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Implementation outcomes of tuberculosis digital adherence technologies: a scoping review using the RE-AIM framework.
Get PDFINTRODUCTION: Globally, tuberculosis (TB) remains one of the leading infectious causes of death, with 1.3 million deaths. Digital adherence technologies (DATs) have the potential to provide person-centred care and improve outcomes. Using the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework, we conducted a scoping review of DAT implementations for TB treatment.
METHODS: We searched seven databases for papers published between January 2000 and April 2023, using keywords for 'tuberculosis' and 'digital adherence technology'. Articles meeting prespecified inclusion criteria and containing data on RE-AIM domains were included. We defined 'reach' as comprising cellphone ownership and engagement by people with TB (PWTB) with DATs, 'adoption' as engagement by healthcare providers with DAT programmes, 'implementation' as the fidelity of the DAT programme implemented and 'maintenance' as longer-term uptake of DATs.
RESULTS: Of 10 313 records, 102 contributed to the synthesis. DATs included short message service (SMS), phone, 99DOTS, video-supported therapy (VST) and pillboxes. For 'reach', across various settings, cellphone access varied from 50%-100% and 2%-31% of PWTB was excluded from accessing DATs due to technology challenges. 36%-100% of PWTB agreed to use a DAT. The weighted mean of DAT engagement over dose-days was 81% for SMS, 85% for phone, 61% for 99DOTS, 87% for pillbox and 82% for VST. Concerning 'implementation', the fidelity of DAT implementations was affected by technological issues such as cellphone coverage, DAT malfunction and provider-facing issues, including failure to initiate intensified patient management following low DAT engagement. Findings related to RE-AIM dimensions of 'adoption' and 'maintenance' were limited.
CONCLUSION: Our findings suggest that the 'reach' of DATs may be limited by a cascade of barriers, including limitations in cellphone accessibility and suboptimal sustained DAT engagement by PWTB. Video and pillbox DATs have higher levels of engagement. Implementation challenges included technological and provider-facing issues. Improving implementation outcomes may be important for TB DATs to achieve a broader public health impact.
PROSPERO REGISTRATION NUMBER: CRD42022326968
Progressive Cone-Rod Synaptic Dysfunction in Dynamin-1 ( DNM1 ) Related Developmental and Epileptic Encephalopathy: A Distinct Retinal Phenotype in Human.
Get PDFDynamin-1 is an essential enzyme involved in the recycling of synaptic vesicles, in particular in the scission of endocytic buds within the pre-synaptic terminal. Heterozygous pathogenic variants in DNM1 result in Developmental and Epileptic Encephalopathy type 31A, where patients exhibit early onset refractory epilepsy, severe-profound intellectual disability and poor visual behaviour. We present data demonstrating that this disorder progressively affects retinal synaptic function which, to our knowledge, is the first report of this phenotype in human. Clinical notes of the proband were reviewed incorporating ophthalmic phenotyping (imaging, electroretinography (ERG), pattern visual evoked potentials (PVEPs) and visual symptoms). Genetic testing was performed using trio whole genome sequencing. Genetic testing confirmed a de-novo pathogenic variant in DNM1, a recurrent heterozygous missense variant, c.709C > T;p.(Arg237Trp). Serial ERG testing at 1, 3, 9 and 12 years old indicated a progressive inner retinal dysfunction affecting both rod and cone synaptic pathways mirroring the abnormalities in the mouse model of dnm1, with normal retinal structure. DNM1 affects retinal synaptic recycling and endocytosis and our findings show likely usefulness of ERG testing in affected individuals. Further work is needed to expand our understanding of how different DNM1 variants affect retinal function
Who Is Most Likely to Experience Corruption When Seeking Healthcare in Nigerian Healthcare Facilities?
Get PDFBACKGROUND: Experiencing corruption when seeking health services remains a significant problem in Nigeria. An effective response requires knowledge of the individual characteristics of those impacted by corruption when seeking healthcare. This study examined the prevalence of corruption among those seeking health services in Nigeria's public healthcare facilities and how it varies among different user groups. METHODS: We used a pre-tested interviewer-administered questionnaire to collect data from 1659 individuals randomly selected from households in two Nigerian states. We collected data on respondents' socio-demographic characteristics and experiences of corrupt practices. We undertook descriptive and binomial logistic regression analyses. RESULTS: Approximately 50% (823) of respondents experienced corrupt practices, such as using connections for faster treatment and bribery when seeking health services. 446 (27%) respondents bribed or made so-called unapproved payments to health providers to obtain health services. Gender was a strong predictor, with male healthcare service users being more likely to experience corrupt practices (%point risk difference=24; 95% CI=20, 29) and bribe or make an unapproved payment to obtain healthcare (%point risk difference=20; 95% CI=15, 25). Residents in the northern state were (%point risk difference=30; 95% CI=26, 35) more likely to experience corrupt practices than residents in the eastern state. People seeking healthcare in urban (%point risk difference=09; 95% CI=-05, 08) and semi-urban (%point risk difference=12; 95% CI=05, 19) locations were more likely to have bribed or made 'unapproved' payments to healthcare providers compared to rural residents. CONCLUSION: Health sector corruption, in its various forms, is frequently reported in both northern and southern Nigeria. However, user experience of corruption varies according to socio-demographic characteristics, and this is often insufficiently acknowledged. To combat corrupt practices in both health sectors, anti-corruption initiatives must be tailored to particular groups and settings, addressing specific disadvantages at individual and community levels
Drug use and needle sharing among adolescents and young adults in Nigeria: A cross-sectional secondary analysis of data from a multi-site clinical trial.
Get PDFBACKGROUND: Adolescents and young adults (AYA, 14-24 years old) have the highest rates of drug use in most low- and middle-income countries. Little is known about the drivers of drug use among AYA in Nigeria and harm reduction services are limited. METHODS: A secondary data analysis was performed of the baseline survey of the 'I-TEST' study involving AYA in Nigeria. The two primary outcomes of interest were lifetime measures of drug use and needle sharing. Logistic regression analyses were performed to obtain odds ratios for the associations between socio-demographic exposures and the two primary outcomes. Odds ratios were subsequently adjusted for age and sex. RESULTS: 1500 AYA survey responses were analysed. Respondents were mostly unemployed, students, and living in southern Nigeria. Drug use was reported by 301/1500(20.3 %) AYA. Among these, 213/301(71.5 %) reported needle sharing. Drug use did not vary by age (OR:0.94, 95 %CI:0.73-1.22) or sex (OR:1.00, 95 %CI:0.77-1.28). AYA in the North-Central zone had higher odds of drug use (OR:1.86, 95 %CI:1.28-2.69) and needle sharing (OR:2.51, 95 %CI:1.07-5.91) compared to AYA in the South-West zone of Nigeria. AYA aged 14-19 had higher odds of needle sharing compared to those aged 20-24 (OR:3.49, 95 %CI:1.94-6.26). Female AYA had higher odds of needle sharing compared to males (OR:5.05, 95 %CI:2.85-8.95). CONCLUSIONS: Drug use and needle sharing are common among AYA in Nigeria. There is an urgent need for harm reduction services and research informed by AYA
A situational analysis of rehabilitation policy and systems in Brazil
Get PDFMultiple health system components, supported by good policy, are needed for the provision of quality rehabilitation care. This study used the Missing Billion Health System Framework to structure a situational analysis of publicly funded rehabilitation services within the Unified Health System in Brazil, focusing on: governance, leadership, health financing, data and evidence, autonomy and awareness, affordability, human resources, health facilities, and assistive technology. We reviewed online policy documents, Health Information System data and published literature and conducted semi-structured interviews with 87 people with disabilities and 57 health and rehabilitation providers in São Paulo, Santos, Brasília, and Arcoverde. The situational analysis showed that the Brazilian policy framework is broadly supportive of rehabilitation provision, and a defined leadership structure assists rehabilitation provision at the national, state, and municipality level. However, there are challenges to rehabilitation service provision including insufficient funding and service availability, and inadequate numbers of rehabilitation professionals, with variation by cadre and region. For service users with disabilities, key challenges to accessing rehabilitation include high costs of transport, communication and information barriers, and long wait times. Available data indicate high-need and low coverage for rehabilitation, although there is a gap in reliable data on service need. In conclusion, this situational analysis highlighted rehabilitation programme and policy strengths in Brazil that could be replicated in other settings, such as the supportive policy and leadership structure. However, there are gaps to be addressed, including geographic inequalities in the availability of rehabilitation professionals and barriers to access for service users
Treatment decision algorithms for tuberculosis screening and diagnosis in children below 5 years hospitalised with severe acute malnutrition: a cost-effectiveness analysis.
Get PDFBACKGROUND: Children with severe acute malnutrition (SAM) are an important risk group for underdiagnosis and death from tuberculosis. In 2022, the World Health Organization (WHO) recommended use of treatment decision algorithms (TDAs) for tuberculosis diagnosis in children. There is currently no cost-effectiveness evidence for TDA-based approaches compared to routine practice. METHODS: The TB-Speed SAM study developed i) a one-step TDA including Xpert, clinical, radiological and echography features, and ii) a two-step TDA, which also included a screening phase, for children under 5 years hospitalised with SAM at three tertiary hospitals in Uganda and Zambia from 4th November 2019 to 20th June 2022. This study is registered with ClinicalTrials.gov, NCT04240990. We assessed the diagnostic accuracy and cost-effectiveness of deploying TB-Speed and WHO TDA-based approaches compared to the standard of care (SOC). Estimated outcomes included children started on tuberculosis treatment, false positive rates, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs). FINDINGS: Per 100 children hospitalised with SAM, averaging 19 children with tuberculosis, the one-step TDA initiated 17 true positive children (95% uncertainty intervals [UI]: 12-23) on tuberculosis treatment, the two-step TDA 15 (95%UI: 10-22), the WHO TDA 14 (95%UI: 9-19), and SOC 4 (95%UI: 2-9). The WHO TDA generated the most false positives (35, 95%UI: 24-46), followed by the one-step TDA (18, 95%UI: 6-29), the two-step TDA (14, 95%UI: 1-25), and SOC (11, 95%UI: 3-17). All TDA-based approaches had ICERs below plausible country cost-effectiveness thresholds compared to SOC (one-step: 34-39/DALY averted, WHO: $40-46/DALY averted). INTERPRETATION: Our findings show that these TDA-based approaches are highly cost-effective for the vulnerable group of children hospitalised with SAM, compared to current practice. FUNDING: Unitaid Grant number: 2017-15-UBx-TB-SPEED
Identifying emergency presentations of chronic liver disease using routinely collected administrative hospital data.
Get PDFBACKGROUND & AIMS: Patients with chronic liver disease (CLD) are often first diagnosed during an emergency hospital admission, when their disease is advanced and survival is very poor. Evaluating their care and outcomes is a clinical research priority, but methods are needed to identify them in routine data. METHODS: We analysed national administrative hospital data in the English National Health Service. We used existing literature, expert clinical opinion, and data-driven approaches to develop three algorithms to identify first-time emergency admissions in 2017-2018. We validated these in 2018-2019 data by assessing the distributions of predictive factors, treatments, and outcomes associated with CLD in the patients captured by each algorithm. RESULTS: Our most specific algorithm identified 10,719 patients with CLD who first presented through emergency hospital admission from April 2018 to March 2019. Alternative, less specific or more sensitive algorithms identified 12,867 or 20,828 patient, respectively. Additional patients identified by more sensitive algorithms had more comorbidities, were less likely to die from CLD, and were less likely to be treated by a gastroenterologist or hepatologist. CONCLUSIONS: Three algorithms are provided that successfully identified patients in administrative hospital data with a first emergency admission for CLD. The choice of algorithm should reflect the aims of the research. IMPACT AND IMPLICATIONS: The more and most sensitive algorithms are recommended in studies when it is important to minimise the number of patients with CLD erroneously missed from the cohort, such as studies measuring disease burden. The most specific algorithms might miss patients whose primary reason for admission is recorded as a sign, symptom, or complication of CLD, but is recommended when the interest is strictly in patients whose primary reason for emergency admission is CLD
Predicting OCT retinal ganglion cell volume from pattern ERGs and VEPs in children with suspected optic neuropathy in a tertiary referral setting.
Get PDFPURPOSE: To determine the relationship between retinal ganglion cell (RGC) structure, measured by optical coherence tomography (OCT), and function measured by electrodiagnostic tests in children with suspected optic neuropathy. METHODS: Children presenting consecutively with suspected optic neuropathy were investigated by visual electrophysiology. ISCEV Standard monocular pattern reversal visual evoked potential (PVEP) P100 and pattern electroretinogram (PERG) P50 and N95, amplitudes and peak times were collected, along with the N95 slope 30 ms after the P50 peak. OCT retinal nerve fibre layer (RNFL) thickness from each peripapillary sector and the average macular RGC volume in a 3.45 mm diameter circle were collated. The sensitivity (SENS) and specificity (SPEC) of abnormal visual electrophysiology measures in predicting OCT structural measures were estimated by receiver operating characteristic (ROC) area under the ROC curve (AUC). RESULTS: Monocular PVEPs and PERGs from 30-degree stimulus fields and OCT RNFL and RGC volume were available from 42 children (84 eyes) aged 5.5-16.3 years (median 12.4 years). PVEP AUC was highest for predicting both RGC macular volume and temporal RNFL thinning (SENS 88%, SPEC 88%), followed by the PERG N95 slope (SENS 79%, SPEC 78%). PERG N95:P50 had the lowest SENS of 62% and SPEC of 61%, which were similar for all RNFL sectors. CONCLUSION: Abnormal PERG N95 slopes and PVEPs predicted severe loss of macular RGC volume and temporal sector RNFL with high diagnostic accuracy. These measures are important additions to the less specific PERG N95:P50, which was broadly sensitive to all RNFL sectors. The N95 slope and PVEPs are valuable objective functional markers of RGC health in children
External validation of an algorithm to detect vertebral level mislabeling and autocontouring errors.
Get PDFBACKGROUND AND PURPOSE: This work performs external validation of a previously developed vertebral body autocontouring tool and investigates a post-processing method to increase performance to clinically acceptable levels. MATERIALS AND METHODS: Vertebral bodies within CT scans from two separate institutions (40 from institution A and 41 from institution B) were automatically 1) localized and enumerated, 2) contoured, and 3) screened as a means of quality assurance (QA) for errors. Identification rate, contour acceptability rate, and QA accuracy were calculated to assess the tool's performance. These metrics were compared to those calculated on CTs from the model's original training dataset, and a post-processing technique was developed to increase the tool's accuracy. RESULTS: When testing the model without post-processing on external datasets A and B, accurate identification rates of 83 % and 92 % were achieved for vertebral bodies (C1-L5). Identification rate, contour acceptability rate and QA accuracy were reduced on both datasets compared to accuracies and rates measured on the model's orginal testing dataset. After algorithm adjustment, identification rate across all vertebrae increased on average by 4 % (p < 0.01) for dataset A and also 4 % on the dataset B (p = 0.01). CONCLUSIONS: A post-processing adjustment within the machine learning pipeline increased performance of vertebral body localization accuracy to acceptable levels for clinical use. External validation of machine learning and deep learning tools is essential to perform before deployment to different insitutions
Community perspectives on maternal dietary diversity in rural Kenya, Mozambique and The Gambia: A PRECISE Network qualitative study.
Get PDFPregnant and lactating women in sub-Saharan Africa are vulnerable to micronutrient inadequacies, with risk of adverse pregnancy outcomes. Adequate intakes of diverse foods are associated with better micronutrient status and recommended by the World Health Organization as part of healthy eating counselling during antenatal care. However, our understanding of community knowledge of dietary diversity within the context of maternal diets is limited. We used a descriptive qualitative approach to explore community perceptions of dietary diversity during pregnancy and lactation, as well as influencing factors in sub-Saharan Africa. A total of 47 in-depth interviews were conducted between May and October 2022 in Kenya, Mozambique and The Gambia with a purposively drawn sample of pregnant women and mothers who had delivered within two years preceding the data collection, their male and female relatives, and community opinion leaders. Other methods included participant observation and photovoice. Data were analyzed using a thematic approach on NVivo software. Dietary diversity was found to be well aligned with local perceptions of healthy meals. All participants were able to differentiate between starchy staple grains and additional foods to provide nutrients. While diverse meals were valued for pregnant and lactating mothers, participants across the three countries shared that maternal diets were not more diverse compared to typical household meals. Furthermore, diverse diets were inaccessible for many in their communities, due to challenges in affordability, seasonality, gender norms, knowledge and preferences. Adequate nutrition knowledge, accessibility of foods, and support of household decision-makers, particularly husbands and partners, were all identified as critical to ensure women have adequate diverse maternal diets