A systematic review of task- shifting for HIV treatment and care in Africa

BACKGROUND: Shortages of human resources for health (HRH) have severely hampered the rollout of antiretroviral therapy (ART) in sub-Saharan Africa. Current rollout models are hospital- and physician-intensive. Task shifting, or delegating tasks performed by physicians to staff with lower-level qualifications, is considered a means of expanding rollout in resource-poor or HRH-limited settings. METHODS: We conducted a systematic literature review. Medline, the Cochrane library, the Social Science Citation Index, and the South African National Health Research Database were searched with the following terms: task shift*, balance of care, non-physician clinicians, substitute health care worker, community care givers, primary healthcare teams, cadres, and nurs* HIV. We mined bibliographies and corresponded with authors for further results. Grey literature was searched online, and conference proceedings searched for abstracts. RESULTS: We found 2960 articles, of which 84 were included in the core review. 51 reported outcomes, including research from 10 countries in sub-Saharan Africa. The most common intervention studied was the delegation of tasks (especially initiating and monitoring HAART) from doctors to nurses and other non-physician clinicians. Five studies showed increased access to HAART through expanded clinical capacity; two concluded task shifting is cost effective; 9 showed staff equal or better quality of care; studies on non-physician clinician agreement with physician decisions was mixed, with the majority showing good agreement. CONCLUSIONS: Task shifting is an effective strategy for addressing shortages of HRH in HIV treatment and care. Task shifting offers high-quality, cost-effective care to more patients than a physician-centered model. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into healthcare teams, and the compliance of regulatory bodies. Task shifting should be considered for careful implementation where HRH shortages threaten rollout programmes

Prognostic imaging biomarkers for diabetic kidney disease (iBEAt): study protocol

Background: Diabetic kidney disease (DKD) remains one of the leading causes of premature death in diabetes. DKD is classified on albuminuria and reduced kidney function (estimated glomerular filtration rate (eGFR)) but these have modest value for predicting future renal status. There is an unmet need for biomarkers that can be used in clinical settings which also improve prediction of renal decline on top of routinely available data, particularly in the early stages. The iBEAt study of the BEAt-DKD project aims to determine whether renal imaging biomarkers (magnetic resonance imaging (MRI) and ultrasound (US)) provide insight into the pathogenesis and heterogeneity of DKD (primary aim) and whether they have potential as prognostic biomarkers in DKD (secondary aim). Methods: iBEAt is a prospective multi-centre observational cohort study recruiting 500 patients with type 2 diabetes (T2D) and eGFR ≥30 ml/min/1.73m2. At baseline, blood and urine will be collected, clinical examinations will be performed, and medical history will be obtained. These assessments will be repeated annually for 3 years. At baseline each participant will also undergo quantitative renal MRI and US with central processing of MRI images. Biological samples will be stored in a central laboratory for biomarker and validation studies, and data in a central data depository. Data analysis will explore the potential associations between imaging biomarkers and renal function, and whether the imaging biomarkers improve the prediction of DKD progression. Ancillary substudies will: (1) validate imaging biomarkers against renal histopathology; (2) validate MRI based renal blood flow measurements against H2O15 positron-emission tomography (PET); (3) validate methods for (semi-)automated processing of renal MRI; (4) examine longitudinal changes in imaging biomarkers; (5) examine whether glycocalyx and microvascular measures are associated with imaging biomarkers and eGFR decline; (6) explore whether the findings in T2D can be extrapolated to type 1 diabetes. Discussion: iBEAt is the largest DKD imaging study to date and will provide valuable insights into the progression and heterogeneity of DKD. The results may contribute to a more personalised approach to DKD management in patients with T2D. Trial registration: Clinicaltrials.gov ( NCT03716401 ).This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.This project is principally funded by the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 115974. This Joint Undertaking receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA with JDRF. This study receives additional support (personnel support) by grants from the Swedish Heart and Lung Foundation [20160872]; the Swedish Research Council [2018–02837; EXODIAB 2009–1039]; the Swedish Foundation for Strategic Research (LUDC-IRC 15–0067) to MFG; and the UK Medical Research Council (MR/R02264X/1) and Kidney Research UK (RP55/2012) to SS. This project is also supported by the National Institute for Health Research (NIHR) Exeter Clinical Research Facility and the NIHR Leeds Clinical Research Facility. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funding bodies, except for JDRF, played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.published version, accepted versio

Association of Vitamin D Metabolites With Arterial Function in the Hemodialysis Fistula Maturation Study

Background Disturbances in vitamin D metabolism are common in patients with end-stage renal disease and may contribute to vascular dysfunction. Study Design Cross-sectional. Setting & Participants We evaluated 558 of 602 participants at baseline of the Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study of a cohort of patients with chronic kidney disease awaiting arteriovenous fistula (AVF) creation surgery. Factor 4 vitamin D metabolites measured with liquid chromatography–tandem mass spectroscopy from samples obtained within 4 weeks prior to AVF surgery. Outcomes Vasodilator functions and measurements of arterial stiffness. Measurements Trained HFM Study personnel measured brachial artery flow-mediated dilation, nitroglycerin-mediated dilation, and carotid-femoral and carotid-radial pulse wave velocities (PWVs) prior to AVF creation. We evaluated associations after basic adjustment for sex, age, and clinical site and more fully adjusted additionally for baseline education, smoking, body mass index, diabetes, dialysis status, and medication use. Results Mean participant age was 55 ± 13 (SD) years and 65% were receiving maintenance dialysis. None of the vitamin D metabolites were significantly associated with flow-mediated dilation, carotid-femoral PWV, or carotid-radial PWV in basic or fully adjusted analyses. Higher serum concentrations of bioavailable vitamin D and 1,25-dihydroxyvitamin D were associated with 0.62% and 0.58% greater nitroglycerin-mediated dilation values, respectively, in basic models; however, these associations were no longer statistically significant with full adjustment. There were no significant associations of vitamin D metabolites with carotid-femoral or carotid-radial PWV in fully adjusted analyses. Limitations Cross-sectional ascertainment of vitamin D metabolites and vascular functions late during the course of kidney disease. Conclusions Serum concentrations of vitamin D metabolites are not associated with vasodilator functions or vascular stiffness at baseline in a cohort study of patients with chronic kidney disease awaiting AVF creation surgery. Laboratory measurements of vitamin D metabolites are unlikely to provide useful information regarding vascular functions in this setting

A novel lifecycle model for Web-based application development in small and medium enterprises

From the issue entitled "Focal Theme: Digital Manufacturing TechnologySoftware engineering's lifecycle models have proven to be very important for traditional software development. However, can these models be applied to the development of Web-based applications as well? In recent years, Web-based applications have become more and more complicated and a lot of efforts have been placed on introducing new technologies such as J2EE, PhP, and .NET, etc., which have been universally accepted as the development technologies for Web-based applications. However, there is no universally accepted process model for the development of Web-based applications. Moreover, shaping the process model for small medium-sized enterprises (SMEs), which have limited resources, has been relatively neglected. Based on our previous work, this paper presents an expanded lifecycle process model for the development of Web-based applications in SMEs. It consists of three sets of processes, i.e., requirement processes, development processes, and evolution processes. Particularly, the post-delivery evolution processes are important to SMEs to develop and maintain quality web applications with limited resources and time