Impact of the 99DOTS digital adherence technology on tuberculosis treatment outcomes in North India: a pre-post study

BACKGROUND

99DOTS is a cellphone-based digital adherence technology. The state of Himachal Pradesh, India, made 99DOTS available to all adults being treated for drug-sensitive tuberculosis (TB) in the public sector in May 2018. While 99DOTS has engaged over 500,000 people across India, few studies have evaluated its effectiveness in improving TB treatment outcomes.

METHODS

We compared treatment outcomes of adults with drug-sensitive TB before and after Himachal Pradesh's 99DOTS launch using data from India's national TB database. The pre-intervention group initiated treatment between February and October 2017 (N = 7722), and the post-intervention group between July 2018 and March 2019 (N = 8322). We analyzed engagement with 99DOTS and used multivariable logistic regression to estimate impact on favorable treatment outcomes (those marked as cured or treatment complete).

RESULTS

In the post-intervention group, 2746 (33.0%) people called 99DOTS at least once. Those who called did so with a wide variation in frequency (< 25% of treatment days: 24.6% of callers; 25-50% of days: 15.1% of callers, 50-75% of days: 15.7% of callers; 75-100% of days: 44.6% of callers). In the pre-intervention group, 7186 (93.1%) had favorable treatment outcomes, compared to 7734 (92.9%) in the post-intervention group. This difference was not statistically significant (OR = 0.981, 95% CI [0.869, 1.108], p = 0.758), including after controlling for individual characteristics (adjusted OR = 0.970, 95% CI [0.854, 1.102]).

CONCLUSIONS

We found no statistically significant difference in treatment outcomes before and after a large-scale implementation of 99DOTS. Additional work could help to elucidate factors mediating site-wise variations in uptake of the intervention.

Measuring Tuberculosis Medication Adherence: A Comparison of Multiple Approaches in Relation to Urine Isoniazid Metabolite Testing Within a Cohort Study in India

Background

Nonadherence to tuberculosis medications is associated with poor outcomes. However, measuring adherence in practice is challenging. In this study, we evaluated the accuracy of multiple tuberculosis adherence measures.

Methods

We enrolled adult Indians with drug-susceptible tuberculosis who were monitored using 99DOTS, a cellphone-based technology. During an unannounced home visit with each participant, we assessed adherence using a pill estimate, 4-day dose recall, a last missed dose question, and urine isoniazid metabolite testing. We estimated the area under the receiver operating characteristic curve (AUC) for each alternate measure in comparison to urine testing. 99DOTS data were analyzed using patient-reported doses alone and patient- and provider-reported doses, the latter reflecting how 99DOTS is implemented in practice. We assessed each measure's operating characteristics, with particular interest in specificity-that is, the percentage of participants detected as being nonadherent by each alternate measure, among those who were nonadherent by urine testing.

Results

Compared with urine testing, alternate measures had the following characteristics: 99DOTS patient-reported doses alone (area under the curve [AUC], 0.65; specificity, 70%; 95% CI, 58%-81%), 99DOTS patient- and provider-reported doses (AUC, 0.61; specificity, 33%; 95% CI, 22%-45%), pill estimate (AUC, 0.55; specificity, 21%; 95% CI, 12%-32%), 4-day recall (AUC, 0.60; specificity, 23%; 95% CI, 14%-34%), and last missed dose question (AUC, 0.65; specificity, 52%; 95% CI, 40%-63%).

Conclusions

Alternate measures missed detecting at least 30% of people who were nonadherent by urine testing. The last missed dose question performed similarly to 99DOTS using patient-reported doses alone. Tuberculosis programs should evaluate the feasibility of integrating more accurate, objective measures, such as urine testing, into routine care.

Das Vorkommen von Glucosaminestern der Hydroxy-zimtsäuren in Gewebekulturen von Nicotiana tabacum

Tissue cultures of Nicotiana tabacum var. “Samsun” contain an array of phenolic compounds. Beside the known glucose and quinyl esters of the hydroxycinnamic acids three hitherto unreported phenolic acid esters were isolated from tobacco tissue cultures. The analytical and spectral data presented in this paper lead to the conclusion that these compounds are glucosamine esters of p-coumaric, caffeic, and ferulic acid.

Imaging markers for Alzheimer disease: which vs how

Revised diagnostic criteria for Alzheimer disease (AD) acknowledge a key role of imaging biomarkers for early diagnosis. Diagnostic accuracy depends on which marker (i.e., amyloid imaging, ¹⁸F-fluorodeoxyglucose [FDG]-PET, SPECT, MRI) as well as how it is measured ("metric": visual, manual, semiautomated, or automated segmentation/computation). We evaluated diagnostic accuracy of marker vs metric in separating AD from healthy and prognostic accuracy to predict progression in mild cognitive impairment. The outcome measure was positive (negative) likelihood ratio, LR+ (LR-), defined as the ratio between the probability of positive (negative) test outcome in patients and the probability of positive (negative) test outcome in healthy controls. Diagnostic LR+ of markers was between 4.4 and 9.4 and LR- between 0.25 and 0.08, whereas prognostic LR+ and LR- were between 1.7 and 7.5, and 0.50 and 0.11, respectively. Within metrics, LRs varied up to 100-fold: LR+ from approximately 1 to 100; LR- from approximately 1.00 to 0.01. Markers accounted for 11% and 18% of diagnostic and prognostic variance of LR+ and 16% and 24% of LR-. Across all markers, metrics accounted for an equal or larger amount of variance than markers: 13% and 62% of diagnostic and prognostic variance of LR+, and 29% and 18% of LR-. Within markers, the largest proportion of diagnostic LR+ and LR- variability was within ¹⁸F-FDG-PET and MRI metrics, respectively. Diagnostic and prognostic accuracy of imaging AD biomarkers is at least as dependent on how the biomarker is measured as on the biomarker itself. Standard operating procedures are key to biomarker use in the clinical routine and drug trials.

[What factors determine the direct medical costs of patients with systemic lupus erythematosus in Germany? Subanalysis of the LUCIE study]

OBJECTIVES

The aim of this study was to evaluate annual direct medical costs of adult SLE patients with active autoantibody positive disease on medication in Germany.

METHODS

A multicentre, observational, retrospective European study with German sub-analysis was performed. Costs were assessed according to national tariffs.

RESULTS

10 German centres included 77 patients. The mean (SD) annual direct medical costs of patients were € 3 452.21 (3 777.07), and were 3.4 times higher in severe than non-severe patients (€ 5 291.07 vs. 1 564.97; p<0.001). Cost of medication (€ 2 349.40) represented 68.1% of the total cost. Flares, especially severe flares, were identified as cost predictors. Each flare increased the annual total cost by € 2 164,01 (p<0,001).

CONCLUSION

The annual direct medical cost of SLE patients in Germany is linked to disease severity. Medical treatments and severe flares were identified as the cost predictors and drivers, respectively.

Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting

The Patient Protection and Affordable Care Act added a new Medicare benefit, the Annual Wellness Visit (AWV), effective January 1, 2011. The AWV requires an assessment to detect cognitive impairment. The Centers for Medicare and Medicaid Services (CMS) elected not to recommend a specific assessment tool because there is no single, universally accepted screen that satisfies all needs in the detection of cognitive impairment. To provide primary care physicians with guidance on cognitive assessment during the AWV, and when referral or further testing is needed, the Alzheimer's Association convened a group of experts to develop recommendations. The resulting Alzheimer's Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition includes review of patient Health Risk Assessment (HRA) information, patient observation, unstructured queries during the AWV, and use of structured cognitive assessment tools for both patients and informants. Widespread implementation of this algorithm could be the first step in reducing the prevalence of missed or delayed dementia diagnosis, thus allowing for better healthcare management and more favorable outcomes for affected patients and their families and caregivers.

The draft "National Plan" to address Alzheimer's disease - National Alzheimer's Project Act (NAPA)

This perspective updates the status of the "National Plan to Address Alzheimer's Disease" and the recommendations of the NAPA Advisory Council's Sub-committee on Research. Here, we identify some of the critical issues the future reiterations of the National Plan should consider during implementation phase of the plan. The Journal invites the scientific community to contribute additional ideas and suggestions towards a national research initiative.

Alzheimer’s Association® TrialMatch™: a next-generation resource for matching patients to clinical trials in Alzheimer’s disease and related disorders

SUMMARY Many clinical trials for Alzheimer’s disease and related disorders struggle to achieve enrollment goals, hampering the progress of research. To help address this problem, the Alzheimer’s Association® has developed and implemented a new clinical trial-matching service designed to increase awareness of ongoing clinical trials among potential participants, improve initial matching of potential participants to enrollment criteria and thus help investigators achieve enrollment goals. This service, Alzheimer’s Association TrialMatch™, uses numerous personal and disease characteristics to match users with potential clinical trials that are currently enrolling participants. It provides users with direct access to trained professional consultants who interpret and explain an individual’s eligibility for specific clinical trials and is designed for use by patients, caregivers, healthy volunteers, physicians and other healthcare providers and researchers. During the first year of operation (July 2010–June 2011), the service received almost 45,000 queries and more than 11,000 completed profiles, which led to 2784 referrals to clinical trials. At least 163 participants of the service are known to have enrolled in a clinical trial. Participants self-report their enrollment into trials.

Amyloid-related imaging abnormalities in amyloid-modifying therapeutic trials: recommendations from the Alzheimer's Association Research Roundtable Workgroup

Amyloid imaging related abnormalities (ARIA) have now been reported in clinical trials with multiple therapeutic avenues to lower amyloid-β burden in Alzheimer's disease (AD). In response to concerns raised by the Food and Drug Administration, the Alzheimer's Association Research Roundtable convened a working group to review the publicly available trial data, attempts at developing animal models, and the literature on the natural history and pathology of related conditions. The spectrum of ARIA includes signal hyperintensities on fluid attenuation inversion recoverysequences thought to represent "vasogenic edema" and/or sulcal effusion (ARIA-E), as well as signal hypointensities on GRE/T2* thought to represent hemosiderin deposits (ARIA-H), including microhemorrhage and superficial siderosis. The etiology of ARIA remains unclear but the prevailing data support vascular amyloid as a common pathophysiological mechanism leading to increased vascular permeability. The workgroup proposes recommendations for the detection and monitoring of ARIA in ongoing AD clinical trials, as well as directions for future research.

Biocoder: A programming language for standardizing and automating biology protocols

Background

Published descriptions of biology protocols are often ambiguous and incomplete, making them difficult to replicate in other laboratories. However, there is increasing benefit to formalizing the descriptions of protocols, as laboratory automation systems (such as microfluidic chips) are becoming increasingly capable of executing them. Our goal in this paper is to improve both the reproducibility and automation of biology experiments by using a programming language to express the precise series of steps taken.

Results

We have developed BioCoder, a C++ library that enables biologists to express the exact steps needed to execute a protocol. In addition to being suitable for automation, BioCoder converts the code into a readable, English-language description for use by biologists. We have implemented over 65 protocols in BioCoder; the most complex of these was successfully executed by a biologist in the laboratory using BioCoder as the only reference. We argue that BioCoder exposes and resolves ambiguities in existing protocols, and could provide the software foundations for future automation platforms. BioCoder is freely available for download at http://research.microsoft.com/en-us/um/india/projects/biocoder/.

Conclusions

BioCoder represents the first practical programming system for standardizing and automating biology protocols. Our vision is to change the way that experimental methods are communicated: rather than publishing a written account of the protocols used, researchers will simply publish the code. Our experience suggests that this practice is tractable and offers many benefits. We invite other researchers to leverage BioCoder to improve the precision and completeness of their protocols, and also to adapt and extend BioCoder to new domains.

A roadmap for the prevention of dementia II: Leon Thal Symposium 2008

This document proposes an array of recommendations for a National Plan of Action to accelerate the discovery and development of therapies to delay or prevent the onset of disabling symptoms of Alzheimer's disease. A number of key scientific and public-policy needs identified in this document will be incorporated by the Alzheimer Study Group into a broader National Alzheimer's Strategic Plan, which will be presented to the 111th Congress and the Obama administration in March 2009. The Alzheimer's Strategic Plan is expected to include additional recommendations for governance, family support, healthcare, and delivery of social services.

Learning biophysically-motivated parameters for alpha helix prediction

Background

Our goal is to develop a state-of-the-art protein secondary structure predictor, with an intuitive and biophysically-motivated energy model. We treat structure prediction as an optimization problem, using parameterizable cost functions representing biological "pseudo-energies". Machine learning methods are applied to estimate the values of the parameters to correctly predict known protein structures.

Results

Focusing on the prediction of alpha helices in proteins, we show that a model with 302 parameters can achieve a Q_α value of 77.6% and an SOV_α value of 73.4%. Such performance numbers are among the best for techniques that do not rely on external databases (such as multiple sequence alignments). Further, it is easier to extract biological significance from a model with so few parameters.

Conclusion

The method presented shows promise for the prediction of protein secondary structure. Biophysically-motivated elementary free-energies can be learned using SVM techniques to construct an energy cost function whose predictive performance rivals state-of-the-art. This method is general and can be extended beyond the all-alpha case described here.

Digital microfluidics using soft lithography

Although microfluidic chips have demonstrated basic functionality for single applications, performing varied and complex experiments on a single device is still technically challenging. While many groups have implemented control software to drive the pumps, valves, and electrodes used to manipulate fluids in microfluidic devices, a new level of programmability is needed for end users to orchestrate their own unique experiments on a given device. This paper presents an approach for programmable and scalable control of discrete fluid samples in a polydimethylsiloxane (PDMS) microfluidic system using multiphase flows. An immiscible fluid phase is utilized to separate aqueous samples from one another, and a novel "microfluidic latch" is used to precisely align a sample after it has been transported a long distance through the flow channels. To demonstrate the scalability of the approach, this paper introduces a "general-purpose" microfluidic chip containing a rotary mixer and addressable storage cells. The system is general purpose in that all operations on the chip operate in terms of unit-sized aqueous samples; using the underlying mechanisms for sample transport and storage, additional sensors and actuators can be integrated in a scalable manner. A novel high-level software library allows users to specify experiments in terms of variables (i.e., fluids) and operations (i.e., mixes) without the need for detailed knowledge about the underlying device architecture. This research represents a first step to provide a programmable interface to the microfluidic realm, with the aim of enabling a new level of scalability and flexibility for lab-on-a-chip experiments.

Cache aware optimization of stream programs

Effective use of the memory hierarchy is critical for achieving high performance on embedded systems. We focus on the class of streaming applications, which is increasingly prevalent in the embedded domain. We exploit the widespread parallelism and regular communication patterns in stream programs to formulate a set of cache aware optimizations that automatically improve instruction and data locality. Our work is in the context of the Synchronous Dataflow model, in which a program is described as a graph of independent actors that communicate over channels. The communication rates between actors are known at compile time, allowing the compiler to statically model the caching behavior.We present three cache aware optimizations: 1) execution scaling, which judiciously repeats actor executions to improve instruction locality, 2) cache aware fusion, which combines adjacent actors while respecting instruction cache constraints, and 3) scalar replacement, which converts certain data buffers into a sequence of scalar variables that can be register allocated. The optimizations are founded upon a simple and intuitive model that quantifies the temporal locality for a sequence of actor executions. Our implementation of cache aware optimizations in the StreamIt compiler yields a 249% average speedup (over unoptimized code) for our streaming benchmark suite on a StrongARM 1110 processor. The optimizations also yield a 154% speedup on a Pentium 3 and a 152% speedup on an Itanium 2.

The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program. Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction

Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.

The development and evaluation of new versions of the written examination for the American Heart Association Advanced Cardiac Life Support provider course

STUDY OBJECTIVE

To create new versions of the written, multiple-choice examination used in the American Heart Association (AHA) Advanced Cardiac Life Support course, evaluate their reliability and difficulty, and then design revised versions with improved reliability and of standardized difficulty.

DESIGN

Psychometric evaluation of new versions of the AHA Advanced Cardiac Life Support test and revisions.

SETTING

AHA Advanced Cardiac Life Support courses.

PARTICIPANTS

Candidates for completion of AHA Advanced Cardiac Life Support provider courses in five states.

INTERVENTION

The course content was divided into 11 content areas that were weighted for importance and appropriateness for testing in a multiple-choice format. The weights were used to construct a blueprint for a 50-question, multiple-choice examination. Five versions of the examination were then constructed based on the content blueprint, drawing from new questions and expert revision of previously written questions. Reliability and difficulty were assessed using 915 administrations at five different sites nationwide. The initial test versions differed in their degree of difficulty, which was not explained by demographic factors. The results were used to revise three of the versions to improve reliability and equalize difficulty of the versions.

MEASUREMENTS AND MAIN RESULTS

The final five versions have estimated reliability ranging from Cronbach's alpha of .62 to .86. Mean scores ranged from 87.4% to 89.1%.

CONCLUSION

After field testing and revision, five examinations with acceptable reliability and roughly equal difficulty were constructed. The new examinations test the participants' knowledge of important aspects of resuscitation science and practice based on a blueprint of the course content.

[Hemorheologic changes in chronic polyarthritis]

The haemorheological status of plasma-(P eta) and blood-viscosity (B eta), erythrocyte aggregation (EA) and erythrocyte filterability (EF), blood sedimentation rate (BSG), haematocrit (HCT), plasma fibrinogen and alpha-2-macroglobulin was investigated on 46 patients suffering from chronic polyarthritis (c.P.). The results were compared with those from a control group of 20 healthy subjects with a similar distribution of age and sex. All the haemorheological data from the c.P. patients showed a significantly decreased blood fluidity (p less than or equal to 0.001 or p less than or equal to 0.01). These differences were highly significant for the female patients (n = 29), but for the men (n = 17) only at slight shift was seen. The comparison of clinically acute and non-acute disease in the patients showed a significant worsening of P eta, B eta and EF during the acute state, while the EA remained unaffected. The limited blood fluidity is seen as a result of the basic illness. At present, the pathophysiological meaning of these findings is still hypothetical: further investigations are required.

[Disseminated Kaposi's sarcoma of the skin in a young homosexual with substance abuse]

This is a report on a young homosexual US citizen with disseminated Kaposi's sarcoma of the skin who has lived in Berlin for about 1 year. During the last few years this malignant variant of the conventional Kaposi's sarcoma-characterized by rapid generalization and aggressive course--has become epidemic in some big cities in the USA. Until now there exist only a few reports from Europe. The data of our patient are representative of the typical epidemiologic, anamnestic, clinical, and diagnostic features of this unusual disease. Acquired immunodeficiency, high frequency of infections, and drug abuse may represent major etiologic factors. This report underlines the possibility that the disseminated type of Kaposi's sarcoma in young men may be observed more often in Europe in the near future.