Despite great advances in antiretroviral therapy (ART) in the last decade, several limitations remain regarding adverse effects, poor adherence, and drug-drug interactions. Switching ART in stable, virologically suppressed patients with the aim of improving tolerability and convenience is a widely used strategy in clinical practice. Several factors need to be considered when switching from a successful antiretroviral regimen, including previous virologic failure and duration of virologic suppression, genetic barriers to resistance of the new regimen and expected level of adherence. Reductions in the number of pills, drugs, or doses are the most common switching strategies.Triple therapy regimens including ritonavir-boosted protease inhibitors (PI/r) are the most frequently switched regimens. Thymidine analogues, which are now uncommon in developed countries, have been successfully replaced with non-thymidine analogues in recent years. The main aim of this switch is to prevent or improve abnormal fat redistribution.Simple one-pill triple regimens such as tenofovir/emtricitabine (TDF/FTC) plus efavirenz (EFV), rilpivirine (RPV) or Elvitegravir/Cobicistat (ELVI/Cobi) may help to improve adherence and reduce some PI/r toxicities. The use of PI/r monotherapy is accepted in EACS Guidelines for selected virologically suppressed patients and may be an option for patients with previous nucleoside analogue toxicities, such as tenofovir-related nephrotoxicity. Raltegravir may be switched to once-daily regimens to improve adherence or it may replace other drugs to avoid interactions in medically complex patients. Unboosted atazanavir is a PI-containing option for patients who do not tolerate ritonavir. Two drug regimens have been assessed in randomized clinical trials and cohort studies with different results because of negative drug interactions leading to unexpected toxicities or low efficacy in some cases.In summary, many switching options are currently available for virologically suppressed patients. However, although switching strategies may be useful for improving ART, not all regimens used in clinical practice are based on data from randomized clinical trials and not all regimens are suitable for everyone. It is therefore important to individualize treatment, taking into consideration not only patient and drug characteristics but also the best evidence available.


In this review, we will highlight the different novel approaches for immunotherapy and will report on prior and ongoing clinical studies.Allergic diseases are among the most common health issues worldwide. Specific immunotherapy has remained the only disease-modifying treatment, but it is not effective in all patients and may cause side effects. Over the last 25 years, allergen molecules from most prevalent allergen sources have been isolated and produced as recombinant proteins. Not only are these molecules useful in improved allergy diagnosis, but they also have the potential to revolutionize the treatment of allergic disease by means of immunotherapy. Panels of unmodified recombinant allergens have already been shown to effectively replace natural allergen extracts in therapy. Through genetic engineering, several molecules have been designed with modified immunological properties. Hypoallergens have been produced that have reduced IgE binding capacity but retained T cell reactivity and T cell peptides which stimulate allergen-specific T cells, and these have already been investigated in clinical trials. New vaccines have been recently created with both reduced IgE and T cell reactivity but retained ability to induce protective allergen-specific IgG antibodies. The latter approach works by fusing  In industrialized societies, allergic diseases are among the most prevalent health issues, affecting up to 25 % of the population . There aAlthough allergic symptoms can often be effectively suppressed using various drugs, only allergen immunotherapy is able to impact on the underlying immune mechanism and leads to long-lasting change in the course of allergic disease . ConventIdeally, allergen extracts should contain stable and sufficient amounts of all relevant allergenic proteins. In reality, however, this is often not the case, as the content and quality of extracts is dependent on the source material, which shows natural variations, thus causing variability –13, 14•.Allergen components can be used in various ways to improve treatment options for allergic patients. Panels of unmodified recombinant or purified natural allergens, which emulate the allergen contents of natural extracts -- albeit in a highly standardized manner and lacking non-allergenic extract components -- have already been used in therapy for grass pollen- and birch pollen-allergic patients , 24. A fIn this article, we will describe the different strategies for the use of recombinant allergens and allergen derivatives for the treatment of allergic patients and provide an overview of studies that have been conducted or are currently ongoing. Additionally, we will discuss the monitoring of immunotherapy outcomes using new, test methods •, and diSeveral disadvantages of extract-based SIT .Synthetic T cell peptides may represent another alternative to recombinant allergens, as they encompass T cell epitopes while lacking the conformational IgE epitopes of the native allergen. When this approach was first investigated in cat-allergic patients, injection of short T cell peptides of Fel d 1, the major cat allergen, were associated with late-onset symptoms of rhinitis, asthma, and pruritus . These iA similar approach was used to vaccinate against the bee venom allergen phospholipase A2 (PLA2), which induced PLA2-specific IgG4, T cell hyporesponsiveness, Th1 cytokine deviation, and PLA2 peptide-specific IL-10 production, and which was well-tolerated by patients , 48. Theper se non-IgE-reactive allergen-derived peptides are covalently coupled to carrier proteins, such as viral proteins, in order to induce allergen-specific IgG antibodies with carrier-based T cell help [A recently developed approach for a safe allergy vaccine is based on the hapten-carrier principle, where ell help . PeptideAlternaria alternata mould [This vaccine design was evaluated with peptides derived from the major allergens from timothy grass pollen (Phl p 1 and Phl p 5) , 53•, bita mould  by chemiAs chemical conjugation may deliver end products of varying composition, it is not ideally suited for vaccine production under GMP conditions, it is not ideally suited for vaccine production. Therefore, defined recombinant fusion proteins consisting of the carrier protein and various numbers and combinations of the allergen-derived peptides were developed . ExamplePhase I and IIa clinical studies  were recently concluded on the BM32 vaccine, which consists of PreS fused to non-allergenic peptides from the 4 major timothy grass pollen allergens Phl p 1, 2, 5, and 6. A double-blind placebo-controlled multicenter phase IIb study (NCT01538979) is currently underway.Another approach that was recently described involves the introduction of random mutations into allergen-encoding DNA and the expression of the recombinant mutants in phage libraries. IgE antibodies of allergic patients are used for phage enrichment to generate allergy vaccines with maintained structure but altered allergenic activity, as evaluated for Fel d 1. The resulting mutants induced blocking antibodies in immunized mice . Table 1Although subcutaneous and immunotherapy are currently the most frequently used routes of allergen delivery, other approaches such as oral, nasal, bronchial, epicutaneous, intraepithelial, intralymphatic, and rectal IT have been explored. Oral immunotherapy  has beenIn this context, one new approach is edible transgenic rice containing storage protein bodies that are resistant to proteolytic degradation and may be suitable for bioencapsulation of allergens –66, 78. Epicutaneous delivery of immunotherapy is another route currently under investigation for immunotherapy , and thiTranscutaneous immunotherapy via laser-generated micropores and co-application of CpG has been described to increase the safety of the therapy by abrogating the Th2 polarizing potential of skin immunization .Another possibility for allergy vaccination is intralymphatic immunotherapy (ILIT). A study with a limited number of patients showed that ILIT with grass pollen or birch pollen extracts reduced nasal allergic symptoms without causing safety problems . Using tPeriplaneta americana arginine kinase) was tested in mice and found to attenuate allergic airway inflammation upon allergen re-exposure better than liposome-entrapped P. americana crude extract [For cockroach allergy, a novel intranasal liposome-adjuvanted vaccine containing Per a 9 . Strong experimental evidence has been provided that these antibodies – mostly IgG – prevent the allergen-induced activation of mast cells and basophils by competing with IgE for the binding to allergen molecules [reviewed in Despite improved efficacy of extract-based immunotherapy, many patients still do not exhibit significant clinical improvement after as much as three years of therapy. In defining the reasons for the failure of SIT, several factors must be considered. First, in the case of complex allergen sources like timothy grass pollen or house dust mite that contain multiple allergens that can trigger symptoms, sensitization profiles may vary significantly between allergic individuals . ExtractThese diagnostic constraints have been partially overcome with the availability of serological tests comprising purified allergen molecules , as onlyIn tests for reactivity to single allergen molecules, a relatively large amount of the purified allergen molecule is used for Ig detection when compared to average titers of allergen-specific antibodies in the serum. Hence, all antibodies in the sample that recognize the respective allergen – IgE as well as IgG – can be bound and detected. In this way, the test allows quantitative measurement of the respective antibody species, which may be relevant, for example, in the quantification of an IgE-boost by vaccination. However, if the IgG-response to SIT has to be measured, results of this test may be misleading because they do not distinguish blocking from non-blocking IgG. Even if only therapeutically irrelevant non-blocking IgG were induced, the test would yield a positive result. Furthermore, when assessing the immunological efficacy of SIT, it is important to determine that a vaccination produced a protective IgG “shield” covering all relevant allergens the patient is sensitized to. In the case of complex allergen sources, many single tests are required to obtain a comprehensive analysis of the patient’s immune response.Allergen microarrays  typicallIn this context, allergen microarrays facilitate analysis of the immune response of a patient treated by specific immunotherapy, enabling the physician to identify “holes” in the protective IgG-shield and to distinguish clinically relevant from insufficient IgG responses upon vaccination.in vivo tests [In addition to these clinically well-established serological tests, several methods are under investigation that may help assess and predict the success of SIT  or distivo tests , while tvo tests .The goal of personalized medicine is to tailor and/or optimize treatment for each individual patient exactly to his or her personal situation. The topic has been widely discussed in the context of genetics, and largely advocates the use of new technologies to customize medicine for the benefit of patients. It may be considered ironic that customized medicine prescribed by medical doctors for individual patients and manually compounded by pharmacists was far more common before production and packaging of medicine became widely industrialized. Along the same lines, conventional allergen immunotherapy could also be regarded as a classic form of personalized medicine. In Europe, therapeutic allergen extract preparations were and still are largely ordered from pharmaceutical companies that produce, package, and label them for individual patients.Similar to other pre-packaged medicines, few immunotherapy preparations have received full regulatory approval in the EU. Although the regulatory situation varies among different countries, drug products customized for individual patients generally do not have the same stringent approval requirements as other drugs . On thishttp://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/WC500003605.pdf ). At this time, allergen vaccines need to undergo tests for market authorization in their final composition. This means that current regulations represent a hurdle for obtaining market authorization for individual components for use in different mixtures according to sensitization profiles of patients. As clinical trials for immunotherapy preparations are extremely costly, the current regulatory situation certainly slows the development of personalized treatment for allergic patients based on individual sensitization patterns. One way to speed up progress and improve the situation would be to allow market authorization for combination vaccines based on studies demonstrating common immunological mechanisms for individual allergen components, as is common practice in the field of vaccines for infectious diseases.In contrast to allergen extracts, market authorization of vaccines based on allergen components, recombinant allergens, allergen derivatives, and allergen peptides is extremely stringent and closely regulated (European Medicines Agency (EMA) guidelines published June 1, 2009: In summary, therefore, although it is already technically possible to treat each individual allergic patient precisely according to his or her sensitization profile, this practice is currently held back by the prevailing market authorization guidelines. Clinical studies investigating common mechanisms of SIT for different defined allergen components are urgently needed as the basis for new guidelines to allow the development of personalized forms of SIT.Allergen-specific immunotherapy (SIT) is the only causative and disease-modifying treatment for IgE-mediated allergies. However, SIT aims to change an already established and misled immune response. The treatment does not cure the disease or restore healthy immune response . BecauseThere is no reason to believe that a prophylactic vaccination against IgE-mediated allergies is not possible, but it would have to fulfil certain requirements. First, and most importantly, the vaccine must be safe. Current SIT preparations are based on natural allergen extracts that can lead to an increase of allergen-specific IgE in allergic patients, and which would therefore bear the risk of sensitizing non-allergic individuals when used as prophylactic treatment . It is pIn this context, recombinant allergen variants lacking the binding sites for allergen-specific IgE would be good candidate molecules for prophylactic vaccination due to the very low risk of sensitization to naturally occurring allergens. The immunological effect of this form of treatment is thought to be the induction of protective blocking IgG antibodies, similar to prophylactic vaccines against infectious diseases. These allergen-specific antibodies should bind to the allergen and thus prevent stimulation of the immune system Fig. . Anotherhttp://medall-fp7.eu). It is thought that individuals with an atopic genetic background are sensitized in the first year(s) of life and become symptomatic when a certain threshold of allergen-specific IgE is reached [A second very important aspect for a prophylactic treatment is the selection of the best time window for vaccination. It is the nature of a prophylactic treatment that it must be performed before the onset of the disease. The investigation of the precise time when sensitization occurs is currently the subject of large birth cohort studies  .The third aspect that must be considered is the selection of the most useful panel of allergens. The definition of the most important allergens  is currently the subject of investigations delineating sensitization profiles in different countries and populations , 107•  should be treated. An initial attempt to further pursue this approach is currently undergoing clinical investigation. Two hypoallergenic fragments of Bet v 1 that have previously been shown to induce protective immune responses but no new IgE antibody responses in birch pollen-allergic patients are currently being used for vaccination of 20 non-allergic adult individuals in a clinical phase I study (NCT01353924).Over the last 25 years, most of the clinically relevant allergens from important allergen sources have been isolated and produced as recombinant molecules. Allergen components are already used in routine diagnostic setting, but they can also improve the monitoring of patients undergoing allergen immunotherapy. Panels of recombinant allergens may also replace natural allergen extracts for the treatment of allergic patients. Genetic engineering allows the production of innovative allergy vaccines designed to reduce side effects, enhance clinical efficacy, and increase treatment convenience. Based on several clinical studies performed with recombinant allergens, hypoallergens, and peptides, it is clear that such vaccines will greatly improve SIT and may be useful for prophylaxis. However, further clinical studies are needed for these new vaccines to become available for patients.


Obesity is the most common nutritional disorder in dogs and a main health and welfare concern worldwide; it links to a shortened lifespan and increased rate of secondary diseases. Surveillance of dog adiposity is a routine practice and is often estimated from body condition scoring (BCS). But BCS is subjective and fairly sensitive, reducing its utility during weight-loss plans. Substitute approaches, simple, cheap and reproducible, are foreseen.This work aimed to assess real time ultrasonography (RTU) usefulness for analysis of sub-cutaneous body fat depots (SCF) in dogs.Twenty-eight dogs were enrolled, representing different sizes , weights  and BCS . RTU images were taken with a multifrequency linear array (at 10 MHz) coupled to a GE scanner, from non-sedated dogs in right lateral recumbency, at five anatomical points: entry of the chest; over the ninth intercostal space; lateral abdominal wall; right inner thigh; and between the third and the fifth lumbar vertebrae. Images were analysed in Image J; means from 3-different locations per image were used to set SCF thickness. Using the JMP program correlation procedure was used to analyse SCF and BCS relationships.BW was poorly associated with SCF thickness , while BCS and SCF were strongly correlated , particularly for data collected at lumbar and abdominal points.Results stress that BW is a poor adiposity predictor and suggest that RTU is a valuable tool to predict dog adiposity.


A 70-year-old with a background of chronic lymphocytic leukemia (CLL) and progressive necrotic cutaneous periorbital lesions was incorrectly managed as having necrotizing fasciitis (NF) when referred to plastic surgery. The underlying pathological process of Richter syndrome was missed until it was too late for this patient. Richter syndrome is a transformation of CLL into higher-grade lymphomas, driven by viral infections, whose successful treatment is dependent on rapid diagnosis and aggressive targeted chemotherapy/immunomodulation. It more commonly presents with lymphadenopathy but may, as in this case, present as a necrotic cutaneous basin, being easily mistaken for other differential diagnosis.What is Richter syndrome?How is Richter syndrome diagnosed?How do you distinguishing between necrotic cutaneous differential diagnoses in patients with CLL?How should Richter syndrome be managed with cutaneous presentations?Richter syndrome is the transformation of CLL into diffuse, large B-cell lymphoma.4Once suspected, Richter syndrome  is diagnosed by demonstrating CLL's histopathological phenotypic change through biopsy of the affected lymph, bone marrow, or as in this case, cutaneous involvement.In a patient with CLL and cutaneous necrosis of the orbit, additional to the more common fungal and infective causes, although NF is less common, as an aggressive potentially deadly soft-tissue/fascial infection, it should be considered and either ruled out or treated.Not only is Richter syndrome frequently a difficult diagnosis to establish but it also presents a therapeutic challenge. Treatment of Richter syndrome is primarily through the administration of monoclonal antibodies, chemotherapy, and steroids in the acute care setting.


The basic-helix-loop-helix (bHLH) transcription factors Ascl1/Mash1, Hes1, and Olig2 regulate the fate choice of neurons, astrocytes, and oligodendrocytes, respectively; however, these factors are coexpressed in self-renewing multipotent neural stem cells (NSCs) even before cell fate determination. This fact raises the possibility that these fate determination factors are differentially expressed between self-renewing and differentiating NSCs with unique expression dynamics. Real-time imaging analysis utilizing fluorescent proteins is a powerful strategy for monitoring expression dynamics. Fusion with fluorescent reporters makes it possible to analyze the dynamic behavior of specific proteins in living cells. However, it is technically challenging to conduct long-term imaging of proteins, particularly those with low expression levels, because a high-sensitivity and low-noise imaging system is required, and very often bleaching of fluorescent proteins and cell toxicity by prolonged laser exposure are problematic. Furthermore, to analyze the functional roles of the dynamic expression of cellular proteins, it is essential to image reporter fusion proteins that are expressed at comparable levels to their endogenous expression. In this review, we introduce our recent reports about the dynamic control of bHLH transcription factors in multipotency and fate choice of NSCs, focusing on real-time imaging of fluorescent reporters fused with bHLH transcription factors. Our imaging results indicate that bHLH transcription factors are expressed in an oscillatory manner by NSCs, and that one of them becomes dominant during fate choice. We propose that the multipotent state of NSCs correlates with the oscillatory expression of several bHLH transcription factors, whereas the differentiated state correlates with the sustained expression of a single bHLH transcription factor. Neural stem cells (NSCs) are multipotent and self-renewable cells that can give rise to neurons, astrocytes, and oligodendrocytes  : therefore, the reporter-bHLH fusion proteins are also very unstable (Imayoshi et al., To acquire these very weak fluorescent signals, we utilized a confocal microscope equipped with a highly sensitive detector (Imayoshi et al., In addition to the highly sensitive and spectral imaging techniques, imaging systems should be optimized for low-noise and reliable quantitative analysis. As the fluorescent signal intensity of reporter-bHLH fusion proteins is very weak, contamination with noise signals impairs the reliable quantitative analysis of the expression dynamics of bHLH transcription factors. To prevent bleaching the fluorescent reporters and avoid photodamage to NSCs by the excitation lasers, the sensitivity of the imaging system is again critically important. Bleaching of the reporters impairs the reliability of the imaging results. During long-term continuous imaging, laser power should be as small as possible, because NSCs are delicate and very sensitive to exogenous perturbations, including photodamage by exposure to a strong laser.NS cell cultures established from Venus-Hes1 fusion knock-in, Venus-Ascl1 fusion BAC Tg, and mCherry-Olig2 fusion BAC Tg mouse strains were used for real-time imaging with confocal fluorescence microscopy. This analysis revealed that the fluorescent fusion reporter proteins with Hes1, Ascl1, or Olig2 exhibited dynamic expression changes in NS cells (Supplementary Movies The oscillatory expression of bHLH transcription factors raised the possibility that NSCs may change their fate preferences over time. Indeed, when cultured NSCs are sorted by their expression levels of each bHLH transcription factor, their differentiation preferences are correlated with bHLH expression levels (Imayoshi et al., In contrast to oscillatory expression of multiple bHLH transcription factors in self-renewing NSCs, one of the bHLH transcription factors is expressed in a sustained manner during cell fate choice, while the others are repressed Figure  Imayosh. For insFrom these analyses, we propose the following model: the oscillatory expression of multiple bHLH transcription factors is correlated with the multipotent and self-renewable state of NSCs, whereas the sustained expression of a selected bHLH transcription factor regulates fate determination Figure  Imayosh,b. To vaPrevious reports have shown some evidence that the bHLH transcription factors Hes1, Ascl1, and Olig2 have multiple functions, such as NSC proliferation, self-renewal, and differentiation. Of course, protein modifications and/or partner co-factor variation may be involved in these different activities of bHLH transcription factors in a complex manner, but our studies revealed that oscillatory versus sustained expression dynamics also contribute to these different functions. More generally, our studies indicated that expression patterns, rather than simply the expression levels, of various transcription factors regulate whether stem cells proliferate or differentiate. In addition to Hes1, Ascl1, and Olig2, other bHLH transcription factors, such as Hes5 and Neurog2, are expressed in an oscillatory manner in NSCs or neural precursor cells (Shimojo et al., bHLH transcription factors regulate other kinds of somatic stem cells and pluripotent stem cells. For example, Ascl1 is essential for the differentiation of neuroendocrine cells from epithelial progenitors of the developing glandular stomach (Kokubu et al., Our studies suggest the importance and future possibilities of imaging techniques for the analysis of the expression dynamics of endogenous proteins at the single-cell level by coupling with various cellular events, such as cell cycle progression and cell differentiation (Miyawaki, The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Preterm infants are especially vulnerable to infection-induced white matter injury, associated with cerebral palsy, cognitive and psychomotor impairment, and other adverse neurological outcomes. The etiology of such lesions is complex and multifactorial. Furthermore, timing and length of exposure to infection also influence neurodevelopmental outcomes. Different mechanisms have been posited to mediate the observed brain injury including microglial activation followed by subsequent release of pro-inflammatory species, glutamate-induced excitotoxicity, and vulnerability of developing oligodendrocytes to cerebral insults. The prevalence of such neurological impairments requires an urgent need for early detection and effective neuroprotective strategies. Accordingly, noninvasive methods of monitoring disease progression and therapy effectiveness are essential. While diagnostic tools using biomarkers from bodily fluids may provide useful information regarding potential risks of developing neurological diseases, the use of magnetic resonance imaging/spectroscopy has emerged as a promising candidate for such purpose. Various pharmacological agents have demonstrated protective effects in the immature brain in animal models; however, few studies have progressed to clinical trials with promising results. In 1867, Virchow first described the pathological changes in the neonatal brain, characterized by softening of the periventricular white matter, and employed the term “congenital encephalomyelitis” where he emphasized the inflammatory nature of the disease . Volpe lThere is evidence for an association between antenatal infection with subsequent neurological injuries including perinatal white matter injury, cerebral palsy, blindness, deafness, and motor and cognitive deficits –10. HoweIn humans, maturation of the adaptive immune system occurs after birth, thus making the innate immune system largely responsible for fighting off infections in the first weeks of life , 27. HowPro-inflammatory cytokines are upregulated in the brain following peripheral lipopolysaccharide (LPS) administration in animal studies; however, mechanisms of how systemic inflammation relay signals to the brain that leads to increased central nervous system (CNS) inflammation and injury continues to be debated . One proStudies have suggested that the BBB may not develop until birth, as it was assumed that such development was associated with the appearance of astrocytes, which do not appear until after birth , 50. A g2 production in the brain which in turn mediates inflammation [Inflammation in the periphery may cause sustained brain inflammation through an indirect mechanism Fig. . Brain eammation .Fig. 1ImAlternatively, the circumventricular organs (CVO)  and theUnderstanding such inflammatory mechanisms in the periphery is particularly helpful for purposes of finding specific biomarkers that can be targeted for easy diagnosis and effective therapeutic options. However, while cytokine detection in the periphery can have implications on inflammatory activities inside the brain, the detection window for such fluctuations in inflammatory cytokine levels may be narrow and unfortunately are not specific of inflammatory brain injury . UnderstBrain injury observed in preterm neonates is likely multifactorial. However, inflammation, excitotoxicity, and immaturity of oligodendrocytes (OL) have been shown to play important contributory roles in impairing normal brain development. Microglial activation is at the cornerstone of inflammatory brain injury in the preterm infant. Implicated in a variety of developmental steps during brain maturation, microglial cells regroup in the periventricular zone, a main site with major axonal crossroads that corresponds to white matter areas that are most vulnerable in PVL, at the end of the second trimester , 64. DurPreterm infants have a high risk of developing white matter lesions in response to perinatal injuries and such injuries may be sensitized by previous exposure to inflammation –73. GlutIntra-amniotic infections are associated with an increased risk of preterm delivery, which, in turn, may be associated with neurological sequelae in former preterm infants . MicrobiIn humans, the clinical use of cranial ultrasound in detecting brain injury is the most prevalent technique used due to its relative safety, convenience of bedside scans, and cost-effectiveness that allows serial scanning of preterm infants at high risks  even if In animals, high-resolution ultrasound is now possible within the first few days of birth in rodents, but this method quickly becomes limited due to skull calcification. Using alternative view angle in older animals offers better penetration without the need for scalp or skull removal . Using aMonitoring brain electrical activity can provide useful information to evaluate brain injury in preterm infants. EEG detects local field potentials produced by neurons that fire off electrical activity . Both trIn a fetal sheep model of neuroinflammation , where aWannabe et al.  suggestsMRI and magnetic resonance spectroscopy (MRS) have become useful due to their high resolution and noninvasive means of monitoring macrostructural, microstructural, and metabolic developmental changes in the neonatal brain. Identifying ongoing brain injury in the setting of infection/inflammation will aid in recognizing newborns in need of targeted neuroprotection. To date, there is clinical evidence that MRI/MRS can identify early signs of injury along with a growing body of experimental data on animals to support such evidence.Traditional magnetic resonance imaging, T1- and T2-weighted imaging, allow in vivo and ex vivo assessment of qualitative macrostructural changes in the brain and can detect overt injury .. [In pre-clinical studies, the ability to compare MRI data and histology provides insights into associated pathological changes following an inflammatory exposure Fig. . Dean et.  found th. . HoweverIn clinical studies, early conventional imaging can reveal more than periventricular cysts with early and sometime persistent periventricular lesions with localized T1 hyperintensities as seen in the sheep model exposed to LPS described earlier , 116. InThe apparent diffusion coefficient (ADC) is used as an assessment of the Brownian motion of water molecules. It is calculated from diffusion-weighted images. The restriction of water motion has been initially described in adult animal stroke models  with simIn pre-clinical studies, the natural evolution of the ADC in the white matter has been quantified following LPS exposure . SimilarFew days following LPS exposure, the ADC gradually increases in animal studies. When compared to histology, the delayed increase in ADC has been associated with increase in edema, tissue rarefaction, decreased cell density, and increase in extracellular space , 126.The radial diffusivity computed from diffusion tensor imaging (DTI) acquisition is traditionally related to myelin integrity as it measures diffusivity perpendicular to the axon. Increase in white matter radial diffusivity has been well described in mature animal model of multiple sclerosis and shown to be a reliable marker of dysmyelination . However. [In humans, the delayed increased in ADC of the white matter has been shown in preterm infants imaged at term equivalent age. Counsell et al.  and Maal.  have dem. .The development of user-independent approaches to quantify the impact of therapy is essential. Recently, tract-based spatial statistics (TBSS) has been identified as a potential tool in this regard. Designed to study fractional anisotropy maps compiled from DTI, TBSS is an approach that evaluates microarchitectural differences between groups in major fiber bundles. As the technique evaluates diffusion characteristics of major fiber bundles, it is not used as a specific tool to assess brain inflammation. TBSS is currently used in a prospective trial to test the efficiency of melatonin to protect the preterm brain (see below).1H-MRS) may be used to investigate brain metabolism and monitor development, which is characterized by a progressive increase in N-acetylaspartate (NAA)  and myo-inositol  [Proton MRS (pathway) , 132. Anpathway) .In human neonates, brain injury was shown to alter the concentrations of NAA and lactate metabolites. In response to HI, NAA/choline ratio was shown to decrease  while la2–) which is known to increase with apoptosis.In animal models of LPS-induced brain inflammation, using very high magnetic field and short echo time, quantifiable increase in lactate concentration using the LCModel was also observed along with the appearance of lipid 13 , a peak The impact of inflammation in the brain can be monitored in newborns and in equivalent animal models using MRI/MRS/DTI. As there are to date no blood biomarkers of cerebral integrity, the assessment of available imaging biomarkers is essential for monitoring brain injury and responses to therapy, but potentials and limitations of such approaches need to be better delineated.As detailed earlier, pre-natal inflammatory exposure can modify the trajectory of brain development in preterm infants. A growing research domain of placental imaging may provide indications about underlying disease mechanisms and potentially serve as a useful biomarker. Pre-clinical studies have shown that in a murine model of placental inflammation, induced by systemic LPS administration, a reduction of T2-weighted intensity could be detected as early as 3–6 and 12 h after LPS exposure followed by a reduced placental perfusion seen by dynamic contrast-enhanced (DCE) T1-weighted imaging 12 h after LPS exposure . In a laUsing conventional imaging, placental hemorrhages and ischemic lesions were detected by T1- and T2-weighted imaging but not chorioamnionitis . In a caPET allows for a noninvasive evaluation of microglia activation in the diseased brain. The technique takes advantage of the fact that the peripheral benzodiazepine receptor is primarily found on activated microglia and such receptors are capable of binding to radioactive ligands, which are in turn detectable using PET . HannestThe role of IL-1β as a pro-inflammatory cytokine involved in eliciting injury in the immature brain has been well established through animal models , 142. ThThe neuroprotective properties of IL-10 have also been demonstrated in premature animal models , 145. ExMinocycline, a second-generation derivative of tetracycline, has demonstrated anti-inflammatory and neuroprotective properties through suppressing microglial activation, reducing white matter injury –152 and Melatonin is a powerful endogenous antioxidant with a high level of biosafety. Its efficacy in alleviating brain injury through promoting myelination, reducing inflammation, and reducing cell death has been demonstrated in various premature animal models –159. FurThe neuroprotective properties of erythropoietin, a hematopoietic cytokine, have also been explored in the neonatal animal models where it was observed to attenuate microglial activation, reduce apoptosis, reduce OL damage, and promote neurogenesis and repair mechanisms –165.Translating these strategies in human preterm infants is challenging and in contrast to animal studies, true neuroprotection assessment is complicated by the fact that detailed tissue analysis is not available and that accurate clinical evaluation can only be performed several years later.In clinical trials, the administration of melatonin has been shown to improve survival outcomes in septic term neonates . A neuro. [Recently, in a Swiss multicenter research trial, erythropoietin has neuroprotective properties in the preterm babies. Leuchter et al.  showed t. .Corticosteroids play an immunomodulatory role by reducing the inflammatory response . However, clinical studies with early administration of corticosteroids as treatment for chronic lung disease in premature infants, while showed short-term benefits in improved ventilation, did not translate into long-term benefits . In pretThe etiology of white matter lesions seen in preterm infants is complex; various factors may predispose the immature brain to such injuries. The activation of the immune system is the body’s natural defense mechanism in fighting off invasive pathogens. However, uncontrolled response due to recurrent or severe infection may produce deleterious consequences including multi-organ failure, brain injury, and increased mortality. Various biochemical biomarkers have been shown to associate with brain injury in the preterm infants; however, there has yet emerged a single robust blood biomarker that is employed in clinical settings today. The emergence of imaging biomarkers as a noninvasive and sensitive diagnostic tool for early detection of cerebral white matter injury is gaining acceptance. Pharmacological interventions in the form of synthetic drugs, recombinant immunomodulators, and hormones have demonstrated anti-inflammatory/protective effects in animal models, however, with few promising candidates that have progressed to clinical trials. Further research is still required to come up with reliable tools to quantify noninvasively inflammation and monitor therapeutic response.


Timeliness, completeness, and accuracy are key requirements for any surveillance system to reliably monitor disease burden and guide efficient resource prioritization. Evidence that electronic reporting of malaria cases by community health workers (CHWs) meet these requirements remains limited.Residents of two adjacent rural districts in Zambia were provided with both passive and active malaria testing and treatment services with malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy by 42 CHWs serving 14 population clusters centred around public sector health facilities. Reference data describing total numbers of RDT-detected infections and diagnostic positivity (DP) were extracted from detailed participant register books kept by CHWs. These were compared with equivalent weekly summaries relayed directly by the CHWs themselves through a mobile phone short messaging system (SMS) reporting platform.versus 25,583, respectively). The majority (81%) of weekly SMS reports were received within one week and the remainder within one month. Overall mean [95% confidence limits] difference between the numbers of register-recorded and SMS-reported RDT-detected malaria infections per CHW per week, as estimated by the Bland Altman method, was only −2.3 . The mean [range] for both the number of RDT-detected malaria infections ) and DP  reported by SMS were generally very consistent with those recorded in the reference paper-based register data and exhibited similar seasonality patterns across all study clusters. Overall, mean relative differences in the SMS reports and reference register data were more consistent with each other for DP than for absolute numbers of RDT-detected infections, presumably because this indicator is robust to variations in patient reporting rates by location, weather, season and calendar event because these are included in both the nominator and denominator.Slightly more RDT-detected malaria infections were recorded in extracted participant registers than were reported in weekly mobile phone summaries but the difference was equivalent to only 19.2% (31,665 The SMS reports captured malaria transmission trends with adequate accuracy and could be used for population-wide, continuous, longitudinal monitoring of malaria transmission. Like many malaria endemic countries, Zambia is experiencing an epidemiological transition with regard to malaria disease burden, with a notable national decline in parasite prevalence and incidence . Public A viable surveillance system for malaria in Zambia needs to routinely collect sufficient data to describe the population’s health status , for theIn poorly-resourced countries, community-based surveillance systems (CBSS) can complement health facility (HF)-based surveillance. This is of particular relevance to malaria control because the infectious human reservoir is primarily comprised of chronic infections associated with sub-acute symptoms distributed across entire at-risk populations  and bothThis study describes and evaluates a prototype mobile phone reporting platform for a CBSS in rural Zambia that was initially established as a programme implemented by CHWs for community-wide passive and active testing with RDTs and treatment of all confirmed cases with Artemether-Lumefantrine (AL), which also allowed monitoring of malaria parasite infection burden as a secondary objective .Plasmodium falciparum is mediated by Anopheles funestus Giles at an estimated entomological inoculation rate of approximately 70 infectious bites per unprotected person per year . In. In10]. per year . Luangwa of 2.9% . Nyimba  of 3.4% . Both diAs described in detail elsewhere , 14 popuThe CHWs’ primary method of collecting study participant information was through the use of a paper-based, pre-defined questionnaire provided in the physical form of a register book. A total of 16 data elements were captured through this method and these included date, cluster, participant identification number, sex, age, visit type (active/passive), village, axilliary temperature, RDT results, clinical symptoms of illness , treatment provided and participant outcome, in addition to access and utilization of specific preventive measures, namely long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS) and intermittent preventive therapy. All the entries in the registers, with each line of data corresponding to a single participant contact, were made in duplicate with carbon paper. During the monthly supervisory visits, original copies of these reports were collected and transported to the NMCC for entry into a correspondingly structured Microsoft excel spreadsheet in fully explicit, line-listed electronic database format, while the CHWs retained the duplicate copies for their own records. All data from the registers were double-entered and verified, reconciled, and then cleaned following descriptive frequency analysis of the distributions of values for each variable.In addition to the paper-based participant registers, weekly aggregate summary reports of these data were collated through mobile phone short messaging service (SMS) via the Airtel® network Figure . A paperThe explicit, unaggregated, line-listed, manually double-entered reference data from the participant registers were independently aggregated by the NMCC into weekly estimates of total number of malaria infections seen by each CHW and the corresponding diagnostic positivity (DP) of tests associated with those participant contacts. The weekly DP was estimated as outlined in the formula below:r) between the two data capture methods, which were also disaggregated by type of patient contact. Though one limitation of analysis by correlation coefficient is that it is possible to obtain high correlation even when the absolute values of the variables are different  difference in the number of RDT-detected malaria infections per week per CHW between the reference paper-based register and SMS reporting platform, as estimated by the Bland-Altman method, was −2.3  infections per CHW per week , symptomology, morbidity, diagnostic testing and treatment for malaria, as well as LLINs and IRS, which are not routinely captured by the national HMIS , 10. ThiThe comparison of the SMS weekly summaries with the reference paper-based, quality-controlled register records indicates some modest incompleteness of the former, with the paper based system recording a higher overall number of malaria infections. This may have been due to under-reporting in the SMS reporting system resulting from challenges in accurately summarising the reference registers data and non-submission of the SMS reports by some of the CHWs when they were required to. Additionally, the manual entry of the SMS-transmitted data into an excel spreadsheet by the study team may have resulted in some reports being lost in the process and not entered into the database because, unlike the paper-based register records, there was no double entry verification of this data.Timeliness, a key performance measure of any public health reporting system , 40 was In the reference paper-based register, the high level of detail that included individual-level data over the entire implementation period provided an invaluable resource in the form of a rigorous epidemiological database for critical analysis of malaria transmission dynamics and risk factors . While sAn obvious limitation of the study was that the SMS platform would have benefited from an automated central server system of data capture when SMS reports were submitted , which wThis SMS reporting system captured malaria transmission trends, as recorded in the reference paper based registers, with adequate accuracy, suggesting potential use in population-wide, continuous and longitudinal monitoring of temporal and geographic trends in disease incidence. Additionally, the summary reports through the SMS platform enabled reasonably timely collation, access to and dissemination of the paper-based surveillance data, which was shared among the study team and district health management teams so they could be used for programmatic decision-making. Given the recent dramatic growth in mobile phone networks globally, and in Africa particularly, such CBSS may be highly effective if mobile technology platforms are harnessed for reporting directly from CHWs to central servers to allow for rapid data access, use and quality assurance by stakeholders at the district, provincial and national levels.


Symptoms in late-onset neuromuscular disorders initiate only from midlife onward and progress with age. These disorders are primarily determined by identified hereditable mutations, but their late-onset symptom manifestation is not fully understood. Here, we review recent research developments on the late-onset autosomal dominant oculopharyngeal muscular dystrophy (OPMD). OPMD is caused by an expansion mutation in the gene encoding for poly-adenylate RNA binding protein1 (PABPN1). The molecular pathogenesis for the disease is still poorly understood. Despite a ubiquitous expression of PABPN1, symptoms in OPMD are limited to skeletal muscles. We discuss recent studies showing that PABPN1 levels in skeletal muscles are lower compared with other tissues, and specifically in skeletal muscles, PABPN1 expression declines from midlife onward. In OPMD, aggregation of expanded PABPN1 causes an additional decline in the level of the functional protein, which is associated with severe muscle weakness in OPMD. Reduced PABNPN1 expression in muscle cell culture causes myogenic defects, suggesting that PABPN1 loss-of-function causes muscle weakness in OPMD and in the elderly. Molecular signatures of OPMD muscles are similar to those of normal muscle aging, although expression trends progress faster in OPMD. We discuss a working hypothesis that aging-associated factors trigger late-onset symptoms in OPMD, and contribute to accelerated muscle weakness in OPMD. We focus on the pharyngeal and eyelid muscles, which are often affected in OPMD patients. We suggest that muscle weakness in OPMD is a paradigm for muscle aging. In aging populations, late-onset disorders are highly common, among which late-onset neuromuscular (NM) disorders are a subset. NM disorders affect muscle fibers and/or the central and peripheral nervous system and the NM junction that control the muscle fibers. At present, these disorders are often incurable. As life expectancy rises, the prevalence of late-onset disorders causing chronic muscle weakness increases. Muscle symptoms can manifest from midlife onward, leading to a drastic functional decline with social and economic burdens. This suggests that in addition to the fundamental genetic defect(s), possible similar aging-associated regulators trigger the late onset of symptoms and progression thereof. For example, protein catabolism, which discards defective or redundant proteins (mainly through the ubiquitin proteasome and autophagy systems), has been implicated as a predominant regulator in normal aging and late-onset diseases . Due toin vitro as a regulator of poly(A) tail length  is marked, among others, by a decrease in muscle mass (atrophy), an increase in fat infiltration and inflammation leading to a decrease in muscle strength and physical performance (Cruz-Jentoft et al., Although OPMD is often grouped within the muscular dystrophies, our studies of RNA expression profiles in OPMD muscles and OPMD models revealed higher similarities with muscles from the elderly rather than with muscular dystrophies or myopathies (Anvar et al., The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Extracellular vesicles (EVs) are membrane-surrounded structures released by most cell types. They are characterized by a specific set of proteins, lipids and nucleic acids. EVs have been recognized as potent vehicles of intercellular communication to transmit biological signals between cells. In addition, pathophysiological roles of EVs in conditions like cancer, infectious diseases and neurodegenerative disorders are well established. In recent years focus has been shifted on therapeutic use of stem cell derived-EVs. Use of stem cell derived-EVs present distinct advantage over the whole stem cells as EVs do not replicate and after intravenous administration, they are less likely to trap inside the lungs. From the therapeutic perspective, the most promising cellular sources of EVs are mesenchymal stem cells (MSCs), which are easy to obtain and maintain. Therapeutic activity of MSCs has been shown in numerous animal models and the beneficial paracrine effect of MSCs may be mediated by EVs. The various components of MSC derived-EVs such as proteins, lipids, and RNA might play a specific therapeutic role. In this review, we characterize the role of EVs in immune and central nervous system (CNS); present evidences for defective signaling of these vesicles in neurodegeneration and therapeutic role of EVs in CNS. Mesenchymal stem/stromal cells (MSCs) are of great interest in regenerative therapy for tissues damaged by various pathological conditions. The chief therapeutic attributes of MSCs are their ability to migrate into injured sites , promoteIn this review we summarize role of EVs in pathophysiology of different neurological and immunological conations, properties and functions of EVs derived from MSCs and their potential therapeutic role in neurological disorders.Figure 1). In broad terms there are three types of EVs, however, in the literature the nomenclature is inconsistent and the term microvesicles is often used as an umbrella term to encompass exosomes and shedding microvesicles .Apoptotic bodies represent another type of EVs. Although they resemble microvesicles they can be distinguished by their large size and irregular shape . In contExtracellular vesicles are composed of various molecules including proteins, lipids, and nucleic acids. Secreted proteins participate in intercellular communication and play a role in cell signaling, differentiation, cell adhesion, angiogenesis, and apoptosis. A variety of cytokines, chemokines, growth factors, extracellular matrix (ECM) proteins and remodeling enzymes have been identified in MSCs derived from different sources and their secretomes .Supplementary Tables S1 and S2). Among the sets of proteins, in addition to cytoplasmic proteins a remarkable number of membrane proteins have been found. The proteins located in the plasma membrane and cytoplasm are more commonly sorted into EVs compared with the proteins in the nucleus and mitochondria of different cell types , umbilical cord blood (UCB), chorion (Cho-SC) and human menstrual fluid (MenSC) MSCs derived-exosomes. From all mentioned vesicles only MenSC -exosomes are able to enhance neurit outgrowth in cortical neuron cultures, while Cho-SC-exosomes cause even decrease of total neuron branch number. Moreover BM- and MenSC-derived exosomes increased the rate of neuritic growth in dorsal root ganglia neurons culture in comparison to control cells (Table 2) which very often suffer from high detection threshold or necessity of normalization of obtained results to the total protein level.ol cells . Similarol cells . Furtherol cells . The reaol cells . In liteExcept proteins EVs contain bioactive lipids. As for proteins, the lipid composition in EVs is distinct from that of the cell origin. Internal membranes of EVs isolated from different cell types are enriched in lysobisphosphatidic acids that modulate budding process and lipids associated with lipid rafts such as cholesterol, ceramide, sphingolipids, and glycerophospholipids with saturated fatty-acyl chains . SphingoThe RNA cargo has been well established as a component of EVs isolated from different cell types . VariousExtracellular vesicles released from parental cells may be broken down, thus releasing their content into extracellular space or neighbor cells may internalize them. The pathways through which EVs enter target cells impact EV-mediated biomolecule delivery. Several types of interactions between EVs and target cells have been demonstrated. Interaction may be direct, resulting in MVs fusion or endocytosis, i.e., observed between mouse dendritic cells  or indirA very large collection of evidence shows that EVs are important regulators of many biological functions such as tissue homeostasis and immune response. EVs may influence the behavior of target cells by several different mechanisms. First they may act as signaling complexes. Indeed, EVs express several surface molecules, i.e., ICAM-1 interacting with the specific receptors LFA-1 present on T cells or δ-like 4 ligand bound to Notch receptors expressed by endothelial cells and neuronal cells thus activating these cells . EVs plaExtracellular vesicles may also transfer receptors, proteins, or bioactive lipids between cells after fusion with the target cell membrane. For example, the chemokine receptor CXCR4 or CCR5 could be transferred from lymphocytes to nonlymphoid cells . EVs-medThe miRNA mediates many biological effects through inhibition of specific mRNA . For exaExtracellular vesicles are involved both in promoting and in inhibiting the immune response, depending on their cell of origin and on the signals present in the microenvironment.Macrophages infected by various pathogens (Mycobacterium and Toxoplasma) release EVs containing pathogen-derived pro-inflammatory molecular determinants inducing the secretion of pro-inflammatory cytokines by recipient macrophages . MycoplaIn vitro priming of DCs with specific antigens results in the production of EVs which can induce in vivo humoral responses against the same antigens .Extracellular vesicles released by neural cells into brain parenchyma could be potentially endocytosed by nearby cells. Then EVs cargos are released into the cytosol of receiving cell or re-express at the cell surface. Astrocytes, which enwrap a number of glutamatergic synapses could capture EVs released at synapses. Back-fusion EVs has been demonstrated to occur in CNS and could concern their cells of origin. On the other hand EVs released from particular neural cells can be engulfed by other type of cells in CNS. EVs secreted by neurons may be transferred between spines of the same neuron or across synapses to end up in afferent neurons. Microglial EVs are able to be internalized by the same cell or by the neighboring microglia in macro-pinocytic fashion . OligodeExtracellular vesicles are increasingly gaining attention in diagnostic tools, being used as potential biomarkers for the detection of early pathological conditions before the onset of clinical symptoms of the disease. The choice of potential sources for EVs includes blood, plasma and cerebrospinal fluids. Relative stability of EVs in body fluids and their ability to pass the blood–brain barrier have suggested to exploit them very easy with minimally invasive procedure . Finding and testing such biomarkers in parallel with other diagnostic tools might be very important in CNS disorders to understand complex neurological conditions.The molecular content of EVs namely proteins, nucleic acids, and lipids reflects the origin and the pathophysiological status of the releasing cells. Several studies have demonstrated that EVs isolated from body fluids of neurological patients comprise molecules implicated in neurodegenerative diseases, metabolic, infectious diseases, or cancer. The concentration of EVs increases upon inflammation accompanied different neurological diseases and it is closely related with disease course .Certain EV proteins provided a tool to distinguish a disease-related condition from a healthy state. For example, amyloid precursor protein fragments (APP) or tau phosphorylated at Thr181 are established biomarkers for Alzheimer’s disease, and phosphorylated tau or α-synuclein are relevant for Parkinson’s disease . The prein vitro research in response to cells infection by viruses spreading on CNS like human immunodeficiency virus 1 , human T-cell leukemia virus-1 , herpes simplex virus-1 , or single-photon emission computed tomography (SPECT).Gaussia luciferase for non-invasive bioluminescence imaging (BLI). BLI is based on the emission of photons in reactions catalyzed by luciferase enzymes. Luciferases emit photons during the oxidation of a substrate, such as D-luciferin, in the presence of oxygen and ATP. BLI of immunodeficient, athymic nude mice systemically injected with exosomes showed a prominent bioluminescence signal in the spleen  of mice. Directly labeled exosomes showed a higher and brighter fluorescence compared to indirectly labeled exosomes. This study showed that both labeling methods were suitable for the in vivo detection of exosomes  nanoparticles are MRI contrast agents that are conventionally used for cell-tracking. SPIOs are based on magnetite or maghemite cores embedded and stabilized with a hydrophilic shell. The SPIO core contains several million iron atoms. These particles create a large dipolar magnetic field  and sign99mTc-HMPAO  under physiologic conditions, and monitored the in vivo distribution of 99mTc-HMPAO-ENVs using SPECT/CT in living mice. SPECT/CT images exhibited a higher uptake of ENVs in the liver and no uptake in the brain , types of EVs (SK and BL), proteomic analysis of EVs (SK and BL), profiling RNA content in EVs (MJ), mechanism of cellular uptake of EVs (SK and BL), biological activities of EVs (SK and BL), role of EVs in immune responses (MM), EVs in the brain neural-glial networks (AA and BL), EVs - based strategies for diagnosis of CNS diseases (AA and BL), non-invasive imaging of EVs (AS), therapeutic potential of MSC-derived EVs in CNS disorders (AA and BL), conclusion (BL).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Acute liver failure affects previously healthy and often young people and has a very high mortality due to rapid multi-organ failure. The diagnosis is based on the presence of coagulopathy  and hepatic encephalopathy within 8 weeks of onset of jaundice in patients with no previous liver disease .In resource-constrained developing countries, hepatitis A, B, and E infections, traditional medicines , drugs, We propose a practical approach that can be used in Intensive Care Unit-equipped hospitals in resource-constrained countries to try and reduce the high mortality rate where liver transplantation is not available.Patients admitted to general medical wards with signs or symptoms of acute liver failure should be screened for acute A, B, E, and possibly D virus hepatitis infections, for anti-nuclear and anti-smooth muscle autoantibodies (when possible) and for recent acetaminophen use, and prothrombin time should be immediately determined. Infections , which may mimic the presentation of acute liver failure should be excluded; high grade fever, splenomegaly, normal international normalized ratio, mild alanine aminotransferase and aspartate aminotransferase elevation help to exclude acute liver failure . As bactPatients initially fully oriented can progress in few hours to acute delirium with agitation and then coma with response to painful stimuli only; thus, they should be assessed as soon as possible after admission using the West Haven Criteria , which hPatients with Grade I or II encephalopathy should be intubated and ventilated in case of sudden deterioration in consciousness level and transferred to the Intensive Care Unit. If not intubated, attention must be paid to aggressive behavior, hyperreflexia, and ankle clonus as they predict progression to Grade III–IV coma and development of severe brain edema . ApproprAntifungal therapy should be started in patients who do not improve with antibiotics. Fever may favor development of cerebral edema, by increasing body metabolism and production of ammonia, and its cerebral uptake and metabolism. Body temperature should be kept at 35–36°C using external cooling and suppressing shivering.Routine computerized tomography scan to detect brain edema should not be performed as moving the patient to the scanner might facilitate increase in intracranial pressure; computerized tomography scan (where available) should be done only when focal neurological signs or pupillary abnormalities  are present. Cerebral edema can be diagnosed clinically based on the presence of spontaneous decerebrate posturing alone or two of the following: hypertension, bradycardia, pupillary changes, neurogenic hyperventilation . For cliCorrection of coagulopathy is indicated only before an invasive procedure ; indeed, the risk of hemorrhage correlates more with the severity of thrombocytopenia rather than coagulopathy. The presence of disseminated intravascular coagulation usually indicates sepsis, which must be considered also in case of unexplained blood pressure decrease, urinary output drop, worsening encephalopathy, and development of severe acidosis.It is very important to anticipate and prevent renal failure by maintaining circulating volume with colloid or fresh frozen plasma (if available). Extracorporeal renal support in the form of hemofiltration may be necessary (when available), if there is an acute renal failure or concern about fluid management.N-acetyl-cysteine administration is the treatment of choice for acetaminophen-related acute liver failure and can be effective also in non-acetaminophen acute liver failure with low grade encephalopathy (As for etiology-specific therapies, alopathy . Nucleosalopathy .A procedure that could be investigated as an additional treatment for acute liver failure is temporary partial portal vein arterialization [reviewed in Ref. ], which In conclusion, acute liver failure should not be considered untreatable without liver transplantation; chances of survival can be increased even in resource-constrained developing countries if patients are appropriately managed.FC had the idea of writing the manuscript and drafted it. BN codrafted the manuscript. DV, BD, and KT contributed to the drafting. SV contributed to the drafting, corrected, and reviewed the manuscript. All the authors approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care.As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs.a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD.We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months.The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs. Cardiovascular disease (CVD) is the leading cause of death globally. While the number of CVD deaths has not changed significantly in high-income countries since 1990, the number of deaths has increased by about 66% in low- and middle-income countries (LMICs) over the same interval[get the most out of known effective interventions within the limitations of available resources rather than recommending unproven interventions that would require early phase studies or those that would require substantial financial and human resource investment for implementation. Clinical quality improvement can be implemented within any setting immediately, and need not be expensive.In the context of scarce resources available to support health care in LMICs, the imperative of clinical quality improvement is to Quality care delivery in lower resource settings does not necessarily mean dissemination and implementation of a universal set of standards formulated in high-income countries. Standards and interventions should be dictated by context and community capacity. Adaptation to local settings is necessary to achieve optimal clinical outcomes and patient satisfaction.As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and narratively summarized currently available evidence on quality improvement for CVD prevention and management in LMICs. In keeping with the Institute of Medicine definition of clinical care quality, we focused on studies that compared specific clinical care quality improvement interventions with usual care and specified measurable health outcomes.a priori with potential quality improvement levers, based on our prior knowledge of the field and examples gleaned from other studies, including other DCP3 reviews.A conceptual framework guided the systematic review. We specified four domains, cross-cutting between two distinct phases of CVD (acute versus chronic) and two levels of intervention  . Acute pTwo authors (EL and AEM) designed an electronic search of MEDLINE and EMBASE electronic databases for the purpose of capturing published reports of CVD care quality improvement studies carried out in LMICs and published in English between January 2000 and June 2014. Pertinent conditions selected for the search were myocardial infarction, acute coronary syndrome (ACS), hypertension, cardiovascular disease, diabetes, stroke, cerebrovascular disease, obesity, CHF, and rheumatic heart disease (RHD). Based on key words identified in an informal review of publications already known to the authors and a survey of the other DCP3 chapter authors, a second set of search terms related to quality improvement was identified  Tables. Two authors (EL and AEM) independently assessed identified studies for eligibility based on the title and abstract. Selected full text papers were then independently reviewed by both authors. Eligibility criteria included: 1) LMIC setting; 2) patient/provider or system level intervention aimed at improving CVD quality of care; 3) outcome included risk factor or disease screening, case-finding, clinic-based CVD prevention , behavioral changes (diet or exercise), improved access to medical care, or clinical guideline implementation; and 4) study design involved a comparison between a clinical quality improvement intervention and usual care, regardless of whether the intervention group served as its own control (“before and after” study) or a separate control group was used.Data were abstracted and each study was categorized into one or more quadrants of the chapter rubric . The fola priori were captured. Based on a review of titles and abstracts, 273 potentially eligible papers were identified. Of these, two authors (EL and AEM) concurred that 49 papers reported population-based studies with clinically meaningful outcomes. The papers were selected for the detailed review  [Seguro Popular insurance were more likely to receive regular blood glucose control monitoring and maintain adequate glucose control compared to their matched, uninsured counterparts [Most studies in the system level-chronic phase category studied expansion of health insurance coverage –32 Tabl. Two stu economy . Based oure (BP) . A similterparts .In rural Nigeria, hypertensive patients living in a district where community-based health insurance was available had significantly lower SBP and diastolic blood pressure (DBP) not observed in the control group without insurance . In ruraMost studies in the patient/provider level–acute phase category studied ACS clinical pathways, 22, 33 In urban China, Du et al. randomized hospitals to implementation of a United States guideline-based ACS pathway, along with interval clinical performance audits and feedback throughout the intervention period and compared the results of these interventions to hospitals continuing usual care practices. Intervention hospitals had higher rates of discharge on recommended therapies compared to usual care hospitals, but no difference was observed in other indicators, including reperfusion within 12 hours of symptom onset in ST-elevation myocardial infarction cases, door-to-needle time, door-to-balloon time, or proportion of high-risk patients undergoing angiography. Similarmedication adherence a key challenge to delivering quality CVD clinical care worldwide. Thus most interventions were related to chronic medication adherence. Types of medication adherence interventions included use of fixed-dose combination pills, “mobile” health care, task shifting, clinical guideline implementation, and patient education.The majority of selected studies (33/49) were in the patient/provider level-chronic phase category , 35–54 . CVD patThom et al. randomized high-risk CVD patients in India (one of four countries studied) to receive combination pills or the usual, multiple-pill therapy. After a mean follow-up of about 15 months, Indian participants randomized to combination pills had a 25% higher absolute adherence compared to those randomized to usual care  and small but significant reductions in both SBP and low-density lipoprotein (LDL) compared with participants randomized to multiple-pill treatments . Zou et Twelve studies investigated the role of mobile health in prevention and management of CHF, diabetes, hypertension, and coronary artery disease in LMICs –39, 41. Four studies evaluated the effects of automated phone texts on diabetes and coronary artery disease prevention. Ramachandran et al. and Shetty et al. found that automated SMS (short message service) messages led to improved glycemic control in Indians with pre-diabetes and diabetes, 18. GooTask shifting refers to the redistribution of tasks among health workforce teams, often from a few, highly trained health providers to a larger contingent of providers with less formal health care training. Our revFive task-shifting studies targeted hypertensive patients–15. RegaTwo studies focused on task shifting interventions in diabetic patients , 42. NesHealth care provider education and guideline implementation have the potential to standardize, improve, and sustain quality of care for vascular and other conditions in LMICs. Studies of the impact of physician education and guideline dissemination yielded mixed results–47. QureThe review found eight studies that evaluated disease management education among patients with hypertension, diabetes, and CHF. –54. Alhaa priori  can be leveraged to measure changes in chronic CVD risk factors and outcomes. Quality improvement studies will be most feasible where key outcomes are part of, or added to, ongoing surveys.System level interventions have been systematically evaluated through pre- and post-intervention “natural experiment” comparisons, observational comparisons of intervention participants and matched usual care participants, or comparisons of geographic areas randomly assigned to receive or not receive the intervention. Stepped-wedge trials introduce interventions to couple step-wise active and systematic program implementation with evaluation . As in tAdopting clinical practice guidelines from high-income countries to LMICs appears to be a great opportunity both for implementing quality improvement standards and benchmarking significant practice and outcome improvements. The ACS and stroke quality improvement studies identified in our review showed some clinical process measure improvements, but like high-income region studies, quality did not consistently improve for all pre-specified outcomes , 5, 34. intensity of care improved chronic disease and risk factor outcomes, regardless of how or through whom it was delivered. While care intensification inevitably requires up-front investment, this investment may be offset by improved downstream CVD outcomes, health gains, and cost-savings. A modeling study by Gaziano et al. projected that despite added costs of hiring community health workers to manage hypertension in South Africa, the intervention would be cost-effective due to health gains and cost savings from prevented hospital admissions and chronic disease complications [Adherence to life saving medications and lifestyle changes is suboptimal world-wide, regardless of country income level . The mosications . The triications .Rapidly increasing access to mobile telecommunications technology may also be a promising tool for chronic disease management. There are now almost seven billion mobile phone users world-wide with more than three-quarters of these users living in LMICs . A 2012 We found that efforts to improve quality care through physician education and guideline dissemination yielded inconsistent results , 46, 47.Our review and the studies we reviewed had limitations, so our results should be interpreted with caution. Due to the diversity of interventions and conditions, we were unable to summarize effect sizes in a meta-analysis. It is possible that most of our included studies were published because of “positive” results—due to the heterogeneity in interventions and targets, we were not able to formally evaluate the results of our review for evidence of publication bias. Also important is that most study durations were relatively short term (<12 months) and sustaining intervention effects may be a big challenge when these programs are implemented in real clinical settings . As in hWe identified good evidence that short-term quality improvement interventions improved the quality of cardiovascular care in low- and middle-income countries, especially for chronic conditions delivered at the patient/provider level. Most studies were short-term. At the patient/provider level, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level ACS quality improvement interventions yielded inconclusive results.What is needed now is more evidence that quality improvement can be sustained in the long term while remaining effective and affordable. Collecting data elements common to implementation research such as acceptability, sustainability, local context, and affordability and collecting and assessing qualitative and process data will help ensure that both positive and negative studies will guide implementation and future research.The majority of CVD patients now live in LMICs, and demographic trends virtually guarantee that the number and proportion will grow in coming decades. In order to ensure that each of these patients receives high quality preventive and acute care, we will need to draw on promising research on clinical quality improvement in order to make the most of the resources directly at hand.S1 Fig(TIF)Click here for additional data file.S1 Table(TIF)Click here for additional data file.S2 Table(TIF)Click here for additional data file.


As highly active antiretroviral therapy (HAART) transforms human immunodeficiency virus (HIV) into a manageable chronic disease, new challenges are emerging in treating children born with HIV, including a number of risks to their physical and psychological health due to HIV infection and its lifelong treatment.We conducted a literature review to evaluate the evidence on the physical and psychological effects of perinatal HIV (PHIV+) infection and its treatment in the era of HAART, including major chronic comorbidities.Perinatally infected children face concerning levels of treatment failure and drug resistance, which may hamper their long-term treatment and result in more significant comorbidities. Physical complications from PHIV+ infection and treatment potentially affect all major organ systems. Although treatment with antiretroviral (ARV) therapy has reduced incidence of severe neurocognitive diseases like HIV encephalopathy, perinatally infected children may experience less severe neurocognitive complications related to HIV disease and ARV neurotoxicity. Major metabolic complications include dyslipidaemia and insulin resistance, complications that are associated with both HIV infection and several ARV agents and may significantly affect cardiovascular disease risk with age. Bone abnormalities, particularly amongst children treated with tenofovir, are a concern for perinatally infected children who may be at higher risk for bone fractures and osteoporosis. In many studies, rates of anaemia are significantly higher for HIV-infected children. Renal failure is a significant complication and cause of death amongst perinatally infected children, while new data on sexual and reproductive health suggest that sexually transmitted infections and birth complications may be additional concerns for perinatally infected children in adolescence. Finally, perinatally infected children may face psychological challenges, including higher rates of mental health and behavioural disorders. Existing studies have significant methodological limitations, including small sample sizes, inappropriate control groups and heterogeneous definitions, to name a few.Success in treating perinatally HIV-infected children and better understanding of the physical and psychological implications of lifelong HIV infection require that we address a new set of challenges for children. A better understanding of these challenges will guide care providers, researchers and policymakers towards more effective HIV care management for perinatally infected children and their transition to adulthood. An estimated 3.2 million children currently live with human immunodeficiency virus (HIV) . ChildreMore than 90% of the world's PHIV+ live in resource-limited settings (RLS) such as sub-Saharan Africa (SSA), where less than a quarter of infected children currently receive HAART  and HIV/Although the majority of these children will be living in RLS, the experiences of PHIV+ in resource-rich settings, who have been treated with HAART for many more years, offer an important window into the long-term impact of perinatal infection and lifelong treatment across all settings. The objective of this review is to summarize and evaluate current evidence on the physical and psychological effects of PHIV+ infection and its treatment in the HAART era, including major chronic comorbidities. Insights will be offered on persistent and emerging challenges in the field of PHIV+ and future directions for research. Although much of the literature in this field comes from resource-rich settings, we will attempt to give appropriate attention to issues affecting PHIV+ in SSA.We conducted an extensive, literature review on the physical and psychological effects of PHIV+ infection and its treatment in the HAART era, including major chronic comorbidities. Our methodology for this review was guided by Grant and Booth  and theiStudies from North America and Europe suggest that PHIV+ have lower probability of achieving both viral suppression and long-term treatment success compared to adults ,18. Dataet al. [Inadequate viral suppression can lead to the development of drug resistance in adults –24 and iet al.  reviewedet al. . The autin utero or during breastfeeding for (unsuccessful) prevention of mother-to-child transmission (PMTCT) [PHIV+ may be at higher risk for treatment failure and drug resistance for several reasons. First, PHIV+ may be exposed to HAART  (PMTCT) . In the  (PMTCT) . Despite (PMTCT) ,30. Seco (PMTCT) . Third,  (PMTCT) –35. Subt (PMTCT) –40. Alth (PMTCT) . Convers (PMTCT) ,43. Fina (PMTCT) .Closely linked to the treatment outcomes for PHIV+ is the issue of medication adherence. Adherence to HAART is the critical behaviour underlying many of the long-term outcomes for children and adolescents with HIV. Systematic reviews of PHIV+ adherence to HAART have reported widely variable adherence estimates, likely due to heterogeneous measurement techniques ,45. ThreIt is in the context of these unique viral and treatment challenges that we must consider the impact of the physical and psychological effects of lifelong HIV infection, HAART treatment and comorbidities over the developmental course. Emerging data in these areas will be the focus of the remainder of this review.Fostering the growth of PHIV+ remains a major challenge throughout the developmental spectrum, from the prenatal to the adolescent phase. Although stillbirth, preterm birth and low birthweight have declined significantly in the era of PMTCT and HAART in resource-rich settings , severalThroughout childhood, PHIV+ tend to have shorter stature, lower bodyweight and delayed entrance into puberty compared to uninfected children, even in the absence of overt AIDS or wasting . This abThe incidence of severe, AIDS-defining neurocognitive diseases, such as HIV encephalopathy, has significantly declined in the HAART era ,74. AmonNonetheless, PHIV+ on HAART may experience less severe neurocognitive complications, including deficits in general cognition, language and speech, gross motor, and fine motor functioning, which can substantially affect their quality of life, social relationships, school achievements and risk behaviours –81. SeveA number of studies reported that HIV-infected children treated with HAART had lower neurocognitive scores, high rates of motor deficits and delayed development compared to uninfected peers –95; howeThe potential effects of ARV-related neurotoxicity on neurodevelopment amongst PHIV+ are not clear and must be weighed against the benefits of CNS viral control. Cognitive impairment and decline in PHIV+ on HAART with good immunologic and systemic viral control  may poinin utero affect neurocognitive development, as well as how these effects might be mitigated. Although studies advocate for the protective effects of HAART early in infancy [A better understanding of the role of HIV infection and HAART on neurocognitive outcomes is needed to optimize treatment and to support the development of PHIV+ through adolescence and into adulthood. The field particularly lacks data from PHIV+ in SSA and data on how HIV infection and HAART exposure  infancy ,97, whic infancy , whetherin utero for PMTCT or some combination [The cardiovascular complications of HIV infection were noted early in the epidemic . Currentbination . Potentibination ,110,111,bination –114 and bination –117 thatbination –122. Thebination ,124.z-scores for left ventricular fractional shortening at around age 10 compared to 325 PHIV+ from the AMP cohort who had widespread use of HAART (p<0.05) [z-scores in PHIV+ from the P2C2 cohort but not from the AMP cohort, suggesting that cardiac damage was more significant for PHIV+ early in life who did not receive effective HAART [More recent data suggest largely protective cardiac effects from HAART, especially early in life. In the largest prospective cohort study to date, 3035 PHIV+ enrolled in PACTG 219/219C were followed from 1993 to 2007 and showed that the use of HAART (versus no HAART) dramatically lowered incidence rates (by an average of 50%) of cardiomyopathy . In suba(p<0.05) . Longer ve HAART .in utero are unclear, as two major studies amongst ART- exposed uninfected infants revealed conflicting results [The effects of HAART exposure  results ,128. The results , whereas results –131. The results ) compare results . The cliin utero – a population that will increase significantly in size with more access to PMTCT under the 90-90-90 target.Although cardiovascular complications have significantly declined in the HAART era, PHIV+ still may be at higher risk for cardiomyopathies. Further research is needed on the long-term myocardial function of PHIV+ and on optimizing HAART regimens to protect cardiac health and to effectively suppress HIV replication. Close monitoring of cardiovascular function for this population is warranted, as is surveillance for HIV-uninfected children exposed to HAART A prominent area of concern is the impact of HIV infection and its treatment on liver function for PHIV+, though there are few paediatric-specific data and long-term outcomes are mostly extrapolated from adult data . PHIV+ tCo-infections can complicate treatment and increase the risks for liver damage, as is seen amongst HIV-infected adults with Hepatitis B virus (HBV) and Hepatitis C virus (HCV) co-infection . There aRenal disease is a growing concern for PHIV+ , and nowThere are few data on survival outcomes amongst PHIV+ with end-stage kidney disease on maintenance dialysis in the HAART era. Two small studies amongst HIV-infected children with end-stage kidney disease on maintenance haemodialysis in the United States reported high mortality associated with cardiovascular disease, leading the authors to recommend routine echocardiography amongst HIV-infected children on dialysis ,163. StuMycobacterium tuberculosis) [A frequent complication of HIV infection is anaemia. HIV infection may alter cytokine and erythropoietin responses by decreasing erythropoiesis through apoptosis of erythroid precursors and infection of auxiliary cells ,168. A nculosis) ,174, alsculosis) ,176. Treculosis) –179, incculosis) ,181. A sculosis) . Anaemiaculosis) . There iculosis) .PHIV+ on HAART are at an increased risk for metabolic disorders –186. LipBody fat changes may ultimately affect adherence to therapy amongst older children and adolescents because they affect body image and the social desire to fit in is a strong motivator of behaviour during adolescent development . In addiDyslipidaemia, including hypertriglyceridaemia (elevated triglyceride levels) and hypercholesterolaemia (elevated LDL-cholesterol levels), is another potential metabolic complication for PHIV+ on HAART . ElucidaInsulin resistance is characterized by reduced insulin stimulation of glucose use by adipose tissue and muscles resulting in increased pancreatic insulin production, and is associated with obesity, dyslipidaemia, hypertension and type 2 diabetes in children . Both PIPHIV+ are at an increased risk for a variety of metabolic complications, but there are few longitudinal data to assess incidence, risk factors and long-term outcomes of these metabolic disorders . ExistinPHIV+ may be at greater risk for lower bone mineral density (BMD) due to viral infection – by affecting BMD-related growth factors ,236 – anThe effects of TDF may vary by developmental stage; studies have reported that TDF-associated BMD loss is less significant in adolescents and adults compared to PHIV+ in pre- or early pubertal stages ,246. YouStudies show that having a sexually transmitted infection (STI) increases the risks for transmission and acquisition of HIV ,249, butThere is limited evidence to inform sexual and reproductive interventions amongst PHIV+. A recent systematic review found evidence that linking sexual and reproductive services with HIV/AIDS services resulted in improved outcomes for women, including HIV and STI incidence, condom use, contraceptive use and retention in care . EffectiDiagnostic and Statistical Manual  found high rates of attention deficit/hyperactivity disorders (29%), anxiety (24%) and depression (25%); however, the authors noted the lack of control groups and small sample sizes as significant limitations [A number of studies reported high rates of mental and behavioural disorders amongst PHIV+ ,263–265.itations ,267. Inditations –270. In itations .There is scarce evidence in the existing literature on the specific role of HIV or HAART in affecting psychological outcomes . SeveralThe advent of HAART drastically changed the course of HIV and significantly decreased HIV-associated morbidity and mortality. Although HAART allows PHIV+ to survive and prosper well into adolescence and adulthood, PHIV+ still face many challenges related to their perinatal infection and lifelong treatment. This review identified major chronic complications and comorbidities affecting all major organ systems. As more PHIV+ access HAART and live longer over the next decades, data that improve the management and ultimately prevention of these complications over the course of the developmental spectrum are critical. For PHIV+ with HIV-related disabilities, rehabilitation interventions are necessary to support their development with a chronic condition, but there are few data in this area ,287. TheMany studies included in this review were conducted in the United States and Europe. PHIV+ in resource-rich settings represent an important population for study as they are mostly older, have been treated with HAART for many more years, and often initiated treatment at earlier ages compared to PHIV+ in RLS. For these reasons, PHIV+ in resource-rich settings offer critical insight into long-term complications and comorbidities and interventions to improve treatment and clinical outcomes. In addition, well-established cohorts such as the PACTG 219/219C in the United States provide opportunities to conduct studies with relatively large sample sizes and close monitoring and follow-up of patients. These cohorts have been particularly useful in investigating complex effects on different organ systems from HIV infection, HAART treatment or a combination of both. On the other hand, we did identify a number of recent studies from SSA, which is encouraging given that the region is home to over 90% of PHIV+ in the world. Studies across regions, both resource-rich and resource-poor, had significant limitations, most often issues of sample size, appropriate control groups, length of follow-up, heterogeneous definitions and assessment methods, and unknown and complex interrelations in aetiology and risk factors. Across all areas of research identified in this review, more research is needed that uses improved methodologies to address limitations. Establishing well-characterized and closely followed cohorts of PHIV+ in SSA and other RLS (as well as HIV-uninfected exposed children) will be essential to answer important questions around lifelong infection and treatment .The combined evidence from this review supports the protective effects of early HAART for PHIV+ against many infection-related complications across organ systems; however, there are unanswered questions around HAART toxicity and management of potential drug side effects, as well as persisting infectious impacts. As the WHO guidelines advocate for the treatment of all PHIV+ with HAART and we work towards the goals of “90-90-90,” hundreds of thousands of PHIV+ will be initiating early and lifelong HAART in the coming years. HIV care programmes, particularly those in SSA, will be tasked with huge challenges in expanding HAART treatment and managing chronic complications and comorbidities of PHIV+. Furthermore, persistent challenges in areas such as infant diagnosis ,290 and