childhood is a self-limiting blistering eruption. At histology, the blisters are subepidermal and may be reported as resembling dermatitis herpetiformis or bullous pemphigoid. Direct immunofluorescence (DIF) of normal or perilesional skin shows a linear band of IgA at the basement membrane. Many of the patients also have a circulating IgA antibody against the basement membrane. Diagnosis of this condition in a resource constrainedcenter, where immunofluorescence is unavailable, may pose diagnostic challenges, and may therefore require high index of suspicion. We describe a case of LAD of childhood in a 7-year-old boy in this report.

McMAC: towards a MAC protocol with multi-constrained QoS provisioning for diverse traffic in Wireless Body Area Networks.

The emergence of heterogeneous applications with diverse requirements for resource-constrained Wireless Body Area Networks (WBANs) poses significant challenges for provisioning Quality of Service (QoS) with multi-constraints (delay and reliability) while preserving energy efficiency. To address such challenges, this paper proposes McMAC, a MAC protocol with multi-constrained QoS provisioning for diverse traffic classes in WBANs. McMAC classifies traffic based on their multi-constrained QoS demands and introduces a novel superframe structure based on the “transmit-whenever-appropriate” principle, which allows diverse periods for diverse traffic classes according to their respective QoS requirements. Furthermore, a novel emergency packet handling mechanism is proposed to ensure packet delivery with the least possible delay and the highest reliability. McMAC is also modeled analytically, and extensive simulations were performed to evaluate its performance. The results reveal that McMAC achieves the desired delay and reliability guarantee according to the requirements of a particular traffic class while achieving energy efficiency.

A strategy to implement and support pre-hospital emergency medical systems in developing, resource-constrained areas of South Africa

Resource-constrained countries are in extreme need of pre-hospital emergency care systems. However, current popular strategies to provide pre-hospital emergency care are inappropriate for and beyond the means of a resource-constrained country, and so new ones are needed—ones that can both function in an under-developed area's particular context and be done with the area's limited resources. In this study, we used a two-location pilot and consensus approach to develop a strategy to implement and support pre-hospital emergency care in one such developing, resource-constrained area: the Western Cape province of South Africa. Local community members are trained to be emergency first aid responders who can provide immediate, on-scene care until a Transporter can take the patient to the hospital. Management of the system is done through local Community Based Organizations, which can adapt the model to their communities as needed to ensure local appropriateness and feasibility. Within a community, the system is implemented in a graduated manner based on available resources, and is designed to not rely on the whole system being implemented first to provide partial function. The University of Cape Town's Division of Emergency Medicine and the Western Cape's provincial METRO EMS intend to follow this model, along with sharing it with other South African provinces.