Jing Cheng

Background: Smoking continues to be a leading cause of preventable morbidity and mortality, and more than 480,000 Americans die annually due to smoking-related illness attributable to smoking and secondhand smoke. More advanced, responsive, and tailored digital interventions using machine learning and artificial intelligence may be a valuable tool for successful smoking cessation referrals. Objective: This study used the dynamic systems development method to incorporate patient and consumer sources of conversational data to develop a technology-assisted motivational interviewing (TAMI) chatbot, a digital agent using machine learning models to deliver motivational interviewing (MI) for tobacco cessation. Methods: During the functional model iteration phase, user-centered design interviews with smokers (n=3) informed the creation of TAMI. The design and build phase involved the use of existing datasets to guide the incorporation of MI-consistent utterances, language recognition, and topic classification to guide a discussion about smoking, and providing a tailored quit plan if indicated. During the implementation phase, user experience interviews with randomly selected participants (n=9) in a pilot trial discussed their experiences with TAMI. Results: User-centered design interviews indicated a desire for a chatbot that was engaging and adaptable to personal interests in quitting smoking. Inductive analysis of user experience interviews revealed that anonymity, regular reminders, and a humanized experience facilitated engagement with TAMI, but technical glitches, chatbot misunderstandings, and issues with rapport were barriers to engagement. Conclusions: Informed by user input and patient and consumer datasets, TAMI can use MI skills to elicit change talk and/or accurately evaluate readiness for tobacco cessation. Further development will enhance TAMI’s ability to seamlessly engage with users when discussing behavior change and assist underserved populations achieve improvements in a variety of health behavior goals.

Background: Chronic pain (CP) is among the most common medical conditions, is the leading cause of disability, and is often refractory to medical treatment. The CDC and the American College of Physicians recommend nonopioid and nonpharmacologic treatment as first-line strategies, including cognitive-behavioral therapy (CBT), mindfulness-based interventions (MBI), and movement-focused interventions (MFI); however, only 3% of people with chronic pain (CP) have access to these evidence-based treatments. Patients from historically minoritized populations and those speaking languages other than English are particularly underserved and may go untreated. Stigma regarding CP and interventions to manage it present additional obstacles. Methods: The Integrating Nonpharmacologic Strategies for Pain with Inclusion, Respect, and Equity (INSPIRE) study evaluates a blend of these non-pharmacologic, evidence-based interventions using a pragmatic, parallel, two-arm RCT comparing intervention participants with wait-list controls. The INSPIRE intervention includes a 12-week curriculum delivered via a multilingual mobile app paired with weekly telehealth coaching. The primary outcome will be the “Pain, Enjoyment, and General Activity (PEG)” scores at 3 months. Secondary outcomes include PEG scores at 6 and 12 months, physical functioning, quality of life, sleep, depression, anxiety, and global satisfaction with treatment at 3, 6, and 12 months. Primary mediators to be examined include pain cognitions and health behaviors. Secondary mediators may include stigma and isolation, trust in healthcare providers, and both engagement and satisfaction with the INSPIRE intervention. The intention-to-treat primary analysis will be conducted with covariates including baseline measures of pain, anxiety, and physical function. Discussion: The full RCT protocol and intervention details are provided following the SPIRIT guidelines. Implications for improving treatment access via culturally and linguistically tailored digital health interventions are discussed along with the potential for health coaching to drive mobile app engagement. Trial registration: ClinicalTrials.gov ID NCT06183281. Trial registration data set can be found here: https://clinicaltrials.gov/study/NCT06183281 and in Additional file 1.

BACKGROUND: Catheter ablation of ventricular arrhythmias, one of the most rapidly growing procedures in cardiac electrophysiology, is associated with magnetic resonance imaging–detected brain lesions in more than half of cases. Although a retrograde aortic approach is conventional, modern tools enable entry through a transseptal approach that may avoid embolization of debris from the arterial system. We sought to test the hypothesis that a transseptal puncture would mitigate brain injury compared with a retrograde aortic approach. METHODS: The TRAVERSE trial (Transseptal Versus Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli) was a multicenter randomized controlled comparative effectiveness trial. Patients with left ventricular arrhythmias undergoing catheter ablation procedures were randomly assigned to a transseptal puncture approach compared (1:1) with a retrograde aortic approach. The primary outcome was the presence of an acute brain lesion detected by magnetic resonance imaging. Secondary outcomes included clinically manifest complications, procedural efficacy, and 6-month neurocognitive assessments. RESULTS: Among the 62 patients randomly assigned to a retrograde aortic approach with postoperative brain magnetic resonance imaging, 28 (45%) exhibited an acute brain lesion compared with 19 of the 69 (28%) of those randomized to a transseptal puncture ( P =0.036). No differences in clinically manifest complications or procedural efficacy were observed. More patients in the retrograde aortic arm were categorized as having a high likelihood of cognitive impairment at 6 months (33% compared with 19% of those in the transseptal arm), but substantial loss to follow-up was present. CONCLUSIONS: Among patients undergoing left ventricular catheter ablation procedures, a transseptal approach reduced the risk of acute brain lesions by nearly half compared with a retrograde aortic approach without sacrificing safety or efficacy. Given a likely embolic pathogenesis, the brain magnetic resonance imaging findings may reflect a propensity to other organ damage; these findings may extend to other procedures requiring left ventricular entry. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03946072.

UNSTRUCTURED Interactions based in Motivational Interviewing (MI) [1], driven by machine learning, may provide an efficient way to evaluate readiness to quit, elicit behavior change preferences, and scalable flexibility to extend reach to more diversified target populations. This study used patient and public sources of conversational data to develop a Technology Assisted Motivational Interviewing chatbot (TAMI), a digital agent employing machine learning models to deliver MI for tobacco cessation. Consistent with the four tasks of MI (engagement, focusing, evocation, and planning), the creation of TAMI involved 1) utilization of existing de-identified datasets to identify specific smoking topics of interest; 2) incorporation of MI-Consistent utterances to enhance relational connection to TAMI and elicit language expressing interest in quitting (change talk); 3) instilling change talk recognition and topic classification to guide discussion with TAMI and 4) providing tailored treatment options if indicated. Informed by patient, provider, and public discussions about smoking, TAMI can explore motivation associated with tobacco use, and privately employ interventions to elicit change talk, or accurately evaluate readiness for tobacco cessation. TAMI is also scalable technology, which opens the possibility of having more tools for clinical assessment, delivering MI, and tailoring cessation referrals to underserved populations or those with other target behavior goals.

Objective: The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose.Method: Patients were enrolled upon admission and randomized to meal‐based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t‐tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight).Results: Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = −.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02).Discussion: Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group.Public significance: The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.

BACKGROUND: Adolescents' school engagement, mental health, and substance use have been major concerns during the COVID-19 pandemic, particularly given disruptions to school instruction. We examined how the instructional setting was associated with academic and health-related outcomes within an adolescent cohort followed during the pandemic.METHODS: During 3 semi-annual follow-up surveys, adolescents (N = 1066 students; 2242 observations) from 8 California high schools responded to items measuring academic self-efficacy, school connectedness, internalizing and externalizing problems, and use of substances. Separate generalized estimating equation models predicted outcomes based on the instructional setting.RESULTS: Relative to in-person instruction, students in remote instruction reported lower academic self-efficacy (Beta: -0.11; 95% confidence interval [CI]: -0.22, -0.01) and school connectedness (Beta: -0.37; 95% CI: -0.48, -0.25), greater odds of past 30-day internalizing problems (AOR: 1.46; 95% CI: 1.09, 1.95), externalizing problems (AOR: 1.36; 95% CI: 1.02, 1.82), and cigarette, cigar, smokeless tobacco, or hookah use (AOR: 2.50; 95% CI: 1.06, 5.91), but lower odds of past 30-day e-cigarette use (AOR: 0.50; 95% CI: 0.30, 0.86).CONCLUSIONS: Multiple adverse outcomes related to school engagement, mental health, and substance use were associated with remote instruction. To reduce such impacts under future emergencies, schools should rely sparingly on remote instruction and provide appropriate supportive resources.

Background: Marijuana leaf vaporizers, which heat plant material and sublimate Δ‐9‐tetrahydrocannabinol without combustion, are popular alternatives to smoking cannabis that are generally perceived to be less harmful. We have shown that smoke from tobacco and marijuana, as well as aerosol from e‐cigarettes and heated tobacco products, impair vascular endothelial function in rats measured as arterial flow‐mediated dilation (FMD). Methods and Results: We exposed 8 rats per group to aerosol generated by 2 vaporizer systems (Volcano and handheld Yocan) using marijuana with varying Δ‐9‐tetrahydrocannabinol levels, in a single pulsatile exposure session of 2 s/min over 5 minutes, and measured changes in FMD. To model secondhand exposure, we exposed rats for 1 minute to diluted aerosol approximating release of uninhaled Volcano aerosol into typical residential rooms. Exposure to aerosol from marijuana with and without cannabinoids impaired FMD by ≈50%. FMD was similarly impaired by aerosols from Yocan (237 °C), and from Volcano at both its standard temperature (185 °C) and the minimum sublimation temperature of Δ‐9‐tetrahydrocannabinol (157 °C), although the low‐temperature aerosol condition did not effectively deliver Δ‐9‐tetrahydrocannabinol to the circulation. Modeled secondhand exposure based on diluted Volcano aerosol also impaired FMD. FMD was not affected in rats exposed to clean air or water vapor passed through the Volcano system. Conclusions: Acute direct exposure and modeled secondhand exposure to marijuana leaf vaporizer aerosol, regardless of cannabinoid concentration or aerosol generation temperature, impair endothelial function in rats comparably to marijuana smoke. Our findings indicate that use of leaf vaporizers is unlikely to reduce the vascular risk burden of smoking marijuana.

Sugar intake has been linked to the global rise in diabetes. However, the unique diabetogenic effect of sugar, independent of weight gain, remains controversial. This study aimed to investigate the associations between total and added sugar intake and diabetes status, and to test whether the sugar–diabetes associations were moderated or mediated by the body mass index (BMI). We performed a nationwide cross-sectional study on 12,889 Chinese adults who were enrolled in the China Health and Nutrition Survey (CHNS) 2011. The data for the total and added sugar intake were measured using three consecutive 24 h recalls, and determined based on the U.S. Department of Agriculture (USDA) National Nutrient Database for Standard Reference, Release 28 (SR28), the Food Patterns Equivalents Database (FPED) 2015–2016, and the labeled ingredients and nutrient contents. A multivariable logistic regression model was used to analyze the associations between the total and added sugar intake and diabetes. A nutrient density model was used to adjust for the total energy intake. A mediation analysis for significant sugar–diabetes associations shown in multivariable logistic analysis (p < 0.05), and a subgroup analysis according to the BMI category were performed, to examine the mediating and moderating effects of the BMI on the sugar–diabetes association, respectively. We included 12,800 individuals, with a mean age of 50.5, in the final analysis. The means of the total and added sugar intake, total sugar (%E), and added sugar (%E) were 28.2 ± 0.2 g/d, 5.0 ± 0.1 g/d, 6.0 ± 0.0%, and 1.0 ± 0.0%, respectively. The overall prevalence of self-reported physician-diagnosed diabetes was 4.0%. A significant association between the total sugar intake and an increased risk of diabetes was found (odds ratio [OR] =1.008, 95% CI 1.001–1.016). The mediation analysis showed a significant mediation effect through the BMI of the effect of the total sugar on diabetes status (p < 0.001), where 11.7% (95% CI: 4.7–35.7%) of the effect of the total sugar on diabetes was mediated through the BMI. The total sugar intake had a significant direct effect on diabetes around the BMI (estimated coefficient = 0.0004, p < 0.001). The overall total-sugar-intake–diabetes association remained significant in normal-weight participants in the subgroup analysis (OR =1.012, 1.000–1.024). In conclusion, although the BMI moderated and mediated the association between the total sugar intake and diabetes, the total sugar still showed some unique weight-independent diabetogenic effects. Our findings call for efforts to prevent and control diabetes by reducing sugar intake, and losing weight appropriately.

A high level of sugar intake has been linked to poor dietary quality and a wide range of chronic diseases. However, data on sugar intake are still scarce in China. This study aimed to provide time trends in the total and added sugar intakes among Chinese children and adolescents from 1997 to 2011. A nationwide ongoing open prospective cohort study of Chinese children and adolescents aged 3–17 years (n = 13,212) was conducted by using data from the China Health and Nutrition Survey (CHNS) 1997–2011 (six 1-year cycles). An individual dietary intake was collected from three consecutive 24-h recalls during randomly allocated home visits. Data for total and added sugar contents were determined based on the U.S. Department of Agriculture (USDA) National Nutrient Database for Standard Reference, Release 28 (SR28), the Food Patterns Equivalents Database (FPED) 2015–2016, and the labeled ingredients and nutrient contents. General linear regression was used to estimate time trends. Over the 15-year period, total sugar and added sugar intakes increased among all age groups studied (3–17 years: total sugar increased from 11.2 ± 0.3 g/d to 28.1 ± 0.5 g/d, added sugar increased from 1.0 ± 0.1 g/d to 7.2 ± 0.3 g/d; 3–6 years: 9.5 ± 0.6 g/d to 25.1 ± 0.9 g/d, 1.3 ± 0.2 g/d to 6.9 ± 0.4 g/d; 7–12 years: 11.4 ± 0.5 g/d to 28.1 ± 0.8 g/d, 0.9 ± 0.1 g/d to 7.1 ± 0.5 g/d; 13–17 years: 11.8 ± 0.4 g/d to 31.4 ± 1.1 g/d, 1.0 ± 0.2 g/d to 7.6 ± 0.6 g/d) (all p for trend < 0.001). Adolescents aged 13–17 years had the highest total sugar intake, and children aged 3–6 years had the highest added sugar intake, except for 2011. Children and adolescents living in urban areas and who were overweight had much higher total and added sugar intakes than those residing in rural areas and of non-overweight/obesity. Furthermore, the dietary sources of total and added sugars have become more diverse over the study period. In conclusion, we observed a notable rise in total and added sugar intakes among children and adolescents across all age groups, both genders, both urban and rural areas, and all BMI categories, with dietary sources of total and added sugars becoming more diverse in China over 15 years.