Effectiveness of Neurostimulation Technologies for the Management of Chronic Pain: A Systematic Review.

OBJECTIVES: To describe the state of the literature for clinical effectiveness of neurostimulation used for the management of chronic pain. METHODS: A systematic review of spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), peripheral nerve field stimulation (PNFS), and supraorbital transcutaneous electrical nerve stimulation in patients with cancer and noncancer chronic pain was conducted. MEDLINE, Embase, CINAHL, and the Cochrane CENTRAL Register of Controlled Trials were searched, using terms like "electrical stimulation therapy" and "pain management." Direction of effect, consistency across studies, and strength of evidence for effects of neurostimulation on chronic pain were narratively synthesized. RESULTS: A total of 15 randomized controlled trials (RCTs) examining SCS, 7 RCTs examining PNS/PNFS, and 1 nonrandomized trial examining supraorbital transcutaneous electrical nerve stimulation (TENS) were included. In nine SCS studies, neurostimulation had positive effects on pain. In three studies, neurostimulation did not significantly reduce pain. For PNS/PNFS, five studies found improvements in pain offered by neurostimulation; pain outcomes were not reported in two studies. In the TENS study, neurostimulation reduced headaches per month and medication consumption. Overall, 21 studies were of low or unclear risk of bias, 4 were high risk of bias, and the TENS study was not appropriate for assessment using the Cochrane Risk of Bias tool. CONCLUSIONS: A robust body of evidence examining SCS and PNS was identified. Only one study for PNFS and TENS was identified; both reported pain reductions. Generally, neurostimulation improved pain control. Future studies should examine the effectiveness of neurostimulation offered early in the trajectory of chronic pain.

High Genetic Diversity of Plasmodium falciparum in the Low-Transmission Setting of the Kingdom of Eswatini.

BACKGROUND: To better understand transmission dynamics, we characterized Plasmodium falciparum genetic diversity in Eswatini, where transmission is low and sustained by importation. METHODS: Twenty-six P. falciparum microsatellites were genotyped in 66% of confirmed cases (2014-2016; N = 582). Population and within-host diversity were used to characterize differences between imported and locally acquired infections. Logistic regression was used to assess the added value of diversity metrics to classify imported and local infections beyond epidemiology data alone. RESULTS: Parasite population in Eswatini was highly diverse (expected heterozygosity [HE] = 0.75) and complex: 67% polyclonal infections, mean multiplicity of infection (MOI) 2.2, and mean within-host infection fixation index (FWS) 0.84. Imported cases had comparable diversity to local cases but exhibited higher MOI (2.4 vs 2.0; P = .004) and lower mean FWS (0.82 vs 0.85; P = .03). Addition of MOI and FWS to multivariate analyses did not increase discrimination between imported and local infections. CONCLUSIONS: In contrast to the common perception that P. falciparum diversity declines with decreasing transmission intensity, Eswatini isolates exhibited high parasite diversity consistent with high rates of malaria importation and limited local transmission. Estimates of malaria transmission intensity from genetic data need to consider the effect of importation, especially as countries near elimination.

"We were afraid of the lion that has roared next to us"; community response to reactive focal mass drug administration for malaria in Eswatini (formerly Swaziland).

BACKGROUND: Reactive focal mass drug administration (rfMDA), or presumptive treatment without malaria testing of household members and neighbours of a passively identified malaria case, is currently being explored as a possible malaria elimination strategy in low transmission settings. One of the primary factors determining the effectiveness of rfMDA on reducing or interrupting transmission is achieving high coverage of the target population with drug administration. This study aims to explore the acceptability of rfMDA and identify facilitators and barriers to its potential implementation, as well as the community's general knowledge, attitudes and beliefs with regard to malaria elimination. METHODS: A qualitative study was performed using focus group discussions (FGDs) among villagers that received rfMDA through the National Malaria Control Programme in the low transmission setting of Eswatini as part of a 2-year clinical trial. FGDs were audio-recorded, transcribed and translated into English. All transcripts were managed in Dedoose and underwent qualitative content analysis. RESULTS: The majority of participants perceived their community to be at high risk of malaria. Witnessing others in their community suffer from malaria, proximity to Mozambique, various ecological factors, and the presence of mosquitoes contributed to this perception. The greatest motivator of participation in rfMDA was witnessing someone else suffer from malaria, since most participants had not personally experienced malaria themselves. Participants valued the education on rfMDA and on malaria in general, particularly when communicated by nurses and other health workers from the Ministry of Health. Participants were overwhelmingly motivated to participate in rfMDA in order to obtain protection from malaria. Most participants did not understand the concept of sub-clinical infection and, therefore, did not perceive the anti-malarial medication given in rfMDA to be a treatment medication. CONCLUSIONS: Perceived risk for malaria was a major driver of acceptability; therefore, future intervention campaigns could aim to better quantify risk to inform interventions and encourage uptake. There were misunderstandings about the asymptomatic reservoir of parasites in humans. Given that this phenomenon is the rationale for rfMDA, this misunderstanding could threaten the uptake of the intervention if it persists in the community. Using local authorities to deliver messaging, additional education on this concept with re-inforcement that risk of malaria is ongoing, even in the absence of frequent cases, may help to maximize and maintain acceptability.

Limitations of Rapid Diagnostic Testing in Patients with Suspected Malaria: A Diagnostic Accuracy Evaluation from Swaziland, a Low-Endemicity Country Aiming for Malaria Elimination.

Background: The performance of Plasmodium falciparum-specific histidine-rich protein 2-based rapid diagnostic tests (RDTs) to evaluate suspected malaria in low-endemicity settings has not been well characterized. Methods: Using dried blood spot samples from patients with suspected malaria at 37 health facilities from 2012 to 2014 in the low-endemicity country of Swaziland, we investigated the diagnostic accuracy of histidine-rich protein 2-based RDTs using qualitative polymerase chain reaction (PCR) (nested PCR targeting the cytochrome b gene) and quantitative PCR as reference standards. To explore reasons for false-negative and/or false-positive results, we used pfhrp2/3-specific PCR and logistic regression analyses of potentially associated epidemiological factors. Results: From 1353 patients, 93.0% of RDT-positive (n = 185) and 31.2% of RDT-negative samples (n = 340) were available and selected for testing. Compared with nested PCR, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RDTs were 51.7%, 94.1%, 67.3%, and 89.1%, respectively. After exclusion of samples with parasite densities <100/µL, which accounted for 75.7% of false-negative results and 33.3% of PCR-detectable infections, the sensitivity, specificity, PPV, and NPV were 78.8%, 93.7%, 62.3%, and 97.1%. Deletions of pfhrp2 were not detected. False-positivity was more likely during the second year and was not associated with demographics, recent malaria, health facility testing characteristics, or potential DNA degradation. Conclusions: In the low-transmission setting of Swaziland, we demonstrated low sensitivity of RDT for malaria diagnosis, owing to an unexpectedly high proportion of low-density infection among symptomatic subjects. The PPV was also low, requiring further investigation. A more accurate point-of-care diagnostic may be needed to support malaria elimination efforts.

Advocating for population health: The role of public health practitioners in the age of artificial intelligence.

Over the past decade, artificial intelligence (AI) has begun to transform Canadian organizations, driven by the promise of improved efficiency, better decision-making, and enhanced client experience. While AI holds great opportunities, there are also near-term impacts on the determinants of health and population health equity that are already emerging. If adoption is unregulated, there is a substantial risk that health inequities could be exacerbated through intended or unintended biases embedded in AI systems. New economic opportunities could be disproportionately leveraged by already privileged workers and owners of AI systems, reinforcing prevailing power dynamics. AI could also detrimentally affect population well-being by replacing human interactions rather than fostering social connectedness. Furthermore, AI-powered health misinformation could undermine effective public health communication. To respond to these challenges, public health must assess and report on the health equity impacts of AI, inform implementation to reduce health inequities, and facilitate intersectoral partnerships to foster development of policies and regulatory frameworks to mitigate risks. This commentary highlights AI's near-term risks for population health to inform a public health response.

RéSUMé: Au cours de la dernière décennie, l'intelligence artificielle (IA) a commencé à transformer les organismes canadiens en leur promettant une plus grande efficience, de meilleurs processus décisionnels et une expérience client enrichie. Bien qu'elle recèle d'immenses possibilités, l'IA aura des effets à court terme ­ qui se font d'ailleurs déjà sentir ­ sur les déterminants de la santé et sur l'équité en santé des populations. Si son adoption n'est pas réglementée, il se peut très bien que les iniquités en santé continuent d'être exacerbées par les préjugés, intentionnels ou non, ancrés dans les systèmes d'IA. Les nouvelles possibilités économiques pourraient être démesurément exploitées par les travailleurs et les travailleuses déjà privilégiés et par les propriétaires des systèmes d'IA, renforçant ainsi la dynamique de pouvoir existante. L'IA pourrait aussi nuire au bien-être des populations en remplaçant les interactions humaines au lieu de favoriser la connexité sociale. De plus, la mésinformation sur la santé alimentée par l'IA pourrait réduire l'efficacité des messages de santé publique. Pour relever ces défis, la santé publique devra évaluer et communiquer les effets de l'IA sur l'équité en santé, en modérer la mise en œuvre pour réduire les iniquités en santé, et faciliter des partenariats intersectoriels pour éclairer l'élaboration de politiques et de cadres réglementaires d'atténuation des risques. Le présent commentaire fait ressortir les risques à court terme de l'IA pour la santé des populations afin d'éclairer la riposte de la santé publique.

Supporting Healthy Aging through the Scale-Up, Spread, and Sustainability of Assistive Technology Implementation: A Rapid Realist Review of Participatory Co-Design for Assistive Technology with Older Adults.

Objective: To identify the key mechanisms, contexts, and outcomes that drive the successful participatory co-design of assistive technologies. Method: A rapid realist review was conducted using a systematic search strategy. After screening, a final set of 28 articles were included. Articles were analyzed for evidence relevant to our initial program theory (IPT), and context-mechanism-outcome configurations were developed, resulting in a revised program theory. Results: All 28 articles included were highly relevant to the IPT, and had sufficient detail regarding the process of participatory co-design. The findings of this review highlight several key context-mechanism-outcome configurations as potential patterns in the data under the two dimensions of the evolving program theory: knowledge integration and the ethico-political dimension. Discussion: This review revealed the key mechanisms of mutual awareness, mutual learning, trust, and reciprocity that need to be taken into account in AT development and assessment. We concluded that participatory co-design requires a restructuring of power relations between end-users and those traditionally in control of technology design. These findings inform the development and assessment of AT for older adults and help guide policy/decision-makers to move forward with the now urgent agenda for scale-up and spread, initiated by the burning platform of the COVID-19 pandemic.

Patients' experience with and perspectives on neuromodulation for pain: a systematic review of the qualitative research literature.

Chronic pain has far-reaching impacts on a person's life and on society more broadly. After failure or intolerance of conservative treatments, neuromodulation may be an option for a subgroup of patients. However, little is known about the patient experience of neuromodulation. We conducted a systematic review of published qualitative research on patient experience with neuromodulation for chronic pain. Four databases were searched: MEDLINE, EMBASE, Psych INFO, and all EMB reviews, from inception to December 4, 2019. We used narrative synthesis to identify key findings from the included studies. The data were qualitatively analyzed using a modified constant comparative analysis to identify key themes across the studies. Seven thousand five hundred forty-two unique citations were retrieved. Sixty-four abstracts were selected by the reviewers and continued to full-text review. After full-text review, 57 studies were excluded with 7 studies included in this systematic review. The included studies were of high quality. Four broad themes emerged: (1) living with chronic pain, (2) expectations, (3) managing challenges, and (4) regaining normalcy. Neuromodulation should be part of an overall pain management plan that may include the need for ongoing emotional and psychosocial support. A deeper knowledge of the patient experience with neuromodulation will assist care teams in providing meaningful support to patients. The results of this study suggest that further research is needed to support neuromodulation as an option for patients living with chronic pain.