Joan F. Hilton

Background: Mobile health interventions have the potential to motivate healthy behaviors. Optimal strategies for engaging patients in cardiac rehabilitation (CR) through mobile health interventions remain unclear. Objective: This study aimed to examine patient engagement in a mobile app platform for CR across patient characteristics and by the method of delivery of nudge messages over the 12 weeks of CR. Methods: The authors analyzed data from the ERA-Nudge (Enhancing Rehabilitation Adherence Through Optimized Nudge) study, a pragmatic randomized trial conducted at an urban safety-net hospital testing nudges (short messages designed using behavioral economics to elicit behavior change) to enhance CR adherence and log healthy activity. Trial patients were given access to a smartphone-based app. Nudges were initially sent as app notifications. Later in the study, patients received nudges as text messages. We assessed patient characteristics associated with app engagement, and we compared time spent in the CR app among patients receiving nudges as app notifications vs text messages. The trial enrolled patients who could engage with messages in either English or Spanish at an urban safety-net hospital with a qualifying CR diagnosis and a smartphone from May 2019 to May 2023. We describe minutes spent in the app across patient characteristics and by type of nudge delivery, and we compare the 2 approaches using unadjusted and multivariate negative binomial regression over the 12 weeks of CR. Results: In total, 223 patients received nudges: 74 via app notification and 149 via text message. Overall, patients spent an average of 219 (SD 328) minutes in the app, and 3 (1.3%) patients used the app for zero minutes. Patients receiving only app nudges spent a mean of 167 (SD 365) minutes in the app, and patients receiving text messages and app nudges spent 245 (SD 306) minutes in the app (unadjusted ratio 1.5, 95% CI 1.1-2.0; P =.02). After adjusting for age category, sex, primary language, CR location (hospital vs home), and highest education achieved, Spanish-preferring patients, patients with some college education, and patients receiving text messages spent more time in the app. Patients receiving nudges as text messages and app notifications spent an adjusted ratio of 1.8 (95% CI 1.2-2.5; P =.002) times as many minutes in the app compared to those getting nudges as app notifications. Conclusions: Among an urban safety-net population, text message nudges were associated with greater time in the app compared to nudges delivered as app notifications. These findings suggest that text messages may result in greater patient engagement for mobile health interventions.

Rationale: Socioeconomically disadvantaged patients with asthma and/or chronic obstructive pulmonary disease (COPD) face barriers to evidence-based care that are difficult to overcome in health care settings with limited resources. Objectives: Evaluate the efficacy of a pulmonary-specialist-health coach consultation model (intervention) for patients with asthma and/or COPD, relative to usual care (control). Methods: Randomized-controlled trial of 16 weeks of intervention versus control for adult English- or Spanish-speaking, low-income patients. Intervention: a lay health coach gathered information from the patient and medical record for remote review by a pulmonary specialist, who provided general recommendations to the primary care clinician. The coach supported implementation of recommendations. Measurements: Primary outcomes were receipt of guideline-based care and medications. Secondary outcomes were receipt of chronic lung disease education, breathing-related quality of life and symptoms, patient-rated quality of care, and adherence to inhaler therapy. Longitudinal models for count data were used to estimate Intervention: Control relative rates. Parallel models for continuous data estimated relative means. Main results: 165 intervention participants received 1.61-fold more guideline-based care than 163 control participants (relative ratio; CI: 1.37-1.90). They were not more likely to receive guideline-based medications in planned analysis using a pooled baseline rate, although post-hoc analysis using arm-specific baseline rates found significant improvement. Intervention patients received more chronic lung disease education and reported greater improvements in breathing-related quality of life, symptoms, and patient-reported quality of care. Conclusions: This intervention offers a scalable approach to improve uptake of clinical guidelines in resource-limited primary care practices managing most asthma and COPD care.

Background: Schistosoma-associated pulmonary arterial hypertension (Sch-PAH), a complication of hepatosplenic schistosomiasis, is still underdiagnosed and undertreated. Sch-PAH is the third-most common cause of pulmonary arterial hypertension (PAH) in Brazil, and it is estimated that there are around 60,000 afflicted individuals. However, there is a lack of data on these patients, especially in endemic areas. Therefore, this study aimed to describe baseline demographic data, hemodynamic severity of disease, and functional impairment of Sch-PAH patients at diagnosis. Methods: For this systematic review, five databases (Embase, PubMed, SciELO, LILACS, and Cochrane) were searched to identify candidate publications reporting clinical, hemodynamic, and functional data at diagnosis of Sch-PAH patients referred to a PAH reference center in Brazil. Studies were excluded if they enrolled patients under the age of 18, the diagnosis was not confirmed by right heart catheterization (RHC), consisted of case reports, or did not report original data. Risk of bias was assessed using the Newcastle–Ottawa Scale and an adapted version for cross-sectional studies. Single-arm meta-analysis with a random-effect model was performed for each variable. Results: From 459 studies identified through systematic database searching, five studies were selected for this meta-analysis. The majority of the included patients were women (67%), New York Heart Association (NYHA) functional class III/IV (57%), mean age 49 years (95% confidence interval [95% CI], 46–52), 6 min walk distance 392 m (95% CI, 291–493), mean pulmonary arterial pressure (mPAP) 59 mmHg (95% CI, 56–61), pulmonary vascular resistance (PVR) 12 WU (95% CI, 11–13) and cardiac index (CI) 2.57 L/min/m² (95% CI, 2.25–2.88). Conclusions: In summary, Sch-PAH has clinical characteristics similar to other forms of PAH, including connective tissue disease and idiopathic PAH. Additional studies or a unified registry would be essential for a better understanding of this relevant disease in Brazil.

Over the past 35 years, research has consistently shown that adverse childhood experiences (ACEs) have a deleterious impact on almost all major mental, physical, and behavioral indicators of wellbe...

The incidence of anal cancer is increasing, especially in high-risk groups, such as PLWH. HPV 16, a high-risk (HR) HPV genotype, is the most common genotype in anal high-grade squamous intraepithelial lesions (HSIL) and squamous cell carcinoma (SCC) in the general population. However, few studies have described the distribution of HR HPV genotypes other than HPV 16 in the anus of PLWH. HPV genotyping was performed by DNA amplification followed by dot-blot hybridization to identify the HR and low-risk (LR) genotypes in benign anal lesions (n = 34), HSIL (n = 30), and SCC (n = 51) of PLWH and HIV-negative individuals. HPV 16 was the most prominent HR HPV identified, but it was less common in HSIL and SCC from PLWH compared with HIV-negative individuals, and other non-HPV 16 HR HPV (non-16 HR HPV) types were more prevalent in samples from PLWH. A higher proportion of clinically normal tissues from PLWH were positive for one or more HPV genotypes. Multiple HPV infection was a hallmark feature for all tissues (benign, HSIL, SCC) of PLWH. These results indicate that the development of anal screening approaches based on HPV DNA testing need to include non-16 HR HPVs along with HPV 16, especially for PLWH. Along with anal cytology, these updated screening approaches may help to identify and prevent anal disease progression in PLWH.

Schistosomiasis is a major cause of pulmonary arterial hypertension (PAH) worldwide, but the prevalence and risk factors for schistosomiasis‐associated PAH (SchPAH) development are not well understood. Schistosomiasis‐associated hepatosplenic disease (SchHSD) is thought to be a major risk factor for PAH development. Herein, we describe our plans for prospectively screening SchHSD subjects for clinical evidence of PAH at two major academic medical centers and national referral hospitals in Addis Ababa, Ethiopia and Lusaka, Zambia. The screening study will primarily be conducted by echocardiography, in addition to clinical assessments. Plasma samples will be drawn and banked for subsequent analysis based on preclinical animal model rationale. If successful, this study will demonstrate feasibility of conducting prospective cohort studies of SchPAH screening in schistosomiasis‐endemic regions of Africa, and provide initial data on clinic‐based disease prevalence and potential mechanistic biomarkers underlying disease pathogenesis.

BACKGROUND Globally, data on antenatal blood transfusion practices are scarce. We sought to characterize the epidemiology of antenatal transfusion in South Africa. STUDY DESIGN AND METHODS A cross‐sectional study was conducted of women who were transfused during pregnancy (>48 hr before anticipated delivery) at two hospitals in Durban and Soweto in 2014 to 2015. Medical record data on demographics, obstetric history, anemia, HIV status, and indications for blood transfusion were abstracted. RESULTS The records on a total of 560 transfused pregnant women were evaluated; mean age was 28 years, 98% were of black African ethnicity, and 28% were HIV positive. At time of transfusion, one‐half were in the first trimester. Hemorrhage was noted in 76% of women, most of which was associated with abortion (67%) or ectopic pregnancy (27%). Most women were transfused with red blood cells (RBCs; median, 2 units); 14% of women were transfused with plasma and 2% with platelets. Median pre‐ and posttransfusion hemoglobin levels were 6.9 g/dL and 9.2 g/dL, respectively; the latter differed by hospital (8.7 g/dL vs. 9.5 g/dL; p < 0.01). Hemorrhage was associated with missing HIV status, lower gestational age, and transfusion of 3 or more RBC units (all p < 0.01). In contrast, diagnoses of anemia (Soweto only) were associated with HIV infection, later gestational age, and lower (<3 units) RBC dose (all p < 0.01). CONCLUSION Abortion and ectopic pregnancy with associated hemorrhage were the leading indications for antenatal transfusion and were concentrated in early gestation. By contrast, anemia was associated with HIV infection and transfusion in the third trimester.

Purpose: To estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco. Method: The 8-week Patient Engagement Project Study intervention, delivered at four services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the nine-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams’ SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least one trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on nine SDM behaviors per patient encounter. Results: In total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all nine SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33–2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team. Conclusions: The intervention increased behaviors supporting SDM during ward rounds on four independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.