Evaluation Tools for Assistive Technologies: A Scoping Review.

OBJECTIVE: Assistive technologies (ATs) support independence and well-being in people with cognitive, perceptual, and physical limitations. Given the increasing availability and diversity of ATs, evaluating the usefulness of current and emerging ATs is crucial for informed comparison. We aimed to chart the landscape and development of AT evaluation tools (ETs; ATETs) across disparate fields in order to improve the process of AT evaluation and development. DATA SOURCES: We performed a scoping review of ATETs through database searching of MEDLINE, Embase, CINAHL, HaPI, PsycINFO, Cochrane Reviews, and Compendex as well as citation mining. STUDY SELECTION: Articles explicitly referencing ATETs were retained for screening. We included ETs if they were designed to specifically evaluate ATs. DATA EXTRACTION: We extracted 5 attributes of ATETs: AT category, construct evaluated, conceptual frameworks, type of end user input used for ATET development, and presence of validity testing. DATA SYNTHESIS: From screening 23,434 records, we included 159 ATETs. Specificity of tools ranged from single to general ATs across 40 AT categories. Satisfaction, functional performance, and usage were the most common constructs of 103 identified. We identified 34 conceptual frameworks across 53 ETs. Finally, 36% incorporated end user input and 80% showed validation testing. CONCLUSIONS: We characterized a wide range of AT categories with diverse approaches to their evaluation based on varied conceptual frameworks. Combining these frameworks in future ATETs may provide more holistic views of AT usefulness. ATET selection may be improved with guidelines for conceptually reconciling results of disparate ATETs. Future ATET development may benefit from more integrated approaches to end user engagement.

Preferences for Pre-exposure Prophylaxis Service Delivery Among Female Sex Workers in Malawi: A Discrete Choice Experiment.

Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE-a powerful elicitation tool to apply to other key populations at risk for HIV.

Effect of Postnatal HIV Treatment on Clinical Mastitis and Breast Inflammation in HIV-Infected Breast-feeding Women.

BACKGROUND: The relationship between mastitis and antiretroviral therapy among HIV-positive, breast-feeding women is unclear. METHODS: In the Breastfeeding, Antiretrovirals, and Nutrition (BAN) study, conducted in Lilongwe, Malawi, 2369 mother-infant pairs were randomized to a nutritional supplement group and to one of three treatment groups: maternal antiretroviral therapy (ART), infant nevirapine (NVP) or standard of care for 24 weeks of exclusive breast-feeding and 4 weeks of weaning. Among 1472 HIV-infected women who delivered live infants between 2004 and 2007, we estimated cumulative incidence functions and sub-distribution hazard ratios (HR) of mastitis or breast inflammation comparing women in maternal ART (n = 487) or infant nevirapine (n = 492) groups to the standard of care (n = 493). Nutritional supplement groups (743 took, 729 did not) were also compared. RESULTS: Through 28-weeks post-partum, 102 of 1472 women experienced at least one occurrence of mastitis or breast inflammation. The 28-week risk was higher for maternal ART (risk difference (RD) 4.5, 95% confidence interval (CI) 0.9, 8.1) and infant NVP (RD 3.6, 95% CI 0.3, 6.9) compared to standard of care. The hazard of late-appearing mastitis or breast inflammation (from week 5-28) was also higher for maternal ART (HR 6.7, 95% CI 2.0, 22.6) and infant NVP (HR 5.1, 95% CI 1.5, 17. 5) compared to the standard of care. CONCLUSIONS: Mastitis or breast inflammation while breast-feeding is a possible side effect for women taking prophylactic ART and women whose infants take NVP, warranting additional research in the context of postnatal HIV transmission.

The association between substance use and sub-optimal HIV treatment engagement among HIV-infected female sex workers in Lilongwe, Malawi.

Female sex workers (FSW) have a high prevalence of substance use and HIV, but the impact of substance use on HIV treatment engagement is not well established. We evaluated the association between alcohol and marijuana use and sub-optimal HIV treatment engagement outcomes among HIV-infected FSW in Lilongwe, Malawi. We enroled FSW using venue-based recruitment into a cross-sectional evaluation assessing substance use and HIV treatment engagement. Seropositive FSW, identified through HIV rapid testing, received rapid CD4 count and viral load testing. We used Poisson regression with robust variance estimates to ascertain associations of alcohol and marijuana use with sub-optimal HIV treatment outcomes: (1) lack of ART use among previously diagnosed, ART-eligible FSW and (2) viral nonsuppression among FSW on ART. Of previously diagnosed, ART-eligible FSW (n = 96), 29% were not using ART. Patterns of hazardous drinking were identified in 30%, harmful drinking in 10%, and alcohol dependence in 12%. ART-eligible FSW with harmful drinking or alcohol dependency were 1.9 (95% CI: 1.0, 3.8) times as likely to not use ART compared to FSW without harmful or dependent drinking. Among those on ART, 14% were virally nonsuppressed. The prevalence ratio for viral nonsuppression was 2.0 (95% CI: 0.6, 6.5) for harmful drinkers and alcohol-dependent FSW. Over 30% of ART-eligible FSW reported using marijuana. Marijuana-using FSW were 1.9 (95% CI: 0.8, 4.6) times as likely to not use ART compared to FSW who were not using marijuana. Given the high prevalence of alcohol use and its association with lack of ART use, ART uptake and alcohol reduction strategies should be tailored for alcohol-using FSW in Malawi.

Vancomycin-resistant Enterococcal Bloodstream Infections in Hematopoietic Stem Cell Transplant Recipients and Patients with Hematologic Malignancies: Impact of Daptomycin MICs of 3 to 4 mg/L.

PURPOSE: Case reports of treatment failure with standard-dose daptomycin (6 mg/kg) have recently surfaced in vancomycin-resistant Enterococcus (VRE) bloodstream infection (BSI) episodes with daptomycin MICs of 3 to 4 mg/L. The clinical implications of daptomycin MICs of 3 to 4 mg/L in VRE BSIs have not been elucidated. METHODS: We performed a single institutional retrospective analysis of adult stem cell transplant recipients and patients with hematologic malignancies diagnosed with VRE BSI from 2006 to 2014 and compared outcomes between those with daptomycin MICs of 3 to 4 mg/L those with 2 mg/L, as determined by Etest. FINDINGS: Forty-two daptomycin-treated VRE BSI episodes, all due to Enterococcus faecium were identified; 19 episodes with daptomycin MICs of 3 to 4 mg/L and 23 episodes with a daptomycin MIC of 2 mg/L. Patients in the higher daptomycin MIC group were more likely to be male, to be stem cell transplant recipients, and to have received high-dose daptomycin treatment (>6 mg/kg). In unadjusted analyses, microbiological failure in the daptomycin MICs 3 to 4 mg/L versus 2 mg/L groups (odds ratio = 1.79, 95% CI, 0.52-6.11; P = 0.35), the median duration of bacteremia (4 days in daptomycin MICs 3-4 mg/L vs 3 days in daptomycin MIC 2 mg/L; P = 0.18) and all-cause 30-day mortality (21% in daptomycin MICs 3-4 mg/L vs 35% in daptomycin MIC 2 mg/L group; P = 0.49) were not different. In adjusted analyses, the association between higher Pitt bacteremia scores and all-cause 30-day mortality was statistically significant (P = 0.0006), whereas the association between daptomycin MICs of 3 to 4 mg/L and all-cause 30-day mortality approached statistical significance (P = 0.06). IMPLICATIONS: Duration of bacteremia and microbiological failure rates did not differ by daptomycin MICs in VRE BSI episodes in our patients, composed of adult stem cell transplant recipients and patients with hematologic malignancies. There was a nonsignificant trend in multivariable analysis suggesting that all-cause 30-day mortality was lower in patients whose VRE bloodstream isolates were with daptomycin MICs of 3 to 4 mg/L.

Critical Review: Building on the HIV Cascade: A Complementary "HIV States and Transitions" Framework for Describing HIV Diagnosis, Care, and Treatment at the Population Level.

The HIV cascade--often referred to as "the HIV continuum"--provides a valuable framework for population-level representations of engagement with the HIV healthcare system. The importance and appeal of this framework are evidenced by a large body of scientific literature, as well as by the adoption of cascade-related indicators by medical and public health organizations worldwide. Despite its centrality in the fields of HIV treatment and prevention, however, the traditional cascade provides limited description of the processes affecting the numbers it represents. Representations that describe these processes and capture the dynamic nature of HIV-infected persons' pathways through the healthcare system are essential for monitoring and predicting intervention effects and epidemic trends. We propose here a complementary schema--termed the "HIV States and Transitions" framework--designed to maintain key strengths of the traditional cascade while addressing key limitations and more fully describing the dynamic aspects of HIV testing, care, and treatment at the population level.

Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis.

BACKGROUND: low balance confidence is a major health problem among older adults restricting their participation in daily life. OBJECTIVES: to determine what interventions are most effective in increasing balance confidence in older adults. DESIGN: systematic review with meta-analysis of randomised controlled trials including at least one continuous end point of balance confidence. Studies, including adults 60 years or older without a neurological condition, were included in our study. METHODS: the standardised mean difference (SMD) of continuous end points of balance confidence was calculated to estimate the pooled effect size with random-effect models. Methodological quality of trials was assessed using the Physical Therapy Evidence Database (PEDro) Scale. RESULTS: thirty studies were included in this review and a meta-analysis was conducted for 24 studies. Interventions were pooled into exercise (n = 9 trials, 453 subjects), Tai Chi (n = 5 trials, 468 subjects), multifactorial intervention (n = 10 trials, 1,233 subjects). Low significant effects were found for exercise and multifactorial interventions (SMD 0.22-0.31) and medium (SMD 0.48) significant effects were found for Tai Chi. CONCLUSION: Tai chi interventions are the most beneficial in increasing the balance confidence of older adults.

Physical activity as a mediator of the impact of chronic conditions on quality of life in older adults.

BACKGROUND: Chronic conditions could negatively affect the quality of life of older adults. This may be partially due to a relative lack of physical activity. We examined whether physical activity mediates the relationship between different chronic conditions and several health outcomes that are important to the quality of life of older adults. METHODS: The data were taken from the Canadian Community Health Survey (cycle 1.1), a cross-section survey completed in 2001. Only respondents who were 65 years or older were included in our study (N = 22,432). The Health Utilities Index Mark 3 (HUI3) was used to measure overall quality of life, and to measure selected health outcomes (dexterity, mobility, pain, cognition, and emotional wellbeing) that are considered to be of importance to the quality of life of older adults. Leisure-time physical activity was assessed by determining weekly energy expenditure (Kcal per week) based on the metabolic equivalents of self-reported leisure activities. Linear and logistic regression models were used to determine the mediating effect of leisure-time physical activity while controlling for demographic variables (age and sex), substance use (tobacco use and alcohol consumption), and obesity. RESULTS: Having a chronic condition was associated with a relative decrease in health utility scores and a relative increase in mobility limitations, dexterity problems, pain, emotional problems (i.e., decreased happiness), and cognitive limitations. These negative consequences could be partially attributed to a relative lack of physical activity in older adults with a chronic condition (14% mediation for the HUI3 score). The corresponding degree of mediation was 18% for mobility limitations, 5% for pain, and 13% for emotional wellbeing (statistically significant mediation was not observed for the other health attributes). These values varied with respect to the different chronic conditions examined in our study. CONCLUSION: Older adults with chronic conditions are less likely to engage in leisure-time physical activities of at least 1,000 Kcal per week, and this association partially accounts for some negative consequences of chronic conditions, including mobility limitations, pain, and emotional problems. These findings provide support for health promotion programs that facilitate or encourage increased leisure-time physical activity in older people with chronic conditions.

A randomized, controlled trial of acupuncture for chronic daily headache.

BACKGROUND: Approximately 4% of adults experience headaches nearly every day. Nonpharmacologic interventions for frequent headaches may be appropriate because medical management alone is often ineffective. OBJECTIVE: To assess the efficacy of acupuncture as an adjunct to medical management for chronic daily headache (CDH). METHODS: We conducted a randomized, controlled trial of 74 patients with CDH that compared medical management provided by neurologists to medical management plus 10 acupuncture treatments. Primary outcome measures were daily pain severity and headache-related quality of life (QoL). RESULTS: Patients who received only medical management did not demonstrate improvement in any of the standardized measures. Daily pain severity scores trended downward but did not differ between treatment groups (P= .60). Relative to medical management only, medical management plus acupuncture was associated with an improvement of 3.0 points (95% CI, 1.0 to 4.9) on the Headache Impact Test and an increase of 8 or more points on the role limitations due to physical problems, social functioning, and general mental health domains of the Short Form 36 Health Survey. Patients who received acupuncture were 3.7 times more likely (CI, 1.7 to 8.1) to report less suffering from headaches at 6 weeks (absolute risk reduction 46%; number needed to treat 2). CONCLUSION: Headache-specialty medical management alone was not associated with improved clinical outcomes among our study population. Supplementing medical management with acupuncture, however, resulted in improvements in health-related QoL and the perception by patients that they suffered less from headaches.

Quantifying delay in access to new medical treatment: an application of risk advancement period methodology.

BACKGROUND: We present a novel application of the concept of risk or rate advancement to compute the extent of delay in adoption of an effective new drug in 2 German health insurance systems. METHODS: We identified individuals with migraines, age 18 to 65 years, in 371 primary care practices in Germany in 1994 (MediPlus, IMS Health database). These included 8173 persons covered under the statutory health insurance system and 503 persons covered by private health insurance. We derived risk and population risk advancement periods for sumatriptan compared with nonserotoninergic acute migraine therapy using multiplicative risk regression and generalized estimating equations, adjusted for patient, physician, and practice cofactors. RESULTS: For patients at the mean age of the cohort, 43 years of age, sumatriptan was prescribed 1.2 (95% confidence interval [CI] = 0.3-2.0) years later among those in the statutory health insurance system compared with those who had private insurance. The lag increased by 0.6 (-0.1 to 1.3) years for every 10 years of patient age. In the age-mix of our sample, access to the health benefits of sumatriptan therapy lagged nearly 1.5 years behind in the statutory health insurance system and for Germany as a whole. CONCLUSIONS: Migraine patients' access to sumatriptan therapy lagged substantially in the statutory health insurance system and in the country as a whole. Risk advancement periods provide a useful methodology for communicating major healthcare issues in a meaningful way to society and policymakers.