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Introduction Bipolar disorder is an often disabling mental illness with a lifetime prevalence of 1textendash2 a high risk of recurrence of manic and depressive episodes, a lifelong elevated risk of suicide and a substantial heritability. The course of illness is frequently characterised by progressive shortening of interepisode intervals with each recurrence and increasing cognitive dysfunction in a subset of individuals with this condition. Clinically, diagnostic boundaries between bipolar disorder and other psychiatric disorders such as unipolar depression are unclear although pharmacological and psychological treatment strategies differ substantially. Patients with bipolar disorder are often misdiagnosed and the mean delay between onset and diagnosis is 5textendash10 years. Although the risk of relapse of depression and mania is high it is for most patients impossible to predict and consequently prevent upcoming episodes in an individual tailored way. The identification of objective biomarkers can both inform bipolar disorder diagnosis and provide biological targets for the development of new and personalised treatments. Accurate diagnosis of bipolar disorder in its early stages could help prevent the long-term detrimental effects of the illness.The present Bipolar Illness Onset study aims to identify (1) a composite blood-based biomarker, (2) a composite electronic smartphone-based biomarker and (3) a neurocognitive and neuroimaging-based signature for bipolar disorder.Methods and analysis The study will include 300 patients with newly diagnosed/first-episode bipolar disorder, 200 of their healthy siblings or offspring and 100 healthy individuals without a family history of affective disorder. All participants will be followed longitudinally with repeated blood samples and other biological tissues, self-monitored and automatically generated smartphone data, neuropsychological tests and a subset of the cohort with neuroimaging during a 5 to 10-year study period.Ethics and dissemination The study has been approved by the Local Ethical Committee (H-7-2014-007) and the data agency, Capital Region of Copenhagen (RHP-2015-023), and the findings will be widely disseminated at international conferences and meetings including conferences for the International Society for Bipolar Disorders and the World Federation of Societies for Biological Psychiatry and in scientific peer-reviewed papers.Trial registration number NCT02888262.

An increasing number of healthcare systems allow people to monitor behavior and provide feedback on health and wellness. Most applications, however, only offer feedback on behavior in form of visualization and data summaries. This paper presents a different approach--called impact factor analysis--in which machine learning techniques are used to infer the progression of a primary health parameter and then apply parameter ranking to investigate which behavioral data have the highest `impact' on health. We have applied this approach to improve the MONARCA personal health application for patients suffering from bipolar disorder. In the MONARCA system, patients report their daily mood score and by analyzing self-reported and automatically sensed behavioral data with this mood score, the system is able to identify the impact of different behavior on the patient's mood. We report from a study involving ten bipolar patients, in which we were able to estimate mood values with an average mean absolute error of 0.5. This was used to rank the behavior parameters whose variations indicate changes in the mental state. The rankings acquired from our algorithms correspond to the patients' rankings, identifying physical activity and sleep as the highest impact parameters. These results revealed the feasibility of identifying behavioral impact factors. This data analysis motivated us to design an impact factor inference engine as part of the MONARCA system. To our knowledge, this is a novel approach in monitoring and control of mental illness, and we argue that the impact factor analysis can be useful in the design of other health and wellness systems.

Measuring changes in psychomotor activity is a potential tool in the monitoring of the course of affective states in bipolar disorder. Previous studies have been cross-sectional and only some have used objective measures. The aim was to investigate state-related differences in objectively-measured psychomotor activity in bipolar disorder. During a 12 weeks study, repeated measurements of heart rate and movement monitoring over several days were collected during different affective states from 19 outpatients with bipolar disorder. Outcomes included activity energy expenditure (AEE) and trunk acceleration (ACC). Symptoms were clinically assessed using Hamilton Depression Rating Scale (HDRS-17) and Young Mania Rating Scale (YMRS). Compared to patients in a euthymic state, patients in a manic state had significantly higher AEE. Compared to patients in a depressive state, patients in a manic state had significantly higher ACC and AEE. There was a significant diurnal variation in ACC and AEE between affective states. Finally, there was a significant correlation between the severity of manic symptoms and ACC and AEE, respectively. This first study measuring psychomotor activity during different affective states using a combined heart rate and movement sensor supports that psychomotor activity is a core symptom in bipolar disorder that is altered during affective states.

Heart rate variability (HRV) has been suggested reduced in bipolar disorder (BD) compared with healthy individuals (HC). This meta-analysis investigated: HRV differences in BD compared with HC, major depressive disorder or schizophrenia; HRV differences between affective states; HRV changes from mania/depression to euthymia; and HRV changes following interventions.A systematic review and meta-analysis reported according to the PRISMA guidelines was conducted. MEDLINE, Embase, PsycINFO, The Cochrane Library and Scopus were searched. A total of 15 articles comprising 2534 individuals were included.HRV was reduced in BD compared to HC (g=-1.77, 95% CI: -2.46; -1.09, P0.001, 10 comparisons, n=1581). More recent publication year, larger study and higher study quality were associated with a smaller difference in HRV. Large between-study heterogeneity, low study quality, and lack of consideration of confounding factors in individual studies were observed.This first meta-analysis of HRV in BD suggests that HRV is reduced in BD compared to HC. Heterogeneity and methodological issues limit the evidence. Future studies employing strict methodology are warranted.

Background Various paper-based mood charting instruments are used in the monitoring of symptoms in bipolar disorder. During recent years an increasing number of electronic self-monitoring tools have been developed. The objectives of this systematic review were 1) to evaluate the validity of electronic self-monitoring tools as a method of evaluating mood compared to clinical rating scales for depression and mania and 2) to investigate the effect of electronic self-monitoring tools on clinically relevant outcomes in bipolar disorder. Methods A systematic review of the scientific literature, reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted. MEDLINE, Embase, PsycINFO and The Cochrane Library were searched and supplemented by hand search of reference lists. Databases were searched for 1) studies on electronic self-monitoring tools in patients with bipolar disorder reporting on validity of electronically self-reported mood ratings compared to clinical rating scales for depression and mania and 2) randomized controlled trials (RCT) evaluating electronic mood self-monitoring tools in patients with bipolar disorder. Results A total of 13 published articles were included. Seven articles were RCTs and six were longitudinal studies. Electronic self-monitoring of mood was considered valid compared to clinical rating scales for depression in six out of six studies, and in two out of seven studies compared to clinical rating scales for mania. The included RCTs primarily investigated the effect of heterogeneous electronically delivered interventions; none of the RCTs investigated the sole effect of electronic mood self-monitoring tools. Methodological issues with risk of bias at different levels limited the evidence in the majority of studies. Conclusions Electronic self-monitoring of mood in depression appears to be a valid measure of mood in contrast to self-monitoring of mood in mania. There are yet few studies on the effect of electronic self-monitoring of mood in bipolar disorder. The evidence of electronic self-monitoring is limited by methodological issues and by a lack of RCTs. Although the idea of electronic self-monitoring of mood seems appealing, studies using rigorous methodology investigating the beneficial as well as possible harmful effects of electronic self-monitoring are needed. Electronic supplementary material The online version of this article (doi:10.1186/s12888-016-0713-0) contains supplementary material, which is available to authorized users.

This position paper presents our preliminary design of context-aware cognitive behavioral therapy for unipolar and bipolar disorders. We report on the background for this study and the methods applied in the ongoing design process. The paper ends by presenting and discussing different design options. We hope this will be useful input for further discussion at the workshop.

Changes in speech have been suggested as sensitive and valid measures of depression and mania in bipolar disorder. The present study aimed at investigating (1) voice features collected during phone calls as objective markers of affective states in bipolar disorder and (2) if combining voice features with automatically generated objective smartphone data on behavioral activities (for example, number of text messages and phone calls per day) and electronic self-monitored data (mood) on illness activity would increase the accuracy as a marker of affective states. Using smartphones, voice features, automatically generated objective smartphone data on behavioral activities and electronic self-monitored data were collected from 28 outpatients with bipolar disorder in naturalistic settings on a daily basis during a period of 12 weeks. Depressive and manic symptoms were assessed using the Hamilton Depression Rating Scale 17-item and the Young Mania Rating Scale, respectively, by a researcher blinded to smartphone data. Data were analyzed using random forest algorithms. Affective states were classified using voice features extracted during everyday life phone calls. Voice features were found to be more accurate, sensitive and specific in the classification of manic or mixed states with an area under the curve (AUC)=0.89 compared with an AUC=0.78 for the classification of depressive states. Combining voice features with automatically generated objective smartphone data on behavioral activities and electronic self-monitored data increased the accuracy, sensitivity and specificity of classification of affective states slightly. Voice features collected in naturalistic settings using smartphones may be used as objective state markers in patients with bipolar disorder.

Objective Diabetes is associated with pulmonary tuberculosis (TB), possibly due to impaired immunity, and diabetes may exacerbate the clinical manifestations of TB. Our aim was to assess the role of diabetes in the clinical manifestations of TB. Methods We studied 1250 patients with pulmonary TB in an urban population in a cross-sectional study in Tanzania. All participants were tested for diabetes and HIV co-infection, and TB culture intensity was assessed. Levels of white blood cells, haemoglobin, acute phase reactants, CD4 count and HIV viral load were measured, and a qualitative morbidity questionnaire was used to identify the prevalence of disease-related symptoms. Results Tuberculosis patients with diabetes had a higher neutrophil count (B 0.5 × 109 cells/l, 95% CI 0.2; 0.9, P = 0.001) than non-diabetic TB patients. Serum C-reactive protein (B 18.8 mg/l, CI 95% 8.2; 29.4, P = 0.001) and alpha-1-acid glycoprotein (B 0.2 g/l, CI 95% 0.03; 0.3, P = 0.02) were similarly higher in patients with diabetes. Diabetes did not affect culture intensity or HIV status, but self-reported fever was three times higher among participants with diabetes than in those without diabetes (OR 2.9, CI 95% 1.5; 5.7, P = 0.002). Conclusion Diabetes is associated with small changes in the manifestations of TB, but may have little clinical significance. Objectif: L’association entre le diabete et la tuberculose (TB) pulmonaire est probablement liee a un deficit immunitaire et le diabete peut aggraver les manifestations cliniques de la TB. Notre objectif etait d’evaluer le role du diabete dans les manifestations cliniques de la TB. Methodes: Nous avons etudie 1250 patients atteints de TB pulmonaire dans une population urbaine dans le cadre d’une etude transversale en Tanzanie. Tous les participants ont ete testes pour le diabete et la coinfection VIH, et le rendement de la culture de TB a eteevalue. Les taux de globules blancs, l’hemoglobine, les reactants de phase aigue, la numeration des CD4 et la charge virale VIH ont ete mesures. Un questionnaire qualitatif sur la morbidite a ete utilise pour determiner la prevalence des symptomes lies a la maladie. Resultats: Les patients TB diabetiques avaient un nombre plus eleve de neutrophiles (B 0,5 x 109 cellules/L, IC95%: 0,2 - 0,9; p = 0,001) que les patients TB non-diabetiques. Le CRP (B 18,8 mg/L, IC95%: 8,2 - 29,4; p = 0,001) et AGP (B 0,2 g/L, IC95%: 0,03 - 0,3; p = 0,02) seriques etaient aussi plus eleves chez les patients diabetiques. Le diabete n’avait pas d’influence sur le rendement de la culture ou le statut VIH, mais la fievre auto-declaree etait trois fois plus elevee chez les patients atteints de diabete que chez ceux sans diabete (OR: 2,9, IC95%: 1,5 - 5,7; p = 0,002). Conclusion: Le diabete est associea de petits changements dans les manifestations de la TB, mais pourrait n’avoir que peu de signification clinique. Objetivo: La diabetes esta asociada con la tuberculosis (TB) pulmonar, posiblemente debido a una inmunidad comprometida, y puede exacerbar las manifestaciones clinicas de la TB. Nuestro objetivo era evaluar el papel de la diabetes en las manifestaciones clinicas de la TB. Metodos: Hemos estudiado a 1250 pacientes con TB pulmonar durante un estudio crosseccional en poblacion urbana de Tanzania. A todos los participantes se les realizaron pruebas para diabetes y VIH, y se evaluo la intensidad del cultivo de TB. Se midieron los niveles de leucocitos, hemoglobina, reactivos de fase aguda, conteo de CD4 y carga viral de VIH, y se utilizo un cuestionario cualitativo de morbilidad para identificar la prevalencia de los sintomas relacionados con la enfermedad. Resultados: Los pacientes con TB y diabetes tenian un mayor conteo de neutrofilos (B 0.5 × 109 celulas/L, 95% CI 0.2;0.9, p = 0.001) que los pacientes no diabeticos-TB. La proteina C-reactiva en suero (B 18.8 mg/L, IC 95% 8.2; 29.4, p = 0.001) y la alfa-1 glicoproteina acida (B 0.2 g/L, IC 95% 0.03;0.3, p = 0.02) eran igualmente altos en pacientes con diabetes. La diabetes no afectaba la intensidad de cultivo o el estatus de VIH, pero la fiebre autoreportada era tres veces mayor entre los participantes con diabetes que entre aquellos sin diabetes (OR 2.9, IC 95% 1.5; 5.7, p = 0.002). Conclusion: La diabetes esta asociada con pequenos cambios en las manifestaciones de la TB, pero pueden tener poco significado clinico.

Undernutrition is common among tuberculosis (TB) patients. The objective of this study was to assess the effect of multi-micronutrient supplementation during TB treatment on weight, body composition, and handgrip strength. A total of 865 patients with smear-positive (PTB+) or -negative (PTB-) pulmonary TB were randomly allocated to receive a daily biscuit with or without multi-micronutrients for 60 d during the intensive phase of TB treatment. Weight, arm fat area, arm muscle area, and handgrip strength were assessed at baseline and after 2 and 5 mo. At 2 mo, the multi-micronutrient supplementation led to a higher handgrip gain (1.22 kg; 95% CI = 0.50, 1.94; P = 0.001) but had no effects on other outcomes. The effects of multi-micronutrient supplementation were modified by HIV infection (P-interaction = 0.002). Among HIV- patients, multi-micronutrient supplementation increased weight gain by 590 g (95% CI = -40, 1210; P = 0.07) and handgrip strength by 1.6 kg (95% CI = 0.78, 2.47; P < 0.001), whereas among HIV+ patients, it reduced weight gain by 1440 g (95% CI = 290, 2590; P = 0.002) and had no effect on handgrip strength (0.07 kg; 95% CI = -1.30, 1.46; P = 0.91). The reduced weight gain among HIV+ patients receiving multi-micronutrient supplementation seemed to be explained by a higher proportion of patients reporting fever. At 5 mo, the effects on weight were sustained, whereas there was no effect on handgrip strength. In conclusion, multi-micronutrient supplementation given as a biscuit is beneficial among HIV- PTB patients and may be recommended to TB programs. More research is needed to develop an effective supplement for HIV+ PTB patients.

E-mental health technologies are under great development and the use is of these technologies is increasing rapidly.During this symposium, results from a randomized controlled trial investigating the effect of smartphone based electronic self-monitoring on the severity of depressive and manic symptoms will be presented and discussed.Further, we will present and discuss the use of automatically generated objective smartphone data on behavioral activities (e.g. social activities, mobility and physical activity) as electronic biomarkers of illness activity in bipolar disorder.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Bipolar Disorder is a common and complex mental disorder with a prevalence of 1-2% and accounts as one of the most important causes of disability at age 15-44 years worldwide.Electronic versions of self-monitoring tools and symptom registration using computers, personal digital assistants (PDAs), text messages, and web interfaces have been described in the literature and a large number of commercial Smartphone applications for patients with bipolar disorder are available.The Next Generation Mobile Platforms for Health, in Mental Disorders project (the NYMPHA-MD project), funded by the European Union's Seventh Framework program for research, technological development and demonstration, focuses on the implementation of a Pre-Commercial Procurement of mobile e-health service for supporting physicians and patients in the treatment of bipolar disorder through continuous patients monitoring in order to dynamically support illness management and potentially identify early warning signs.The NYMPHA-MD project will define the framework of a Pre-Commercial Procurement for the provisioning of next generation services advocated for mental health treatment with a special focus on bipolar disorder based on the use of new technologies, open standards and open platforms.The NYMPHA-MD project will focus on identifying requirements involved in the structuring of mental health services with a focus on bipolar disorder treatment including medical, technological, patients, legal, ethical, policy, risk management and business-orientation needs in order to construct a reference model of service provisioning useful in different European contexts.Disclosure of interestThe author has not supplied his declaration of competing interest.

Rating scales used to assess the severity of depression e.g. the Hamilton Depression Rating Scale 17-item (HDRS-17) partly rely on the patient's subjective experience and reporting. Such subjective measures tend to have low reliability and adding objective measures to complement the assessment of depression severity would be a major step forward.To investigate correlations between electronic monitoring of psychomotor activity and severity of depression according to HDRS-17.A total of 36 patients with unipolar disorder (n = 18) or bipolar disorder (n = 18) and 31 healthy control persons aged 18-60 years were included. Psychomotor activity was measured using a combined heart rate and movement sensor device (Actiheart) for 3 consecutive days, 24 h a day.We found that sleeping heart rate (beats/min) correlated with HDRS-17 in both patients with unipolar disorder and bipolar disorder (unadjusted model: B = 0.46, 95% CI 0.037-0.89, P = 0.034). In contrast, correlations between activity energy expenditure (kJ/kg/day), cardio-respiratory fitness (mlO2/min/kg) and HDRS-17 were non-significant.These results suggest that measuring sleeping heart rate in non-experimental daily life could be an objective supplementary method to measure the severity of depression and perhaps indicate presence of insomnia.

Bipolar Disorder is a disease that is manifested with cycling periods of polar episodes, namely mania and depression. Depressive episodes are manifested through disturbed mood, psychomotor retardation, behaviour change, decrease in energy levels and length of sleep. Manic episodes are manifested through elevated mood, psychomotor acceleration and increase in intensity of social interactions. In this paper we report results of a clinical trial with bipolar patients that amongst other aspects, investigated whether changes in general behaviour of patients due to onset of a bipolar episode, can be captured through the analysis of smartphone usage. We have analysed changes in smartphone usage, specifically app usage and how these changes correlate with the self-reported patient state. We also used psychiatric evaluation scores provided by the clinic to understand correlation of the patient smartphone behaviour before the psychiatric evaluation and after the psychiatric evaluation. The results show that patients have strong correlation of patterns of app usage with different aspects of their self-reported state including mood, sleep and irritability. While, on the other hand, the patients' application usage shows discernable changes in the period before and after psychiatric evaluation.

The daily electronic self-monitoring Smartphone software “MONARCA” was used by 17 patients with bipolar disorder for 3 consecutive months. Patients were rated fortnightly using Hamilton Depression rating Scale 17 items (HDRS-17) and Young Mania rating Scale (YMRS) (102 ratings) with blinding for Smartphone data. Objective Smartphone measures such as physical and social activity correlated with clinically rated depressive symptoms. Self-monitored depressive symptoms correlated significantly with HDRS-17 items score.

BACKGROUND: There is increasing evidence to suggest that different Mycobacterium tuberculosis lineages cause variations in the clinical presentation of tuberculosis (TB). Certain M. tuberculosis genotypes/lineages have been shown to be more likely to cause active TB in human populations from a distinct genetic ancestry. This study describes the genetic biodiversity of M. tuberculosis genotypes in Mwanza city, Tanzania and the clinical presentation of the disease caused by isolates of different lineages.METHODS: Two-hundred-fifty-two isolates from pulmonary TB patients in Mwanza, Tanzania were characterized by spoligotyping, and 45 isolates were further characterized by mycobacterium interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR). The patients' level of the acute phase reactants AGP, CRP and neutrophil counts, in addition to BMI, were measured and compared to the M. tuberculosis lineage of the infectious agent for each patient.RESULTS: The most frequent genotype was ST59 (48 out of 248 [19.4%]), belonging to the Euro-American lineage LAM11_ZWE, followed by ST21 (CAS_KILI lineage [44 out of 248 [17.7%]). A low degree of diversity (15.7% [39 different ST's out of 248 isolates]) of genotypes, in addition to a high level of mixed M. tuberculosis sub-populations among isolates with an unreported spoligotype pattern (10 out of 20 isolates [50.0%]) and isolates belonging to the ST53 lineage (13 out of 25 [52%]) was observed. Isolates of the 'modern' (TbD1-) Euro-American lineage induced higher levels of α1-acid glycoprotein (β = 0.4, P = 0.02; 95% CI [0.06-0.66]) and neutrophil counts (β = 0.9, P = 0.02; 95% CI [0.12-1.64]) and had lower BMI score (β = -1.0, P = 0.04; 95% CI[-1.89 - (-0.03)]). LAM11_ZWE ('modern') isolates induced higher levels of CRP (β = 24.4, P = 0.05; 95% CI[0.24-48.63]) and neutrophil counts (β = 0.9, P = 0.03; 95% CI[0.09-1.70]).CONCLUSION: The low diversity of genotypes may be explained by an evolutionary advantage of the most common lineages over other lineages combined with optimal conditions for transmission, such as overcrowding and inadequate ventilation. The induction of higher levels of acute phase reactants in patients infected by 'modern' lineage isolates compared to 'ancient' lineages may suggest increased virulence among 'modern' lineage isolates.

SUMMARYWe assessed the role of tuberculosis (TB) disease and HIV infection on the level of physical activity. A combined heart rate and movement sensor was used to assess habitual physical activity in TB patients and non-TB controls. The association between sputum-negative TB, sputum-positive TB, HIV and physical activity estimates were assessed in multivariable linear regression models adjusted for age, sex, haemoglobin and alpha-1-acid glycoprotein (AGP). Sputum-positive [eB0·43, 95% confidence interval (CI) 0·29–0·64] and sputum-negative (eB0·67, 95% CI 0·47–0·94) TB as well as HIV infection (eB0·59, 95% CI 0·46–0·75) were associated with reduced activity compared to controls. Anaemia accounted for a substantial part of the effects of HIV, while elevated AGP primarily mediated the TB effect. The level of physical activity is highly influenced by TB and HIV, and mainly mediated through anaemia of infection and associated with elevated acute phase response.

To the Editors: In patients latently infected with Mycobacterium tuberculosis , immunosuppression significantly augments the risk of progression to active tuberculosis (TB) and TB is still one of the most frequent opportunistic infections worldwide. Prevention of TB in HIV-positive patients using the tuberculin skin testing (TST) followed by targeted preventive treatment is an effective strategy, but has thus far shown limited clinical success, in part due to the lack of a reliable test for latent TB infection (LTBI) 1. Interferon (IFN)-γ release assays (IGRAs) have shown great potential in the improvement of LTBI diagnosis, but the tests perform suboptimally in immunocompromised populations. We and others have previously shown that HIV-positive patients have high rates of indeterminate QuantiFERON®-TB Gold In-Tube test (QFT-IT) results and that this, at least in part, is due to low CD4 T-cell count 2–4. We and others have also shown that IFN-γ-inducible protein 10 (IP-10/CXCL-10) is an alternative biomarker may improve immunodiagnosis of M. tuberculosis infection. IP-10 is induced specifically and in large quantities upon in vitro stimulation of whole blood with M. tuberculosis -specific antigens. We have developed an IP-10 based test 5 and shown that the IP-10 test performs comparably to the QFT-IT in adult patients with intact immune function 6. We compared the sensitivity of an IP-10 based test with the QFT-IT for diagnosing M. tuberculosis infection in HIV-negative and HIV-positive patients with culture-confirmed active pulmonary tuberculosis (PTB). 300 patients newly diagnosed with PTB were recruited prospectively through the National Tuberculosis and Leprosy Programme (Mwanza, Tanzania). Blood was drawn for IGRA and HIV testing, and CD4 cell counts. Sputum was collected for microscopy and M. tuberculosis culture. Patients >15 yrs of age with a positive sputum culture result were enrolled. All HIV-positive patients were newly diagnosed in the study …

Sub-Saharan Africa is experiencing the highest relative increase in diabetes (1), but data are scarce, with only nine countries reporting prevalence surveys within the last decade (2). While biological and behavioral risk factors for diabetes are fairly well-described in high-income settings, it is not known to what extent such risk factors contribute to the diabetes epidemic in low-resource settings. The aim of the current study was to assess whether conventional Western population risk factors for diabetes are appropriate in identifying individuals with diabetes among urban Tanzanians. The study took place in the urban setting of Mwanza City, which is located in northwestern Tanzania. The current study was part of a larger nutrition study (2006–2009) (3), and 743 healthy control subjects chosen from among tuberculosis patients were invited to participate. Individuals ≥15 years of age, nonpregnant, and without severe diseases were invited to participate. Ethical permission was obtained from the Medical Research Coordinating Committee of the National Institute for Medical Research, Tanzania. Standardized questionnaires were used to collect …

There is a growing interest in personal health technologies that sample behavioral data from a patient and visualize this data back to the patient for increased health awareness. However, a core challenge for patients is often to understand the connection between specific behaviors and health, i.e. to go beyond health awareness to disease insight. This paper presents MONARCA 2.0, which records subjective and objective data from patients suffering from bipolar disorder, processes this, and informs both the patient and clinicians on the importance of the different data items according to the patient's mood. The goal is to provide patients with a increased insight into the parameters influencing the nature of their disease. The paper describes the user-centered design and the technical implementation of the system, as well as findings from an initial field deployment.

OBJECTIVE: Strong evidence suggests diabetes may be associated with tuberculosis (TB) and could influence TB treatment outcomes. We assessed the role of diabetes on sputum culture conversion and mortality among patients undergoing TB treatment.METHODS: A total of 1250 Tanzanian TB patients were followed prospectively during TB treatment with sputum culture after 2 and 5 months. Survival status was assessed at least 1 year after initiation of treatment. At baseline, all participants underwent testing for diabetes and HIV, and the serum concentration of the acute phase reactant alpha-1 glycoprotein (AGP) was determined.RESULTS: There were no differences between participants with and without diabetes regarding the proportion of positive cultures at 2 (3.8% vs. 5.8%) and 5 (1.3% vs. 0.9%) months (P > 0.46). However, among patients with a positive TB culture, relatively more patients with diabetes died before the 5-month follow-up. Within the initial 100 days of TB treatment, diabetes was associated with a fivefold increased risk of mortality (RR 5.09, 95% CI 2.36; 11.02, P < 0.001) among HIV uninfected, and a twofold increase among HIV co-infected patient (RR 2.33 95% CI 1.20; 4.53, P = 0.012), while diabetes was not associated with long-term mortality. Further adjustment with AGP did not change the estimates.CONCLUSION: Diabetes considerably increases risk of early mortality during TB treatment. The effect may not be explained by increased severity of TB, but could be due to impaired TB treatment response. Research is needed to clarify the mechanism and to assess whether glycaemic control improves survival.

An increasing number of pervasive healthcare systems are being designed, that allow people to monitor and get feedback on their health and wellness. To address the challenges of self-management of mental illnesses, we have developed the MONARCA system - a personal monitoring system for bipolar patients. We conducted a 14 week field trial in which 12 patients used the system, and we report findings focusing on their experiences. The results were positive; compared to using paper-based forms, the adherence to self-assessment improved; the system was considered very easy to use; and the perceived usefulness of the system was high. Based on this study, the paper discusses three HCI questions related to the design of personal health technologies; how to design for disease awareness and self-treatment, how to ensure adherence to personal health technologies, and the roles of different types of technology platforms.

BACKGROUND As diabetes impairs tuberculosis (TB) treatment outcomes, it is essential to identify diabetes among TB patients. While little is known about predictors of diabetes among healthy individuals in Africa, predictors among TB patients are almost non-existent. OBJECTIVE To assess potential predictors for diabetes among newly diagnosed pulmonary TB patients in Tanzania. METHODS TB patients were tested for diabetes using an oral glucose tolerance test, demographic information was collected and anthropometric measurements taken. The association between diabetes and possible predictors were examined using logistic regression analyses. RESULTS Of 1205 TB patients, 16.4% (n = 197) had diabetes, 9.0% (n = 108) were aged ≥55 years, 3.3% (n = 40) were overweight (body mass index [BMI] ≥ 25 kg/m(2)) and 12.7% (n = 152) severely underweight (BMI < 16 kg/m(2)). Diabetes was most prevalent in the 45-55 year age group, and increasing weight, BMI and waist circumference were associated with diabetes. Severe underweight (BMI < 16 kg/m(2)) among male TB patients (sex-BMI interaction, P = 0.02) was associated with diabetes (OR 2.52, P = 0.004). CONCLUSION Diabetes is a common comorbidity among TB patients. Although diabetes was associated with obesity and was more prevalent among the middle-aged, the majority of TB patients with diabetes comorbidity were young and lean. With diabetes as a major risk factor for TB, and with the lack of strong predictors for diabetes, universal diabetes screening should be implemented in the TB programme.

While BCG vaccine protects against severe tuberculosis (TB) in children, its effect against adult TB is questionable. Furthermore, it is not known if HIV co-infection modifies the effect of BCG. Among 352 pairs of Tanzanian TB cases and matched controls, the BCG scar was associated with a reduced risk of TB (OR 0.3, 95% CI 0.2 to 0.7, p=0.005), irrespective of HIV status (interaction, p=0.623). BCG vaccination considerably reduced the risk of TB, both among individuals with and without HIV infection.

Diabetes is associated with pulmonary tuberculosis (TB), possibly due to impaired immunity, and diabetes may exacerbate the clinical manifestations of TB. Our aim was to assess the role of diabetes in the clinical manifestations of TB.We studied 1250 patients with pulmonary TB in an urban population in a cross-sectional study in Tanzania. All participants were tested for diabetes and HIV co-infection, and TB culture intensity was assessed. Levels of white blood cells, haemoglobin, acute phase reactants, CD4 count and HIV viral load were measured, and a qualitative morbidity questionnaire was used to identify the prevalence of disease-related symptoms.Tuberculosis patients with diabetes had a higher neutrophil count (B 0.5 × 10(9) cells/l, 95% CI 0.2; 0.9, P = 0.001) than non-diabetic TB patients. Serum C-reactive protein (B 18.8 mg/l, CI 95% 8.2; 29.4, P = 0.001) and alpha-1-acid glycoprotein (B 0.2 g/l, CI 95% 0.03; 0.3, P = 0.02) were similarly higher in patients with diabetes. Diabetes did not affect culture intensity or HIV status, but self-reported fever was three times higher among participants with diabetes than in those without diabetes (OR 2.9, CI 95% 1.5; 5.7, P = 0.002).Diabetes is associated with small changes in the manifestations of TB, but may have little clinical significance.

Background False negative and indeterminate Interferon Gamma Release Assay (IGRA) results are a well documented problem. Cigarette smoking is known to increase the risk of tuberculosis (TB) and to impair Interferon-gamma (IFN-γ) responses to antigenic challenge, but the impact of smoking on IGRA performance is not known. The aim of this study was to evaluate the effect of smoking on IGRA performance in TB patients in a low and high TB prevalence setting respectively. Methods Patients with confirmed TB from Denmark (DK, n = 34; 20 smokers) and Tanzania (TZ, n = 172; 23 smokers) were tested with the QuantiFERON-TB Gold In tube (QFT). Median IFN-γ level in smokers and non smokers were compared and smoking was analysed as a risk factor for false negative and indeterminate QFT results. Results Smokers from both DK and TZ had lower IFN-γ antigen responses (median 0.9 vs. 4.2 IU/ml, p = 0.04 and 0.4 vs. 1.6, p Conclusions Cigarette smoking was associated with false negative and indeterminate IGRA results in both a high and a low TB endemic setting independent of HIV status.

BackgroundDiabetes and TB are associated, and diabetes is increasingly common in low-income countries where tuberculosis (TB) is highly endemic. However, the role of diabetes for TB has not been assessed in populations where HIV is prevalent.MethodsA case-control study was conducted in an urban population in Tanzania among culture-confirmed pulmonary TB patients and non-TB neighbourhood controls. Participants were tested for diabetes according to WHO guidelines and serum concentrations of acute phase reactants were measured. The association between diabetes and TB, and the role of HIV as an effect modifier, were examined using logistic regression. Since blood glucose levels increase during the acute phase response, we adjusted for elevated serum acute phase reactants.ResultsAmong 803 cases and 350 controls the mean (SD) age was 34.8 (11.9) and 33.8 (12.0) years, and the prevalence of diabetes was 16.7% (95% CI: 14.2; 19.4) and 9.4% (6.6; 13.0), respectively. Diabetes was associated with TB (OR 2.2, 95% CI: 1.5; 3.4, pConclusionDiabetes is a risk factor for TB in HIV uninfected, whereas the association in HIV infected patients needs further study. The increasing diabetes prevalence may be a threat to TB control.

This study aimed to estimate deficits in weight, arm fat area (AFA), arm muscle area (AMA) and handgrip strength among smear-positive pulmonary TB (PTB+) patients starting treatment. We conducted a cross-sectional study among PTB+ patients and age- and sex-matched neighborhood controls. HIV status, anthropometric measurements and handgrip strength were determined. Deficits in weight, AFA, AMA and handgrip strength associated with PTB+ and HIV were estimated using multiple regression analysis. We recruited 355 pairs of PTB+ patients and controls. PTB+ was associated with deficits of 10.0 kg (95% CI 7.3; 12.7) in weight and 6.8 kg (95% CI 5.2; 8.3) in handgrip strength among females and 9.1 kg (95% CI 7.3; 10.9) in weight and 6.8 kg (95% CI 5.2; 8.4) in handgrip strength among males. In both sexes, PTB+ was associated with deficits in AFA and AMA. Among females, HIV was associated with deficits in AMA and handgrip strength, but the deficit in handgrip strength was larger among PTB+ patients (3.2 kg 95% CI 1.3; 5.2) than controls (-1.6 kg 95% CI -4.8; 1.5) (interaction, P = 0.009). These findings suggest that deficits in weight and handgrip strength among patients starting TB treatment are severe. Thus, nutritional support may be necessary to ensure reversal of the deficits, and may improve treatment outcomes.

While BCG vaccine protects against severe tuberculosis (TB) in children, its effect against adult TB is questionable. Furthermore, it is not known if HIV co-infection modifies the effect of BCG. Among 352 pairs of Tanzanian TB cases and matched controls, the BCG scar was associated with a reduced risk of TB (OR 0.3, 95% CI 0.2 to 0.7, p=0.005), irrespective of HIV status (interaction, p=0.623). BCG vaccination considerably reduced the risk of TB, both among individuals with and without HIV infection.

Introduction Electronic self-monitoring of affective symptoms using cell phones is suggested as a practical and inexpensive way to monitor illness activity and identify early signs of affective symptoms. It has never been tested in a randomised clinical trial whether electronic self-monitoring improves outcomes in bipolar disorder. We are conducting a trial testing the effect of using a Smartphone for self-monitoring in bipolar disorder. Methods We developed the MONARCA application for Android-based Smartphones, allowing patients suffering from bipolar disorder to do daily self-monitoring—including an interactive feedback loop between patients and clinicians through a web-based interface. The effect of the application was tested in a parallel-group, single-blind randomised controlled trial so far including 78 patients suffering from bipolar disorder in the age group 18–60 years who were given the use of a Smartphone with the MONARCA application (intervention group) or to the use of a cell phone without the application (placebo group) during a 6-month study period. The study was carried out from September 2011. The outcomes were changes in affective symptoms (primary), social functioning, perceived stress, self-rated depressive and manic symptoms, quality of life, adherence to medication, stress and cognitive functioning (secondary and tertiary). Analysis Recruitment is ongoing. Ethics Ethical permission has been obtained. Dissemination Positive, neutral and negative findings of the study will be published. Registration details The trial is approved by the Regional Ethics Committee in The Capital Region of Denmark (H-2-2011-056) and The Danish Data Protection Agency (2013-41-1710). The trial is registered at ClinicalTrials.gov as NCT01446406.

IntroductionOne third of the world's population is estimated to be latently infected with Mycobacterium tuberculosis (LTBI). Surveys of LTBI are rarely performed in resource poor TB high endemic countries like Tanzania although low-income countries harbor the largest burden of the worlds LTBI. The primary objective was to estimate the prevalence of LTBI in household contacts of pulmonary TB cases and a group of apparently healthy neighborhood controls in an urban setting of such a country. Secondly we assessed potential impact of LTBI on inflammation by quantitating circulating levels of an acute phase reactant: alpha-1-acid glycoprotein (AGP) in neighborhood controls.MethodsThe study was nested within the framework of two nutrition studies among TB patients in Mwanza, Tanzania. Household contacts- and neighborhood controls were invited to participate. The study involved a questionnaire, BMI determination and blood samples to measure AGP, HIV testing and a Quantiferon Gold In tube (QFN-IT) test to detect signs of LTBI.Results245 household contacts and 192 neighborhood controls had available QFN-IT data. Among household contacts, the proportion of QFT-IT positive was 59% compared to 41% in the neighborhood controls (p = 0.001). In a linear regression model adjusted for sex, age, CD4 and HIV, a QFT-IT positive test was associated with a 10% higher level of alpha-1-acid glycoprotein(AGP) (10(B) 1.10, 95% CI 1.01; 1.20, p = 0.03), compared to individuals with a QFT-IT negative test.ConclusionLTBI is highly prevalent among apparently healthy urban Tanzanians even without known exposure to TB in the household. LTBI was found to be associated with elevated levels of AGP. The implications of this observation merit further studies.

Bipolar disorder is a great challenge to patients, relatives and clinicians, and there is a need for development of new methods to identify prodromal symptoms of affective episodes in order to provide efficient preventive medical and behavioural intervention. Clinical trials prove that electronic monitoring is a feasible, valid and acceptable method. Hence it is recommended, that controlled trials on the effect of electronic monitoring on patients' course of illness, level of function and quality of life are conducted.

Background Due to the association between diabetes and pulmonary tuberculosis (TB), diabetes may threaten the control of TB. In a prospective cohort study nested in a nutrition trial, we investigated the role of diabetes on changes in anthropometry, grip strength, and clinical parameters over a five months follow-up period. Methods Among pulmonary TB patients with known diabetes status, we assessed anthropometry and clinical parameters (e.g. haemoglobin) at baseline and after two and five months of TB treatment. A linear mixed-effects model (repeated measurements) was used to investigate the role of diabetes during recovery. Results Of 1205 TB patients, the mean (standard deviation) age was 36.6 (13.0) years, 40.9% were females, 48.9% were HIV co-infected, and 16.3% had diabetes. TB patients with diabetes co-morbidity experienced a lower weight gain at two (1.3 kg, CI95% 0.5; 2.0, p = 0.001) and five months (1.0 kg, CI95% 0.3; 1.7, p = 0.007). Similarly, the increase in the level of haemoglobin was lower among TB patients with diabetes co-morbidity after two (Δ 0.6 g/dL, CI95% 0.3; 0.9 p Conclusion TB patients initiating TB treatment with diabetes co-morbidity experience delayed recovery of body mass and haemoglobin, which are important for the functional recovery from disease.