Effectiveness of DialBetesPlus, a self-management support system for diabetic kidney disease: Randomized controlled trial.

We evaluated the effectiveness of a mobile health (mHealth) intervention for diabetic kidney disease patients by conducting a 12-month randomized controlled trial among 126 type 2 diabetes mellitus patients with moderately increased albuminuria (urinary albumin-to-creatinine ratio (UACR): 30-299 mg/g creatinine) recruited from eight clinical sites in Japan. Using a Theory of Planned Behavior (TPB) behavior change theory framework, the intervention provides patients detailed information in order to improve patient control over exercise and dietary behaviors. In addition to standard care, the intervention group received DialBetesPlus, a self-management support system allowing patients to monitor exercise, blood glucose, diet, blood pressure, and body weight via a smartphone application. The primary outcome, change in UACR after 12 months (used as a surrogate measure of renal function), was 28.8% better than the control group's change (P = 0.029). Secondary outcomes also improved in the intervention group, including a 0.32-point better change in HbA1c percentage (P = 0.041). These improvements persisted when models were adjusted to account for the impacts of coadministration of drugs targeting albuminuria (GLP-1 receptor agonists, SGLT-2 inhibitors, ACE inhibitors, and ARBs) (UACR: -32.3% [95% CI: -49.2%, -9.8%] between-group difference in change, P = 0.008). Exploratory multivariate regression analysis suggests that the improvements were primarily due to levels of exercise. This is the first trial to show that a lifestyle intervention via mHealth achieved a clinically-significant improvement in moderately increased albuminuria.

Efficacy of StepAdd, a Personalized mHealth Intervention Based on Social Cognitive Theory to Increase Physical Activity Among Patients With Type 2 Diabetes Mellitus: Protocol for a Randomized Controlled Trial.

BACKGROUND: Increasing physical activity improves glycemic control in patients with type 2 diabetes (T2D). Mobile health (mHealth) interventions have been proven to increase exercise, but engagement often fades with time. As the use of health behavior theory in mHealth design can increase effectiveness, we developed StepAdd, an mHealth intervention based on the constructs of social cognitive theory (SCT). StepAdd improves exercise behavior self-efficacy and self-regulation through the use of goal-setting, barrier-identifying, and barrier-coping strategies, as well as automatic feedback functions. A single-arm pilot study of StepAdd among 33 patients with T2D showed a large increase in step count (mean change of 4714, SD 3638 daily steps or +86.7%), along with strong improvements in BMI (mean change of -0.3 kg/m2) and hemoglobin A1c level (mean change of -0.79 percentage points). OBJECTIVE: In this study, we aim to investigate the efficacy and safety of StepAdd, an mHealth exercise support system for patients with T2D, via a large, long, and controlled follow-up to the pilot study. METHODS: This is a randomized, open-label, multicenter study targeting 160 patients with T2D from 5 institutions in Japan with a 24-week intervention. The intervention group will record daily step counts, body weight, and blood pressure using the SCT-based mobile app, StepAdd, and receive feedback about these measurements. In addition, they will set weekly step count goals, identify personal barriers to walking, and define strategies to overcome these barriers. The control group will record daily step counts, body weight, and blood pressure using a non-SCT-based placebo app. Both groups will receive monthly consultations with a physician who will advise patients regarding lifestyle modifications and use of the app. The 24-week intervention period will be followed by a 12-week observational period to investigate the sustainability of the intervention's effects. The primary outcome is between-group difference in the change in hemoglobin A1c values at 24 weeks. The secondary outcomes include other health measures, measurements of steps, measurements of other behavior changes, and assessments of app use. The trial began in January 2023 and is intended to be completed in December 2025. RESULTS: As of September 5, 2023, we had recruited 44 patients. We expect the trial to be completed by October 8, 2025, with the follow-up observation period being completed by December 31, 2025. CONCLUSIONS: This trial will provide important evidence about the efficacy of an SCT-based mHealth intervention in improving physical activities and glycemic control in patients with T2D. If this study proves the intervention to be effective and safe, it could be a key step toward the integration of mHealth as part of the standard treatment received by patients with T2D in Japan. TRIAL REGISTRATION: Japan Registry of Clinical Trials (JRCT) jRCT2032220603; https://rctportal.niph.go.jp/en/detail?trial_id=jRCT2032220603. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53514.

Effect of Step Count Measurement on Glycemic Control: Secondary Analysis of a Randomized Controlled Trial.

Although walking has proven efficacy for glycemic control, patients struggle to meet daily step goals. This secondary analysis investigated the effect of step count measurement rate on glycemic control. Patients with type 2 diabetes from eight hospitals in Japan participated in a 12-month randomized controlled trial. The intervention group received DialBetesPlus, a self-management support system that allowed patients to monitor step count using a pedometer. We divided the intervention group into two groups based on whether daily step count measurement rate (the percentage of days with pedometer use) increased or decreased during the last three months of the intervention (month 10-12), relative to the first three months of the intervention (month 1-3). Patients with a reduced measurement rate experienced a worsening in glycemic control, with between-group difference of 0.516% in the amount of change in HbA1c (p=0.012). We conclude that step count measurement may lead to a better glycemic profile.

Time since liver transplant and immunosuppression withdrawal outcomes: Systematic review and individual patient data meta-analysis.

BACKGROUND & AIMS: Successful immunosuppression withdrawal (ISW) is possible for a subfraction of liver transplant (LT) recipients but the factors that define the risk of ISW failure are largely unknown. One candidate prognostic factor for ISW success or operational tolerance (OT) is longer time between LT and ISW which we term "pre-withdrawal time". To clarify the impact of pre-withdrawal time span on subsequent ISW success or failure, we conducted a systematic review with meta-analysis. METHODS: We systematically interrogated the literature for LT recipient ISW studies reporting pre-withdrawal time. Eligible articles from Embase, Medline, and the Cochrane Central Register of Controlled Trials were used for backward and forward citation searching. Pre-withdrawal time individual patient data (IPD) was requested from authors. Pooled mean differences and time-response curves were calculated using random-effects meta-analyses. RESULTS: We included 17 studies with 691 patients, 15 of which (620 patients) with IPD. Study-level risk of bias was heterogeneous. Mean pre-withdrawal time was greater by 427 days [95% confidence interval (CI) 67-788] in OT compared to non-OT patients. This increase was potentiated to 799 days (95% CI 369-1229) or 1074 days (95% CI 685-1463) when restricting analysis to adult or European study participants. In time-response meta-analysis for adult or European ISW candidates, likelihood of OT increased by 7% (95% CI 4-10%) per year after LT (GRADE low- and moderate-certainty of evidence, respectively). CONCLUSIONS: Our data support the impact of pre-withdrawal time in ISW decision-making for adult and European LT recipients. PROSPERO REGISTRATION: CRD42021272995.

StepAdd: A personalized mHealth intervention based on social cognitive theory to increase physical activity among type 2 diabetes patients.

OBJECTIVE: Investigate the preliminary efficacy and feasibility of a personalized mobile health (mHealth) intervention based on social cognitive theory (SCT) to promote physical activity among type 2 diabetes patients via self-monitoring, goal setting, and automatic feedback. METHODS: We conducted a pilot study involving 33 type 2 diabetes patients attending Mitsui Memorial Hospital in Japan using a pre-post evaluation design over 12 weeks. Participants measured daily step count, body weight, and blood pressure at home, with the measurements synchronized with the StepAdd application (app) automatically. Participants used the app to review daily results, update personalized step goals, identify individualized barriers to achieving the step goals, find coping strategies to overcome each barrier, and implement these strategies, thereby building effective coping skills to meet the goals. Pharmacists examined the usage of the app and provided coaching on lifestyle modifications. Ultimately, patients established skills to enhance diabetes self-care by using the app. RESULTS: Daily step count increased dramatically with high statistical significance (p < 0.0001), from a mean of 5436 steps/day to 10,150 steps/day, an 86.7 % increase. HbA1c (p = 0.0001) and BMI (p = 0.0038) also improved. Diabetes self-care in diet, exercise, and foot care as well as self-management behavior, self-regulation, and self-efficacy in achieving daily step goals showed significant improvements. The retention rate of the study was very high, at 97.0 % (n = 32). CONCLUSIONS: A personalized smartphone-based mHealth intervention based on SCT is feasible and effective at promoting physical activity among type 2 diabetes patients. The methodology of the intervention could be readily applied to other patient populations.

Preliminary Efficacy, Feasibility, and Perceived Usefulness of a Smartphone-Based Self-Management System With Personalized Goal Setting and Feedback to Increase Step Count Among Workers With High Blood Pressure: Before-and-After Study.

BACKGROUND: High blood pressure (BP) and physical inactivity are the major risk factors for cardiovascular diseases. Mobile health is expected to support patients' self-management for improving cardiovascular health; the development of fully automated systems is necessary to minimize the workloads of health care providers. OBJECTIVE: The objective of our study was to evaluate the preliminary efficacy, feasibility, and perceived usefulness of an intervention using a novel smartphone-based self-management system (DialBetes Step) in increasing steps per day among workers with high BP. METHODS: On the basis of the Social Cognitive Theory, we developed personalized goal-setting and feedback functions and information delivery functions for increasing step count. Personalized goal setting and feedback consist of 4 components to support users' self-regulation and enhance their self-efficacy: goal setting for daily steps, positive feedback, action planning, and barrier identification and problem-solving. In the goal-setting component, users set their own step goals weekly in gradual increments based on the system's suggestion. We added these fully automated functions to an extant system with the function of self-monitoring daily step count, BP, body weight, blood glucose, exercise, and diet. We conducted a single-arm before-and-after study of workers with high BP who were willing to increase their physical activity. After an educational group session, participants used only the self-monitoring function for 2 weeks (baseline) and all functions of DialBetes Step for 24 weeks. We evaluated changes in steps per day, self-reported frequencies of self-regulation and self-management behavior, self-efficacy, and biomedical characteristics (home BP, BMI, visceral fat area, and glucose and lipid parameters) around week 6 (P1) of using the new functions and at the end of the intervention (P2). Participants rated the usefulness of the system using a paper-based questionnaire. RESULTS: We analyzed 30 participants (n=19, 63% male; mean age 52.9, SD 5.3 years); 1 (3%) participant dropped out of the intervention. The median percentage of step measurement was 97%. Compared with baseline (median 10,084 steps per day), steps per day significantly increased at P1 (median +1493 steps per day; P<.001), but the increase attenuated at P2 (median +1056 steps per day; P=.04). Frequencies of self-regulation and self-management behavior increased at P1 and P2. Goal-related self-efficacy tended to increase at P2 (median +5%; P=.05). Home BP substantially decreased only at P2. Of the other biomedical characteristics, BMI decreased significantly at P1 (P<.001) and P2 (P=.001), and high-density lipoprotein cholesterol increased significantly only at P1 (P<.001). DialBetes Step was rated as useful or moderately useful by 97% (28/29) of the participants. CONCLUSIONS: DialBetes Step intervention might be a feasible and useful way of increasing workers' step count for a short period and, consequently, improving their BP and BMI; self-efficacy-enhancing techniques of the system should be improved.

Glycemic Control, Renal Progression, and Use of Telemedicine Phone Consultations Among Japanese Patients With Type 2 Diabetes Mellitus During the COVID-19 Pandemic: Retrospective Cohort Study.

BACKGROUND: Reduced or delayed medical follow-ups have been reported during the COVID-19 pandemic, which may lead to worsening clinical outcomes for patients with diabetes. The Japanese government granted special permission for medical institutions to use telephone consultations and other remote communication modes during the COVID-19 pandemic. OBJECTIVE: We aimed to evaluate changes in the frequency of outpatient consultations, glycemic control, and renal function among patients with type 2 diabetes before and during the COVID-19 pandemic. METHODS: This is a retrospective single-cohort study conducted in Tokyo, Japan, analyzing results for 3035 patients who visited the hospital regularly. We compared the frequency of outpatient consultations attended (both in person and via telemedicine phone consultation), glycated hemoglobin A1c (HbA1c), and estimated glomerular filtration rate (eGFR) among patients with type 2 diabetes mellitus during the 6 months from April 2020 to September 2020 (ie, during the COVID-19 pandemic) with those during the same period of the previous year, 2019, using Wilcoxon signed rank tests. We conducted a multivariate logistic regression analysis to identify factors related to the changes in glycemic control and eGFR. We also compared the changes in HbA1c and eGFR from 2019 to 2020 among telemedicine users and telemedicine nonusers using difference-in-differences design. RESULTS: The overall median number of outpatient consultations attended decreased significantly from 3 (IQR 2-3) in 2019 to 2 (IQR 2-3) in 2020 (P<.001). Median HbA1c levels deteriorated, though not to a clinically significant degree (6.90%, IQR 6.47%-7.39% vs 6.95%, IQR 6.47%-7.40%; P<.001). The decline in median eGFR was greater during the year 2019-2020 compared to the year 2018-2019 (-0.9 vs -0.5 mL/min/1.73 m2; P=.01). Changes in HbA1c and eGFR did not differ between patients who used telemedicine phone consultations and those who did not. Age and HbA1c level before the pandemic were positive predictors of worsening glycemic control during the COVID-19 pandemic, whereas the number of outpatient consultations attended was identified as a negative predictor of worsening glycemic control during the pandemic. CONCLUSIONS: The COVID-19 pandemic resulted in reduced attendance of outpatient consultations among patients with type 2 diabetes, and these patients also experienced deterioration in kidney function. Difference in consultation modality (in person or by phone) did not affect glycemic control and renal progression of the patients.

Biomarkers for the Diagnosis of Heart Failure in People with Diabetes: A Consensus Report from Diabetes Technology Society.

Diabetes Technology Society assembled a panel of clinician experts in diabetology, cardiology, clinical chemistry, nephrology, and primary care to review the current evidence on biomarker screening of people with diabetes (PWD) for heart failure (HF), who are, by definition, at risk for HF (Stage A HF). This consensus report reviews features of HF in PWD from the perspectives of 1) epidemiology, 2) classification of stages, 3) pathophysiology, 4) biomarkers for diagnosing, 5) biomarker assays, 6) diagnostic accuracy of biomarkers, 7) benefits of biomarker screening, 8) consensus recommendations for biomarker screening, 9) stratification of Stage B HF, 10) echocardiographic screening, 11) management of Stage A and Stage B HF, and 12) future directions. The Diabetes Technology Society panel recommends 1) biomarker screening with one of two circulating natriuretic peptides (B-type natriuretic peptide or N-terminal prohormone of B-type natriuretic peptide), 2) beginning screening five years following diagnosis of type 1 diabetes (T1D) and at the diagnosis of type 2 diabetes (T2D), 3) beginning routine screening no earlier than at age 30 years for T1D (irrespective of age of diagnosis) and at any age for T2D, 4) screening annually, and 5) testing any time of day. The panel also recommends that an abnormal biomarker test defines asymptomatic preclinical HF (Stage B HF). This diagnosis requires follow-up using transthoracic echocardiography for classification into one of four subcategories of Stage B HF, corresponding to risk of progression to symptomatic clinical HF (Stage C HF). These recommendations will allow identification and management of Stage A and Stage B HF in PWD to prevent progression to Stage C HF or advanced HF (Stage D HF).

The Use of Information and Communication Technology-Based Self-management System DialBeticsLite in Treating Abdominal Obesity in Japanese Office Workers: Prospective Single-Arm Pilot Intervention Study.

BACKGROUND: Making lifestyle changes is an essential element of abdominal obesity (AO) reduction. To support lifestyle modification and self-management, we developed an information and communication technology-based self-management system-DialBeticsLite-with a fully automated dietary evaluation function for the treatment of AO. OBJECTIVE: The objective of this study was to evaluate the preliminary efficacy and feasibility of DialBeticsLite among Japanese office workers with AO. METHODS: A 2- to 3-month prospective single-arm pilot intervention study was designed to assess the effects of the intervention using DialBeticsLite. The information and communication technology system was composed of 4 modules: data transmission (body weight, blood pressure, blood glucose, and pedometer count); data evaluation; exercise input; and food recording and dietary evaluation. Eligible participants were workers who were aged ≥20 years and with AO (waist circumference ≥85 cm for men and ≥90 cm for women). Physical parameters, blood tests, nutritional intake, and self-care behavior were compared at baseline and after the intervention. RESULTS: A total of 48 participants provided completed data for analysis, which yielded a study retention rate of 100%. The average age was 46.8 (SD 6.8) years, and 92% (44/48) of participants were male. The overall average measurement rate of DialBeticsLite, calculated by dividing the number of days with at least one measurement by the number of days of the intervention, was 98.6% (SD 3.4%). In total, 85% (41/48) of the participants reported that their participation in the study helped them to improve their lifestyle. BMI, waist circumference, and visceral fat area decreased significantly after the intervention (P<.001). In addition, the daily calorie intake reduced significantly (P=.02). There was a significant improvement in self-care behavior in terms of exercise and diet (P=.001). CONCLUSIONS: Using DialBeticsLite was shown to be a feasible and potentially effective method for reducing AO by providing users with a motivational framework to evaluate their lifestyle behaviors.

Effect of Information and Communication Technology-Based Self-management System DialBeticsLite on Treating Abdominal Obesity in the Specific Health Guidance in Japan: Randomized Controlled Trial.

BACKGROUND: Mobile health (mHealth) interventions, a more cost-effective approach compared with traditional methods of delivering lifestyle coaching in person, have been shown to improve physical parameters and lifestyle behavior among overweight populations. In Japan, the Specific Health Checkups and Specific Health Guidance (SHG) started in 2008 to treat obesity and abdominal obesity. However, the effectiveness of SHG is limited owing to its in-person counseling. The effect of mHealth on SHG has yet to be demonstrated. OBJECTIVE: This study aims to determine whether a mobile self-management app (DialBeticsLite) could make the SHG more beneficial among patients with abdominal obesity to achieve a reduction in visceral fat area (VFA). METHODS: This study was an open-label, 2-arm, parallel-design randomized controlled trial. We recruited 122 people in September 2017 and randomly assigned them into either the intervention or control group. All participants attended an educational group session that delivered information regarding diet and exercise. In addition, participants in the intervention group were asked to use DialBeticsLite for 3 months. DialBeticsLite facilitated the daily recording of several physical parameters and lifestyle behavior and provided feedback to encourage an improvement in behavior. The primary outcome was the change in VFA from baseline to the 3-month follow-up. Secondary outcomes included changes in both physical and metabolic parameters from baseline to the 3-month follow-up. The Welch 2-tailed t test was conducted to analyze the effects of DialBeticsLite on both the primary and secondary outcomes. RESULTS: Of the 122 participants recruited, 75 (61.5%) were analyzed because 47 (38.5%) were excluded: 37 (30.3%) because of ineligibility and 10 (8.2%) because of withdrawal of consent. The mean age was 49.3 (SD 6.1) years in the intervention group (41/75, 55%) and 48.5 (SD 5.3) years in the control group (34/75, 45%), and all participants were men, although unintentionally. The baseline characteristics did not differ significantly between the intervention and control groups, except for VFA. The average change of VFA was -23.5 (SD 20.6) cm2 in the intervention group and +1.9 (SD 16.2) cm2 in the control group (P<.001). Statistically significant differences were also found for the change of body weight, BMI, and waist circumference. These findings did not change after adjusting for VFA at the baseline. The intervention had no significant effect on any of the metabolic parameters. An exploratory analysis showed significant associations between the change in VFA and steps per day and between the change in VFA and calorie intake per day within the intervention group. CONCLUSIONS: Our findings indicate that an mHealth intervention facilitating the daily monitoring of several physical parameters and lifestyle behavior can be highly effective in inducing visceral fat loss and weight loss among adults eligible for SHG. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000042045; https://tinyurl.com/4vat3v53.

Efficacy of the Self-management Support System DialBetesPlus for Diabetic Kidney Disease: Protocol for a Randomized Controlled Trial.

BACKGROUND: Diabetic kidney disease (DKD) is one of the main complications of type 2 diabetes mellitus (T2DM). DKD is a known risk factor for end-stage renal disease, cardiovascular disease, and all-cause death. Effective intervention for early-stage DKD is vital to slowing down the progression of kidney disease and improve prognoses. Mobile health (mHealth) is reportedly effective in supporting patients' self-care and improving glycemic control, but the impact of mHealth on DKD has yet to be shown. OBJECTIVE: The purpose of this study is to evaluate the efficacy of standard therapy with the addition of a self-management support system, DialBetesPlus, in patients with DKD and microalbuminuria. METHODS: This study is a prospective, randomized, open-label, multicenter clinical trial. The target population consists of 160 patients diagnosed with T2DM accompanied by microalbuminuria. We randomly assigned the patients to 2 groups-the intervention group using DialBetesPlus in addition to conventional therapy and the control group using conventional therapy alone. DialBetesPlus is a smartphone application that supports patients' self-management of T2DM. The study period was 12 months, with a follow-up survey at 18 months. The primary outcome was a change in albuminuria levels at 12 months. Secondary outcomes included changes in physical parameters, blood test results (glycemic control, renal function, and lipid metabolism), lifestyle habits, self-management scores, medication therapy, and quality of life. RESULTS: The study was approved in April 2018. We began recruiting patients in July 2018 and completed recruiting in August 2019. The final 18-month follow-up was conducted in March 2021. We recruited 159 patients and randomly allocated 70 into the intervention group and 61 into the control group, with 28 exclusions due to withdrawal of consent, refusal to continue, or ineligibility. The first results are expected to be available in 2021. CONCLUSIONS: This is the first randomized controlled trial assessing the efficacy of mHealth on early-stage DKD. We expect that albuminuria levels will decrease significantly in the intervention group due to improved glycemic control with ameliorated self-care behaviors. TRIAL REGISTRATION: UMIN-CTR UMIN000033261; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000037924. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31061.

Machine Learning-Based Screening of Healthy Meals From Image Analysis: System Development and Pilot Study.

BACKGROUND: Recent research has led to the development of many information technology-supported systems for health care control, including systems estimating nutrition from images of meals. Systems that capture data about eating and exercise are useful for people with diabetes as well as for people who are simply on a diet. Continuous monitoring is key to effective dietary control, requiring systems that are simple to use and motivate users to pay attention to their meals. Unfortunately, most current systems are complex or fail to motivate. Such systems require some manual inputs such as selection of an icon or image, or by inputting the category of the user's food. The nutrition information fed back to users is not especially helpful, as only the estimated detailed nutritional values contained in the meal are typically provided. OBJECTIVE: In this paper, we introduce healthiness of meals as a more useful and meaningful general standard, and present a novel algorithm that can estimate healthiness from meal images without requiring manual inputs. METHODS: We propose a system that estimates meal healthiness using a deep neural network that extracts features and a ranking network that learns the relationship between the degrees of healthiness of a meal using a dataset prepared by a human dietary expert. First, we examined whether a registered dietitian can judge the healthiness of meals solely by viewing meal images using a small dataset (100 meals). We then generated ranking data based on comparisons of sets of meal images (850 meals) by a registered dietitian's viewing meal images and trained a ranking network. Finally, we estimated each meal's healthiness score to detect unhealthy meals. RESULTS: The ranking estimated by the proposed network and the ranking of healthiness based on the dietitian's judgment were correlated (correlation coefficient 0.72). In addition, extracting network features through pretraining with a publicly available large meal dataset enabled overcoming the limited availability of specific healthiness data. CONCLUSIONS: We have presented an image-based system that can rank meals in terms of the overall healthiness of the dishes constituting the meal. The ranking obtained by the proposed method showed a good correlation to nutritional value-based ranking by a dietitian. We then proposed a network that allows conditions that are important for judging the meal image, extracting features that eliminate background information and are independent of location. Under these conditions, the experimental results showed that our network achieves higher accuracy of healthiness ranking estimation than the conventional image ranking method. The results of this experiment in detecting unhealthy meals suggest that our system can be used to assist health care workers in establishing meal plans for patients with diabetes who need advice in choosing healthy meals.

Using the RE-AIM framework to evaluate internal and external validity of mobile phone-based interventions in diabetes self-management education and support.

OBJECTIVE: We evaluated the extent to which studies that tested short message service (SMS)- and application (app)-based interventions for diabetes self-management education and support (DSMES) report on factors that inform both internal and external validity as measured by the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework. MATERIALS AND METHODS: We systematically searched PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and IEEE Xplore Digital Library for articles from January 1, 2009, to February 28, 2019. We carried out a multistage screening process followed by email communications with study authors for missing or discrepant information. Two independent coders coded eligible articles using a 23-item validated data extraction tool based on the RE-AIM framework. RESULTS: Twenty studies (21 articles) were included in the analysis. The comprehensiveness of reporting on the RE-AIM criteria across the SMS- and app-based DSMES studies was low. With respect to internal validity, most interventions were well described and primary clinical or behavioral outcomes were measured and reported. However, gaps exist in areas of attrition, measures of potential negative outcomes, the extent to which the protocol was delivered as intended, and description on delivery agents. Likewise, we found limited information on external validity indicators across adoption, implementation, and maintenance domains. CONCLUSIONS: Reporting gaps were found in internal validity but more so in external validity in the current SMS- and app-based DSMES literature. Because most studies in this review were efficacy studies, the generalizability of these interventions cannot be determined. Future research should adopt the RE-AIM dimensions to improve the quality of reporting and enhance the likelihood of translating research to practice.

Willingness of Patients Prescribed Medications for Lifestyle-Related Diseases to Use Personal Health Records: Questionnaire Study.

BACKGROUND: Personal health record (PHR) systems let individuals utilize their own health information to maintain and improve quality of life. Using PHRs is expected to support self-management in patients with lifestyle-related diseases. OBJECTIVE: The aim of this study was to identify predictors of the willingness to use PHRs among patients who are prescribed medications for lifestyle-related diseases. METHODS: We recruited pharmacy patrons, aged 20 years or older, who had received at least one medication indicated for hypertension, dyslipidemia, or diabetes. Participants completed self-administered questionnaires regarding their previous diseases, awareness of health care, experience in using PHRs, willingness to use PHRs, and barriers to using PHRs. Data were analyzed using multivariate logistic regression models. RESULTS: Of the 3708 subjects meeting eligibility criteria, 2307 replies (62.22%) were collected. While only 174 (7.54%) participants had previous PHR experience, 853 (36.97%) expressed willingness to use PHRs. In the multivariate analysis, considering exercise to be important for health management (odds ratio [OR] 1.57, 95% CI 1.12-2.21; P=.009), obtaining medical information from books or magazines (OR 1.23, 95% CI 0.96-1.59; P=.10), and obtaining medical information from the internet (OR 1.45, 95% CI 1.13-1.87; P=.004) were newly identified predictors. These were in addition to known predictors, such as being employed, owning information terminals, and previous PHR experience. CONCLUSIONS: Patients who have an active and positive attitude toward health seem to be more willing to use PHRs. Investigating willingness should contribute to the development of more useful PHRs for self-management among patients prescribed medications for lifestyle-related diseases.

Use of Ghost Cytometry to Differentiate Cells with Similar Gross Morphologic Characteristics.

Imaging flow cytometry shows significant potential for increasing our understanding of heterogeneous and complex life systems and is useful for biomedical applications. Ghost cytometry is a recently proposed approach for directly analyzing compressively measured signals of cells, thereby relieving a computational bottleneck for real-time data analysis in high-throughput imaging cytometry. In our previous work, we demonstrated that this image-free approach could distinguish cells from two cell lines prepared with the same fluorescence staining method. However, the demonstration using different cell lines could not exclude the possibility that classification was based on non-morphological factors such as the speed of cells in flow, which could be encoded in the compressed signals. In this study, we show that GC can classify cells from the same cell line but with different fluorescence distributions in space, supporting the strength of our image-free approach for accurate morphological cell analysis. © 2020 International Society for Advancement of Cytometry.

Feasibility of a T-Shirt-Type Wearable Electrocardiography Monitor for Detection of Covert Atrial Fibrillation in Young Healthy Adults.

Covert atrial fibrillation (AF) accounts for cryptogenic stroke aetiology in elderly patients and in younger populations. However, asymptomatic AF is difficult to diagnose based on a short electrocardiography (ECG) recording. We evaluated the feasibility of a self-applied continuous ECG monitoring device that can record automatically, easily, and noninvasively in a younger population. We investigated community screening for asymptomatic AF using a wireless single-lead ECG with an electrode embedded in a T-shirt. One hundred men with a CHADS2 score ≥1 who were free from AF and <65 years of age were enrolled. We instructed the participants to wear ECG monitoring devices for at least 4 days/week over 2 months. The proportion of participants with newly detected AF (NDAF) and the monitoring time were evaluated. The mean CHADS2 score was 1.43 ± 0.62. The mean patient age was 52.5 ± 5.4 years. The mean monitoring time was 222 ± 199 hours. NDAF continuing for >30 seconds was detected in 10 participants (10.0%). AF continuing for >6 minutes was detected in 2 participants (2.0%). The T-shirt-type wearable ECG monitoring system was suitable for continuous, daily long-term use among young people with high physical activity, and it had the distinct capability of identifying covert AF.

Usage Patterns of GlucoNote, a Self-Management Smartphone App, Based on ResearchKit for Patients With Type 2 Diabetes and Prediabetes.

BACKGROUND: Preventing progression from prediabetes to diabetes-or slowing the progression of diabetes-is an urgent task worldwide. Previous studies have shown that mobile health (mHealth) may powerfully support self-management for patients with type 2 diabetes. Certainly, mHealth improves health care efficiency and gives patients convenient access to self-management of their own health. Many health care apps are available right now, and their use in clinical studies with large-scale real-life data is expected. However, the usage patterns of those apps-especially in the absence of intervention by medical professionals-remain unknown. OBJECTIVE: We developed GlucoNote, an app that uses Apple's ResearchKit to support self-management for patients with type 2 diabetes and prediabetes; the app does not require prescription or intervention by medical professionals. We evaluated its usage patterns via a remotely conducted study. METHODS: iPhone users across Japan who have type 2 diabetes or prediabetes were free to download GlucoNote and to participate in the study after they provided consent electronically on the app. The 522 users who enrolled in the study within 1 year of its release were analyzed. We analyzed the retention rates of 357 participants who recorded at least 1 of 4 items-body weight, blood sugar, blood pressure, or dietary information. Characteristics of participants who used GlucoNote longer than 4 weeks (robust users) were compared with those of participants who did not (nonrobust users). The changes among robust users were evaluated. RESULTS: The median observation and retention durations were 382 days (interquartile range [IQR] 275-423) and 8 days (IQR 1-63), respectively. The retention rates for 2 days and for 4, 8, and 12 weeks were 0.627 (95% CI 0.575-0.675), 0.353 (0.304-0.403), 0.272 (0.227-0.319), and 0.220 (0.179-0.265), respectively. Men were more likely to be robust users than women (P=.02). At week 0, robust users were more likely than nonrobust users to have a higher daily energy intake (median 1595 [IQR 1198-1788] kcal vs 1451 [IQR 769-1657] kcal; P=.04) and have higher daily step counts (median 6108 [IQR 3797-9227] vs 5171 [IQR 2885-7258]; P=.001). Among robust users, body weight decreased from weeks 0 to 4 (mean 71.3 [SD 14.1] kg to 70.8 [SD 13.9] kg; P=.002) by mean 0.6% (SD 1.6). CONCLUSIONS: GlucoNote offered a valuable opportunity to evaluate usage patterns of apps. Future challenges include improving low retention rates and evaluating their effects.