An SMS chatbot digital educational program to increase healthy eating behaviors in adolescence: A multifactorial randomized controlled trial among 7,890 participants in the Danish National Birth Cohort.

BACKGROUND: Few cost-effective strategies to shift dietary habits of populations in a healthier direction have been identified. We examined if participating in a chatbot health education program transmitted by Short Messages Service ("SMS-program") could improve adolescent dietary behaviors and body weight trajectories. We also explored possible added effects of maternal or peer involvement. METHODS AND FINDINGS: We conducted a randomized controlled trial (RCT) among adolescents from the Danish National Birth Cohort (DNBC). Eligible were adolescents who during 2015 to 2016 at age 14 years had completed a questionnaire assessing height, weight, and dietary habits. Two thirds were offered participation in an SMS-program, whereas 1/3 ("non-SMS group") received no offer. The SMS program aimed to improve 3 key dietary intake behaviors: sugar-sweetened beverages (SSBs), fruit and vegetables (FV), and fish. The offered programs had 3 factorially randomized schemes; the aims of these were to test effect of asking the mother or a friend to also participate in the health promotion program, and to test the effect of a 4-week individually tailored SMS program against the full 12-week SMS program targeting all 3 dietary factors. Height and weight and intakes of SSB, FV, and fish were assessed twice by a smartphone-based abbreviated dietary questionnaire completed at 6 months (m) and 18 m follow-up. Main outcome measures were (1) body mass index (BMI) z-score; and (2) an abbreviated Healthy Eating Index (mini-HEI, 1 m window, as mean of z-scores for SSB, FV, and fish). Among the 7,890 randomized adolescents, 5,260 were assigned to any SMS program; 63% (3,338) joined the offered program. Among the 7,890 randomized, 74% (5,853) and 68% (5,370) responded to follow-ups at 6 m and 18 m, respectively. Effects were estimated by intention-to-treat (ITT) analyses and inverse probability weighted per-protocol (IPW-PP) analyses excluding adolescents who did not join the program. Mean (standard deviation (SD)) mini-HEI at baseline, 6 m and 18 m was -0.01 (0.64), 0.01 (0.59), and -0.01 (0.59), respectively. In ITT-analyses, no effects were observed, at any time point, in those who had received any SMS program compared to the non-SMS group, on BMI z-score (6 m: -0.010 [95% confidence interval (CI) -0.035, 0.015]; p = 0.442, 18 m: 0.002 [95% CI -0.029, 0.033]; p = 0.901) or mini-HEI (6 m: 0.016 [95% CI -0.011, 0.043]; p = 0.253, 18m: -0.016 [95% CI -0.045, 0.013]; p = 0.286). In IPW-PP analyses, at 6 m, a small decrease in BMI z-score (-0.030 [95% CI -0.057, -0.003]; p = 0.032) was observed, whereas no significant effect was observed in mini-HEI (0.027 [95% CI -0.002, 0.056]; p = 0.072), among those who had received any SMS program compared to the non-SMS group. At 18 m, no associations were observed (BMI z-score: -0.006 [95% CI -0.039, 0.027]; p = 0.724, and mini-HEI: -0.005 [95% CI -0.036, 0.026]; p = 0.755). The main limitations of the study were that DNBC participants, though derived from the general population, tend to have higher socioeconomic status than average, and that outcome measures were self-reported. CONCLUSIONS: In this study, a chatbot health education program delivered through an SMS program had no effect on dietary habits or weight trajectories in ITT analyses. However, IPW-PP-analyses, based on those 63% who had joined the offered SMS program, suggested modest improvements in weight development at 6 m, which had faded at 18 m. Future research should focus on developing gender-specific messaging programs including "booster" messages to obtain sustained engagement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02809196 https://clinicaltrials.gov/study/NCT02809196.

Consumer-Led Screening for Atrial Fibrillation: Frontier Review of the AF-SCREEN International Collaboration.

The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional-led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single-time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.

Emerging Technologies for Identifying Atrial Fibrillation.

Atrial fibrillation (AF) is a major cause of morbidity and mortality globally, and much of this is driven by challenges in its timely diagnosis and treatment. Existing and emerging mobile technologies have been used to successfully identify AF in a variety of clinical and community settings, and while these technologies offer great promise for revolutionizing AF detection and screening, several major barriers may impede their effectiveness. The unclear clinical significance of device-detected AF, potential challenges in integrating patient-generated data into existing healthcare systems and clinical workflows, harm resulting from potential false positives, and identifying the appropriate scope of population-based screening efforts are all potential concerns that warrant further investigation. It is crucial for stakeholders such as healthcare providers, researchers, funding agencies, insurers, and engineers to actively work together in fulfilling the tremendous potential of mobile technologies to improve AF identification and management on a population level.

Hexokinase-II positively regulates glucose starvation-induced autophagy through TORC1 inhibition.

Hexokinase-II (HK-II) catalyzes the first step of glycolysis and also functions as a protective molecule; however, its role in protective autophagy has not been determined. Results showed that inhibition of HK-II diminished, while overexpression of HK-II potentiated, autophagy induced by glucose deprivation in cardiomyocyte and noncardiomyocyte cells. Immunoprecipitation studies revealed that HK-II binds to and inhibits the autophagy suppressor, mTOR complex 1 (TORC1), and that this binding was increased by glucose deprivation. The TOS motif, a scaffold sequence responsible for binding TORC1 substrates, is present in HK-II, and mutating it blocked its ability to bind to TORC1 and regulate protective autophagy. The transition from glycolysis to autophagy appears to be regulated by a decrease in glucose-6 phosphate. We suggest that HK-II binds TORC1 as a decoy substrate and provides a previously unrecognized mechanism for switching cells from a metabolic economy, based on plentiful energy, to one of conservation, under starvation.

Health Care Satisfaction in Relation to Gender Identity: Behavioral Risk Factor Surveillance Survey, 20 States (2014-2018).

BACKGROUND: Health care satisfaction is a key component of patient-centered care. Prior research on transgender populations has been based on convenience samples, and/or grouped all gender minorities into a single category. OBJECTIVE: The objective of this study was to quantify differences in health care satisfaction among transgender men, transgender women, gender nonconforming, and cisgender adults in a diverse multistate sample. RESEARCH DESIGN: Cross-sectional analysis of 2014-2018 Behavioral Risk Factor Surveillance System data from 20 states, using multivariable logistic models. SUBJECTS: We identified 167,468 transgender men, transgender women, gender-nonconforming people, cisgender women, and cisgender men and compared past year health care satisfaction across these groups. RESULTS: Transgender men and women had the highest prevalence of being "not at all satisfied" with the health care they received (14.6% and 8.6%, respectively), and gender-nonconforming people had the lowest prevalence of being "very satisfied" with their health care (55.7%). After adjustment for sociodemographic characteristics, transgender men were more likely to report being "not at all satisfied" with health care than cisgender men (odds ratio: 4.45, 95% confidence interval: 1.72-11.5) and cisgender women (odds ratio: 3.40, 95% confidence interval: 1.31-8.80). CONCLUSIONS: Findings indicate that transgender and gender-nonconforming adults report considerably less health care satisfaction relative to their cisgender peers. Interventions to address factors driving these differences are needed.

Premature Atrial and Ventricular Contraction Detection using Photoplethysmographic Data from a Smartwatch.

We developed an algorithm to detect premature atrial contraction (PAC) and premature ventricular contraction (PVC) using photoplethysmographic (PPG) data acquired from a smartwatch. Our PAC/PVC detection algorithm is composed of a sequence of algorithms that are combined to discriminate various arrhythmias. A novel vector resemblance method is used to enhance the PAC/PVC detection results of the Poincaré plot method. The new PAC/PVC detection algorithm with our automated motion and noise artifact detection approach yielded a sensitivity of 86% for atrial fibrillation (AF) subjects while the overall sensitivity was 67% when normal sinus rhythm (NSR) subjects were also included. The specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy values for the combined data consisting of both NSR and AF subjects were 97%, 81%, 94% and 92%, respectively, for PAC/PVC detection combined with our automated motion and noise artifact detection approach. Moreover, when AF detection was compared with and without PAC/PVC, the sensitivity and specificity increased from 94.55% to 98.18% and from 95.75% to 97.90%, respectively. For additional independent testing data, we used two datasets: a smartwatch PPG dataset that was collected in our ongoing clinical study, and a pulse oximetry PPG dataset from the Medical Information Mart for Intensive Care III database. The PAC/PVC classification results of the independent testing on these two other datasets are all above 92% for sensitivity, specificity, PPV, NPV, and accuracy. The proposed combined approach to detect PAC and PVC can ultimately lead to better accuracy in AF detection. This is one of the first studies involving detection of PAC and PVC using PPG recordings from a smartwatch. The proposed method can potentially be of clinical importance as this enhanced capability can lead to fewer false positive detections of AF, especially for those NSR subjects with frequent episodes of PAC/PVC.

Novel Method of Atrial Fibrillation Case Identification and Burden Estimation Using the MIMIC-III Electronic Health Data Set.

BACKGROUND: Atrial fibrillation (AF) portends poor prognoses in intensive care unit patients with sepsis. However, AF research is challenging: Previous studies demonstrate that International Classification of Disease (ICD) codes may underestimate the incidence of AF, but chart review is expensive and often not feasible. We aim to examine the accuracy of nurse-charted AF and its temporal precision in critical care patients with sepsis. METHODS: Patients with sepsis with continuous electrocardiogram (ECG) waveforms were identified from the Medical Information Mart for Intensive Care (MIMIC-III) database, a de-identified, single-center intensive care unit electronic health record (EHR) source. We selected a random sample of ECGs of 6 to 50 hours' duration for manual review. Nurse-charted AF occurrence and onset time and ICD-9-coded AF were compared to gold-standard ECG adjudication by a board-certified cardiac electrophysiologist blinded to AF status. Descriptive statistics were calculated for all variables in patients diagnosed with AF by nurse charting, ICD-9 code, or both. RESULTS: From 142 ECG waveforms (58 AF and 84 sinus rhythm), nurse charting identified AF events with 93% sensitivity (95% confidence interval [CI]: 87%-100%) and 87% specificity (95% CI: 80%-94%) compared to the gold standard manual ECG review. Furthermore, nurse-charted AF onset time was within 1 hour of expert reader onset time for 85% of the reviewed tracings. The ICD-9 codes were 97% sensitive (95% CI: 88-100%) and 82% specific (95% CI: 74-90%) for incident AF during admission but unable to identify AF time of onset. CONCLUSION: Nurse documentation of AF in EHR is accurate and has high precision for determining AF onset to within 1 hour. Our study suggests that nurse-charted AF in the EHR represents a potentially novel method for AF case identification, timing, and burden estimation.

Willingness to adopt wearable devices with behavioral and economic incentives by health insurance wellness programs: results of a US cross-sectional survey with multiple consumer health vignettes.

BACKGROUND: The number of health-related wearable devices is growing but it is not clear if Americans are willing to adopt health insurance wellness programs based on wearables and the incentives with which they would be more willing to adopt. METHODS: In this cross-sectional study we used a survey methodology, usage vignettes and a dichotomous scale to examine U.S. residents' willingness to adopt wearables (WTAW) in six use-cases where it was mandatory to use a wearable device and share the resulting data with a health insurance company. Each use-case was tested also for the influence of additional economic incentives on WTAW. RESULTS: A total of 997 Americans across 46 states participated in the study. Most of them were 25 to 34 years old (40.22%), 57.27% were female, and 74.52% were white. On average, 69.5% of the respondents were willing to adopt health-insurance use-cases based on wearable devices, though 77.8% of them were concerned about issues related to economic benefits, data privacy and to a lesser extent, technological accuracy. WTAW was 11-18% higher among consumers in use-cases involving health promotion and disease prevention. Furthermore, additional economic incentives combined with wearables increased WTAW overall. Notably, financial incentives involving providing healthcare credits, insurance premium discount, and/or wellness product discounts had particularly greater effectiveness for increasing WTAW in the consumer use-cases involving participation: for health promotion (RR = 1.06 for financial incentive, 95% CI: 1.01-1.11; P = 0.018); for personalized products and services (RR = 1.11 for financial incentive, 95% CI: 1.01-1.21; P = 0.018); and for automated underwriting discount at annual renewal (RR = 1.28 for financial incentive, 95% CI: 1.20-1.37; P < 0.001). CONCLUSIONS: Under the adequate economic, data privacy and technical conditions, 2 out of 3 Americans would be willing to adopt health insurance wellness programs based on wearable devices, particularly if they have benefits related to health promotion and disease prevention, and particularly with financial incentives.

Wearing Your Heart on Your Sleeve: the Future of Cardiac Rhythm Monitoring.

PURPOSE OF REVIEW: This review describes the novel category of wearable ECG monitors and identifies where patients, healthcare providers, and device manufacturers should focus efforts to maximize the clinical benefit of these devices. RECENT FINDINGS: Notable wearable ECG monitors include the AliveCor Kardia devices, Apple Watch Series 4, and several others. The most common use case is monitoring for atrial fibrillation. The available evidence validates the ability of the Kardia devices and Apple Watch to distinguish atrial fibrillation from sinus rhythm. Key questions for manufacturers include how to calibrate each device's algorithms and streamline workflows for healthcare providers. Wearable ECG monitors are currently most useful to detect atrial fibrillation. Further study is needed to demonstrate whether wearable ECG monitors improve patient outcomes, and to expand their use into other indications. Device manufacturers and healthcare providers must work together to establish new workflows to process and act on wearable ECG data.

Association of religiosity and spirituality with quality of life in patients with cardiovascular disease: a systematic review.

PURPOSE: This review systematically identified and critically appraised the available literature that has examined the association between religiosity and/or spirituality (R/S) and quality of life (QOL) in patients with cardiovascular disease (CVD). METHODS: We searched several electronic online databases (PubMed, SCOPUS, PsycINFO, and CINAHL) from database inception until October 2017. Included articles were peer-reviewed, published in English, and quantitatively examined the association between R/S and QOL. We assessed the methodological quality of each included study. RESULTS: The 15 articles included were published between 2002 and 2017. Most studies were conducted in the US and enrolled patients with heart failure. Sixteen dimensions of R/S were assessed with a variety of instruments. QOL domains examined were global, health-related, and disease-specific QOL. Ten studies reported a significant positive association between R/S and QOL, with higher spiritual well-being, intrinsic religiousness, and frequency of church attendance positively related with mental and emotional well-being. Approximately half of the included studies reported negative or null associations. CONCLUSIONS: Our findings suggest that higher levels of R/S may be related to better QOL among patients with CVD, with varying associations depending on the R/S dimension and QOL domain assessed. Future longitudinal studies in large patient samples with different CVDs and designs are needed to better understand how R/S may influence QOL. More uniformity in assessing R/S would enhance the comparability of results across studies. Understanding the influence of R/S on QOL would promote a holistic approach in managing patients with CVD.

Global Mortality From Firearms, 1990-2016.

Importance: Understanding global variation in firearm mortality rates could guide prevention policies and interventions. Objective: To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories. Design, Setting, and Participants: This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths. Exposures: Firearm ownership and access. Main Outcomes and Measures: Cause-specific deaths by age, sex, location, and year. Results: Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of those deaths. In 1990, there were an estimated 209 000 (95% UI, 172 000 to 235 000) deaths from firearm injuries. Globally, the majority of firearm injury deaths in 2016 were homicides (64.0% [95% UI, 54.2%-68.0%]; absolute value, 161 000 deaths [95% UI, 107 000-182 000]); additionally, 27% were firearm suicide deaths (67 500 [95% UI, 55 400-84 100]) and 9% were unintentional firearm deaths (23 000 [95% UI, 18 200-24 800]). From 1990 to 2016, there was no significant decrease in the estimated global age-standardized firearm homicide rate (-0.2% [95% UI, -0.8% to 0.2%]). Firearm suicide rates decreased globally at an annualized rate of 1.6% (95% UI, 1.1-2.0), but in 124 of 195 countries and territories included in this study, these levels were either constant or significant increases were estimated. There was an annualized decrease of 0.9% (95% UI, 0.5%-1.3%) in the global rate of age-standardized firearm deaths from 1990 to 2016. Aggregate firearm injury deaths in 2016 were highest among persons aged 20 to 24 years (for men, an estimated 34 700 deaths [95% UI, 24 900-39 700] and for women, an estimated 3580 deaths [95% UI, 2810-4210]). Estimates of the number of firearms by country were associated with higher rates of firearm suicide (P < .001; R2 = 0.21) and homicide (P < .001; R2 = 0.35). Conclusions and Relevance: This study estimated between 195 000 and 276 000 firearm injury deaths globally in 2016, the majority of which were firearm homicides. Despite an overall decrease in rates of firearm injury death since 1990, there was variation among countries and across demographic subgroups.

Body-mass index and mortality among adults with incident type 2 diabetes.

BACKGROUND: The relation between body weight and mortality among persons with type 2 diabetes remains unresolved, with some studies suggesting decreased mortality among overweight or obese persons as compared with normal-weight persons (an "obesity paradox"). METHODS: We studied participants with incident diabetes from the Nurses' Health Study (8970 participants) and Health Professionals Follow-up Study (2457 participants) who were free of cardiovascular disease and cancer at the time of a diagnosis of diabetes. Body weight shortly before diagnosis and height were used to calculate the body-mass index (BMI, the weight in kilograms divided by the square of the height in meters). Multivariable Cox models were used to estimate the hazard ratios and 95% confidence intervals for mortality across BMI categories. RESULTS: There were 3083 deaths during a mean period of 15.8 years of follow-up. A J-shaped association was observed across BMI categories (18.5 to 22.4, 22.5 to 24.9 [reference], 25.0 to 27.4, 27.5 to 29.9, 30.0 to 34.9, and ≥35.0) for all-cause mortality (hazard ratio, 1.29 [95% confidence interval {CI}, 1.05 to 1.59]; 1.00; 1.12 [95% CI, 0.98 to 1.29]; 1.09 [95% CI, 0.94 to 1.26]; 1.24 [95% CI, 1.08 to 1.42]; and 1.33 [95% CI, 1.14 to 1.55], respectively). This relationship was linear among participants who had never smoked (hazard ratios across BMI categories: 1.12, 1.00, 1.16, 1.21, 1.36, and 1.56, respectively) but was nonlinear among participants who had ever smoked (hazard ratios across BMI categories: 1.32, 1.00, 1.09, 1.04, 1.14, and 1.21) (P=0.04 for interaction). A direct linear trend was observed among participants younger than 65 years of age at the time of a diabetes diagnosis but not among those 65 years of age or older at the time of diagnosis (P<0.001 for interaction). CONCLUSIONS: We observed a J-shaped association between BMI and mortality among all participants and among those who had ever smoked and a direct linear relationship among those who had never smoked. We found no evidence of lower mortality among patients with diabetes who were overweight or obese at diagnosis, as compared with their normal-weight counterparts, or of an obesity paradox. (Funded by the National Institutes of Health and the American Diabetes Association.).

Adapting Behavioral Interventions for Social Media Delivery.

Patients are increasingly using online social networks (ie, social media) to connect with other patients and health care professionals--a trend called peer-to-peer health care. Because online social networks provide a means for health care professionals to communicate with patients, and for patients to communicate with each other, an opportunity exists to use social media as a modality to deliver behavioral interventions. Social media-delivered behavioral interventions have the potential to reduce the expense of behavioral interventions by eliminating visits, as well as increase our access to patients by becoming embedded in their social media feeds. Trials of online social network-delivered behavioral interventions have shown promise, but much is unknown about intervention development and methodology. In this paper, we discuss the process by which investigators can translate behavioral interventions for social media delivery. We present a model that describes the steps and decision points in this process, including the necessary training and reporting requirements. We also discuss issues pertinent to social media-delivered interventions, including cost, scalability, and privacy. Finally, we identify areas of research that are needed to optimize this emerging behavioral intervention modality.

Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: In 2010, overweight and obesity were estimated to cause 3·4 million deaths, 3·9% of years of life lost, and 3·8% of disability-adjusted life-years (DALYs) worldwide. The rise in obesity has led to widespread calls for regular monitoring of changes in overweight and obesity prevalence in all populations. Comparable, up-to-date information about levels and trends is essential to quantify population health effects and to prompt decision makers to prioritise action. We estimate the global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013. METHODS: We systematically identified surveys, reports, and published studies (n=1769) that included data for height and weight, both through physical measurements and self-reports. We used mixed effects linear regression to correct for bias in self-reports. We obtained data for prevalence of obesity and overweight by age, sex, country, and year (n=19,244) with a spatiotemporal Gaussian process regression model to estimate prevalence with 95% uncertainty intervals (UIs). FINDINGS: Worldwide, the proportion of adults with a body-mass index (BMI) of 25 kg/m(2) or greater increased between 1980 and 2013 from 28·8% (95% UI 28·4-29·3) to 36·9% (36·3-37·4) in men, and from 29·8% (29·3-30·2) to 38·0% (37·5-38·5) in women. Prevalence has increased substantially in children and adolescents in developed countries; 23·8% (22·9-24·7) of boys and 22·6% (21·7-23·6) of girls were overweight or obese in 2013. The prevalence of overweight and obesity has also increased in children and adolescents in developing countries, from 8·1% (7·7-8·6) to 12·9% (12·3-13·5) in 2013 for boys and from 8·4% (8·1-8·8) to 13·4% (13·0-13·9) in girls. In adults, estimated prevalence of obesity exceeded 50% in men in Tonga and in women in Kuwait, Kiribati, Federated States of Micronesia, Libya, Qatar, Tonga, and Samoa. Since 2006, the increase in adult obesity in developed countries has slowed down. INTERPRETATION: Because of the established health risks and substantial increases in prevalence, obesity has become a major global health challenge. Not only is obesity increasing, but no national success stories have been reported in the past 33 years. Urgent global action and leadership is needed to help countries to more effectively intervene. FUNDING: Bill & Melinda Gates Foundation.

Teenage smoking behaviour following a high-school smoking ban in Chile: interrupted time-series analysis.

OBJECTIVE: To evaluate the effect of a smoking ban in high schools on smoking behaviour among Chilean students. METHODS: We conducted an interrupted time-series analysis, using repeated cross-sectional data from Chile's school population survey (2000-2011) for high-school students aged 12-18 years and a control group of persons aged 19-24 years. Poisson regression models were used to assess trends in smoking behaviour before and after the policy changes. The outcome measures were self-reported smoking prevalence (any smoking in the past month) and high frequency of smoking (smoking 15 days or more per month). FINDINGS: From 2005 to 2011, the prevalence of smoking declined among high-school students by 6.8% per year compared with 3.6% decline per year in the control group. The decline in the target group was 2.9% (95% confidence interval, CI: 0.18 to 5.00) greater. We estimated that 5-6 years after enforcing the law, smoking prevalence among high-school students was 13.7% lower as a result of the ban. The impact of the smoking ban was primarily driven by declines in smoking prevalence among students in grades 8 to 10. The smoking ban did not significantly alter the frequency of smoking. CONCLUSION: The 2005 school smoking ban reduced smoking prevalence among younger high-school students in Chile. Further interventions targeting older individuals and frequent smokers may be needed.

Induction of the matricellular protein CCN1 through RhoA and MRTF-A contributes to ischemic cardioprotection.

Activation of RhoA, a low molecular-weight G-protein, plays an important role in protecting the heart against ischemic stress. Studies using non-cardiac cells demonstrate that the expression and subsequent secretion of the matricellular protein CCN1 is induced by GPCR agonists that activate RhoA. In this study we determined whether and how CCN1 is induced by GPCR agonists in cardiomyocytes and examined the role of CCN1 in ischemic cardioprotection in cardiomyocytes and the isolated perfused heart. In neonatal rat ventricular myocytes (NRVMs), sphingosine 1-phosphate (S1P), lysophosphatidic acid (LPA) and endothelin-1 induced robust increases in CCN1 expression while phenylephrine, isoproterenol and carbachol had little or no effect. The ability of agonists to activate the small G-protein RhoA correlated with their ability to induce CCN1. CCN1 induction by S1P was blocked when RhoA function was inhibited with C3 exoenzyme or a pharmacological RhoA inhibitor. Conversely overexpression of RhoA was sufficient to induce CCN1 expression. To delineate the signals downstream of RhoA we tested the role of MRTF-A (MKL1), a co-activator of SRF, in S1P-mediated CCN1 expression. S1P increased the nuclear accumulation of MRTF-A and this was inhibited by the functional inactivation of RhoA. In addition, pharmacological inhibitors of MRTF-A or knockdown of MRTF-A significantly diminished S1P-mediated CCN1 expression, indicating a requirement for RhoA/MRTF-A signaling. We also present data indicating that CCN1 is secreted following agonist treatment and RhoA activation, and binds to cells where it can serve an autocrine function. To determine the functional significance of CCN1 expression and signaling, simulated ischemia/reperfusion (sI/R)-induced apoptosis was assessed in NRVMs. The ability of S1P to protect against sI/R was significantly reduced by the inhibition of RhoA, ROCK or MRTF-A or by CCN1 knockdown. We also demonstrate that ischemia/reperfusion induces CCN1 expression in the isolated perfused heart and that this functions as a cardioprotective mechanism, evidenced by the significant increase in infarct development in response to I/R in the cardiac specific CCN1 KO relative to control mice. Our findings implicate CCN1 as a mediator of cardioprotection induced by GPCR agonists that activate RhoA/MRTF-A signaling.

Leisure-time physical activity and endometrial cancer risk: dose-response meta-analysis of epidemiological studies.

Although considerable evidence suggests that leisure-time physical activity is associated with a reduced risk of endometrial cancer (EC), the shape of dose-response relationship has not been investigated and previous meta-analyses have not accounted for differences in measures of physical activity. To address such issues, we conducted linear and nonlinear dose-response meta-analyses by metabolic equivalent of task (MET)-hour/week and hour/week, respectively, based on observational studies published up to September 2013 identified from PubMed and Embase databases. Summary relative risks (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model. In the linear dose-response analysis, an increase in leisure-time physical activity by 3 MET-hour/week was associated with an ∼2% reduced risk of EC (summary RR = 0.98, p = 0.02, 95% CI = 0.95-1.00, I(2) = 53%, p(heterogeneity) = 0.06, three case-control studies and three cohort studies, 3,460 cases, range of activity = 0-50 MET-hour/week) and an increase by an hour/week was associated with an ∼5% reduced risk of EC (summary RR = 0.95, p < 0.001, 95% CI = 0.93-0.98, I(2) = 31%, p(heterogeneity) = 0.20, four case-control studies and two cohort studies, 3,314 cases, range of activity = 0-12 hour/week). Nonlinear dose-response meta-analysis suggested that the curve may plateau at 10 MET-hour/week (p(change) in slope = 0.04) but this statistical significance was sensitive to one study. No evidence of a nonlinear association was indicated by hour/week (p(change) in slope > 0.69). In conclusion, an increase in leisure-time physical activity may continue to decrease EC risk, within the range of 0-50 MET-hour/week or 0-15 hour/week. Future studies should evaluate possible independent role of intensity of physical activity and effect modification by obesity.

Comparison of paper- and web-based dietary records: a pilot study.

BACKGROUND/AIMS: Paper-based dietary records (Paper-DR) can be replaced by web-based dietary records (Web-DR) in both epidemiological studies and clinical practice to reduce the time and logistic burden. We aimed to compare Paper-DR and Web-DR. METHODS: We compared the matching of different food items (n = 1,103) from Paper-DR and Web-DR for energy and 48 nutrients among 16 pregnant volunteers, with DR for the same individuals matched for the same 4 days. Paper-DR were coded into the web-based version (referred to as Paper-Web-DR) independently by the same research dietitian. The Wilcoxon signed-rank test comparing mean rank differences, Spearman's ρ to measure associations and Bland-Altman limits of agreement to evaluate the level of agreement between the two dietary methods across the range of parameters were used. Volunteers also completed an evaluation questionnaire regarding the user acceptability of Paper-DR and Web-DR. RESULTS: A high correlation between Paper-DR and Web-DR was noted. There were statistically insignificant differences among 45 nutrients, except for free sugars (p < 0.001), α-linolenic acid (p = 0.041), folate (p = 0.036) and pantothenic acid (p = 0.023). Volunteers found the Paper-DR equally time-consuming as the Web-DR. The majority of the volunteers (75%) preferred the Web-DR. CONCLUSIONS: Paper-DR and Web-DR were comparable across a range of nutritional parameters, with a few exceptions. The Web-DR was more convenient for the majority and has substantial logistic and cost advantages.

Methods for structural sexism and population health research: Introducing a novel analytic framework to capture life-course and intersectional effects.

Accumulating evidence links structural sexism to gendered health inequities, yet methodological challenges have precluded comprehensive examinations into life-course and/or intersectional effects. To help address this gap, we introduce an analytic framework that uses sequential conditional mean models (SCMMs) to jointly account for longitudinal exposure trajectories and moderation by multiple dimensions of social identity/position, which we then apply to study how early life-course exposure to U.S. state-level structural sexism shapes mental health outcomes within and between gender groups. Data came from the Growing Up Today Study, a cohort of 16,875 children aged 9-14 years in 1996 who we followed through 2016. Using a composite index of relevant public policies and societal conditions (e.g., abortion bans, wage gaps), we assigned each U.S. state a year-specific structural sexism score and calculated participants' cumulative exposure by averaging the scores associated with states they had lived in during the study period, weighted according to duration of time spent in each. We then fit a series of SCMMs to estimate overall and group-specific associations between cumulative exposure from baseline through a given study wave and subsequent depressive symptomology; we also fit models using simplified (i.e., non-cumulative) exposure variables for comparison purposes. Analyses revealed that cumulative exposure to structural sexism: (1) was associated with significantly increased odds of experiencing depressive symptoms by the subsequent wave; (2) disproportionately impacted multiply marginalized groups (e.g., sexual minority girls/women); and (3) was more strongly associated with depressive symptomology compared to static or point-in-time exposure operationalizations (e.g., exposure in a single year). Substantively, these findings suggest that long-term exposure to structural sexism may contribute to the inequitable social patterning of mental distress among young people living in the U.S. More broadly, the proposed analytic framework represents a promising approach to examining the complex links between structural sexism and health across the life course and for diverse social groups.