The Relation of Attitude Toward Technology and Mastery Experience After an App-Guided Physical Exercise Intervention: Randomized Crossover Trial.

BACKGROUND: Physical exercise has been found to assert a positive impact on many muscular conditions. Exercise under face-to-face supervision is the gold standard, but access to it is limited, for instance, for economic reasons. App-guided therapy is an intervention that is more affordable and easily accessible. However, attitude toward technology is a key predictor for media adoption and is therefore expected to shape user experience during app-guided therapy. This might be of particular importance for mastery experience, which is crucial for promoting exercise-related self-efficacy and perceived usefulness of the interaction. Both should empower patients to continuously exercise. OBJECTIVE: This study sought to test whether attitudes toward technology predict mastery experience and perceived usefulness of the interaction after an app- versus a physiotherapist-guided treatment. We expect that attitudes toward technology positively predict both outcomes in case of the app-guided but not in case of the physiotherapist-guided treatment. METHODS: Patients (n=54) with clinically diagnosed hip osteoarthritis participated in 2 training sessions with the same exercise intervention, once guided by an app on a tablet computer and once guided by a physiotherapist in a German university hospital. The order of the sessions was randomized. Attitude toward technology was assessed as predictor before the first session, while mastery experience and the global perceived usefulness of interaction as self-reported outcomes after each session. RESULTS: In line with our hypotheses, attitude toward technology predicted mastery experience (b=0.16, standard error=0.07, P=.02) and usefulness of interaction (b=0.17, standard error=0.06, P=.01) after the app-based training but not after the training delivered by a physiotherapist (P>.3 in all cases). Mastery experience was lower for the app-based training but reached a very similar level as the physiotherapist-guided training for those holding a very positive attitude toward technology. CONCLUSIONS: The attitude toward technology predicts the extent of mastery experience after app-guided exercise therapy. As mastery experience is highly important for self-efficacy and future exercise behavior, attitudes toward technology should be considered when delivering app-guided exercise treatments. TRIAL REGISTRATION: German Clinical Trials Register DRKS00015759; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015759.

Effectiveness of Human Versus Computer-Based Instructions for Exercise on Physical Activity-Related Health Competence in Patients with Hip Osteoarthritis: Randomized Noninferiority Crossover Trial.

BACKGROUND: Hip and knee osteoarthritis is ranked as the 11th highest contributor to global disability. Exercise is a core treatment in osteoarthritis. The model for physical activity-related health competence describes possibilities to empower patients to perform physical exercises in the best possible health-promoting manner while taking into account their own physical condition. Face-to-face supervision is the gold standard for exercise guidance. OBJECTIVE: The aim of this study was to evaluate whether instruction and guidance via a digital app is not inferior to supervision by a physiotherapist with regard to movement quality, control competence for physical training, and exercise-specific self-efficacy. METHODS: Patients with clinically diagnosed hip osteoarthritis were recruited via print advertisements, emails and flyers. The intervention consisted of two identical training sessions with one exercise for mobility, two for strength, and one for balance. One session was guided by a physiotherapist and the other was guided by a fully automated tablet computer-based app. Both interventions took place at a university hospital. Outcomes were assessor-rated movement quality, and self-reported questionnaires on exercise-specific self-efficacy and control competence for physical training. Participants were randomly assigned to one of two treatment sequences. One sequence started with the app in the first session followed by the physiotherapist in the second session after a minimum washout phase of 27 days (AP group) and the other sequence occurred in the reverse order (PA group). Noninferiority was defined as a between-treatment effect (gIG)<0.2 in favor of the physiotherapist-guided training, including the upper confidence interval. Participants, assessors, and the statistician were neither blinded to the treatment nor to the treatment sequence. RESULTS: A total of 54 participants started the first training session (32 women, 22 men; mean age 62.4, SD 8.2 years). The treatment sequence groups were similar in size (PA: n=26; AP: n=28). Seven subjects did not attend the second training session (PA: n=3; AP: n=4). The app was found to be inferior to the physiotherapist in all outcomes considered, except for movement quality of the mobility exercise (gIG -0.13, 95% CI -0.41-0.16). In contrast to the two strengthening exercises in different positions (supine gIG 0.76, 95% CI 0.39-1.13; table gIG 1.19, 95% CI 0.84-1.55), movement quality of the balance exercise was close to noninferiority (gIG 0.15, 95% CI -0.17-0.48). Exercise-specific self-efficacy showed a strong effect in favor of the physiotherapist (gIG 0.84, 95% CI 0.46-1.22). In terms of control competence for physical training, the app was only slightly inferior to the physiotherapist (gIG 0.18, 95% CI -0.14-0.50). CONCLUSIONS: Despite its inferiority in almost all measures of interest, exercise-specific self-efficacy and control competence for physical training did improve in patients who used the digital app. Movement quality was acceptable for exercises that are easy to conduct and instruct. The digital app opens up possibilities as a supplementary tool to support patients in independent home training for less complex exercises; however, it cannot replace a physiotherapist. TRIAL REGISTRATION: German Clinical Trial Register: DRKS00015759; http://www.drks.de/DRKS00015759.

Effects of protocol on prevention of delirium in hospitalized hip fracture patients: A quality improvement project.

BACKGROUND: Delirium is a sudden change of consciousness experienced by hospitalized patients that results in negative outcomes. The incidence of delirium is under-reported and can be prevented in many patients. The purpose of this evidence-based study was to determine if the incidence of delirium decreased with the use of prevention interventions for hip fracture patients. METHODS: The project was a prospective quality improvement project. An audit of medical records using the CHART-DEL instrument was conducted pre- and post-implementation of an evidence-based protocol. Medical records were reviewed until discharge for the use of prevention interventions and the diagnosis of delirium. RESULTS: The sample included 90 hip fracture patients, 45 patients in both the pre- and post-implementation groups. The hip fracture protocol was used by admitting physicians in 31% of admissions and prevention interventions were documented by nurses in 75.6% of medical records. The incidence of delirium was similar in both groups; 11.1% in the pre-implementation group and 15.6% in the post-implementation group and was not statistically significant. DISCUSSION: Healthcare workers should take measures to reduce the incidence of delirium. There is a need for further studies on the use of protocols in the identification, prevention, and treatment of delirium in hospitalized patients.

Risk Factors and Maternal Morbidity Associated with Unintentional Hysterotomy Extension at the Time of Cesarean Delivery.

OBJECTIVE: Our aim was to estimate the incidence of unintentional hysterotomy extension at the time of cesarean delivery and to identify associated risk factors and maternal morbidity. STUDY DESIGN: We conducted a secondary analysis of a randomized controlled trial evaluating chlorhexidine-alcohol versus iodine-alcohol for skin antisepsis in women undergoing cesarean delivery. We included patients with a low transverse hysterotomy. The primary outcome was the incidence of unintentional hysterotomy extension. Logistic regression was performed to identify independent factors associated with hysterotomy extension. Maternal morbidity was compared between patients with and without extension. RESULTS: Of 1,038 patients meeting the inclusion criteria, 71 (6.8%; 95% confidence interval [CI]: 5.4-8.5%) experienced a hysterotomy extension. Of several potential risk factors assessed, the second stage of labor was the only independent predictor of hysterotomy extension (adjusted odds ratio: 10.2; 95% CI: 2.6-39.8). Hysterotomy extension was associated with increased operative time (73 vs. 55.3 minutes; p< 0.01), need for blood transfusion (relative risk: 5; 95% CI: 1.6-15.2), and rate of additional surgical injury (RR: 17; 95% CI: 6.9-41.8). CONCLUSION: Hysterotomy extensions are not infrequent at the time of cesarean delivery and are associated with increased maternal morbidity. Cesarean delivery during the second stage of labor is the main independent risk factor for hysterotomy extension.

Family Planning and Pregnancy Management in Adults with Congenital Heart Disease.

With advances in congenital heart disease management, there are an increasing number of women reaching reproductive age. Pregnancy results in a surge of hormones and increased demands on both the cardiovascular (CV) and respiratory systems. Depending on the heart defect and the treatments the mother has undergone, these hemodynamic changes can result in an increased risk of maternal CV events and an increased risk of fetal morbidity and mortality. Thus, it is important to have a comprehensive approach to adult congenital heart disease patients involving pre-pregnancy planning in addition to diligent peri- and post-partum care.

Resolution of a Low-Lying Placenta and Placenta Previa Diagnosed at the Midtrimester Anatomy Scan.

OBJECTIVES: To identify the incidence and resolution rates of a low-lying placenta or placenta previa and to assess the optimal time to perform follow-up ultrasonography (US) to assess for resolution. METHODS: We conducted a retrospective cohort study of women with a diagnosis of a low-lying placenta or placenta previa at routine anatomic screening. Follow-up US examinations were reviewed to estimate the proportion of women who had resolution. A Kaplan-Meier survival curve was generated to estimate the median time to resolution. The distance of the placental edge from the internal cervical os was used to categorize the placenta as previa or low-lying (0.1-10 or ≥ 10-20 mm). A time-to-event analysis was used to estimate predictive factors and the time to resolution by distance from the os. RESULTS: A total of 1663 (8.7%) women had a diagnosis of a low-lying placenta or placenta previa. The cumulative resolution for women who completed 1 or more additional US examinations was 91.9% (95% confidence interval, 90.2%-93.3%). The median time to resolution was 10 (interquartile range [IQR], 7-13) weeks. The distance from the internal cervical os was known for 658 (51.0%) women. The probability of resolution was inversely proportional to the distance from the internal os: 99.5% (≥10-20 mm), 95.4% (0.1-10 mm), and 72.3% (placenta previa; P < .001). The median times to resolution were 9 (IQR, 7-12) weeks for 10 to 20 mm, 10 (IQR, 7-13) weeks for 0.1 to 10 mm, and 12 (IQR, 9-15) weeks for placenta previa (P = .0003, log rank test). CONCLUSIONS: A low-lying placenta or placenta previa diagnosed at the midtrimester anatomy survey resolves in most patients. Resolution is near universal in patients with an initial distance from the internal os of 10 mm or greater.

Mode of delivery in nulliparous women with gestational hypertension undergoing early term induction of labor.

OBJECTIVE: To evaluate perinatal outcomes in nulliparous women undergoing induction of labor for gestational hypertension at term. STUDY DESIGN: Retrospective cohort study of nulliparous women with gestational hypertension undergoing induction of labor ≥37 weeks. Mode of delivery and perinatal outcomes were compared for women who delivered at 370-6/7, 380-6/7, and ≥390/7 weeks gestation. RESULTS: The cohort included 320 women: 67 (21%) at 370-6/7, 76 (24%) at 380-6/7, and 177 (55%) at ≥390/7. There was no increase in cesarean delivery (CD) in women delivering earlier, with 26.9% (370-6/7), 19.7% (380-6/7) and 29.9% (≥390/7) requiring CD (p values = 0.39). Compared to ≥39 weeks, composite maternal morbidity was lowest in women delivering at 380-6/7 (adjusted odds ratio [aOR] 0.45, 95% confidence interval (CI) 0.24-0.84). Composite neonatal morbidity was similar among the groups. When compared to women delivering at ≥390/7 weeks, women delivered at 380-6/7 were less likely to experience any adverse maternal or neonatal outcome (aOR 0.50, 95% CI 0.28-0.90). CONCLUSIONS: Compared to induction of labor at ≥39 weeks, early term induction of labor was not associated with an increased risk of CD in nulliparous women with gestational hypertension.

Impact of Gestational Weight Gain on Perinatal Outcomes in Obese Women.

Objective This study aims to evaluate perinatal outcomes, according to gestational weight gain (GWG) in obese women. Study Design A retrospective cohort of perinatal outcomes in obese women who gained below, within, or above the 2009 Institute of Medicine guidelines and delivered ≥ 36 weeks. Additionally, outcomes, according to the rate of GWG (kg/week; minimal [< 0.16], moderate [0.16-0.49], or excessive [> 0.49]) were compared among women delivering preterm. Results Overall, 5,651 obese women delivered ≥ 36 weeks. GWG above guidelines was associated with increased cesarean section (adjusted odds ratio [aOR]: 1.44, 95% confidence interval [CI]: 1.21-1.72), gestational hypertension (aOR: 1.58, 95% CI: 1.21-2.06), and macrosomia (birth weight ≥ 4,000 g) (aOR: 2.08, 95% CI: 1.62-2.67). GWG below recommendations was associated with less large for gestational age infants (aOR: 0.60, 95% CI: 0.47-0.75). A total of 6,663 women delivered ≥ 20 weeks. Minimal weekly GWG was associated with increased spontaneous preterm birth (aOR: 1.56, 95% CI: 1.23-1.98) and more small for gestational age (SGA) infants (aOR: 1.55, 95% CI: 1.19-2.01). Excessive weekly GWG was associated with increased indicated preterm birth (aOR: 1.61, 95% CI: 1.29-2.01), cesarean section (aOR: 1.39, 95% CI: 1.20-1.61), preeclampsia (aOR: 1.83, 95% CI: 1.49-2.26), neonatal intensive care unit admission (aOR: 1.33, 95% CI: 1.08-1.63), and macrosomia (aOR: 2.40, 95% CI: 1.94-2.96). Conclusions Obese women with excessive GWG had worse outcomes than women with GWG within recommendations. Limited GWG was associated with increased spontaneous preterm birth and SGA infants.

Universal cervical length screening: implementation and outcomes.

BACKGROUND: Transvaginal measurement of cervical length (CL) has been advocated as a screening tool to prevent preterm birth, but controversy remains regarding the overall utility of universal screening. OBJECTIVE: We aimed to evaluate the acceptability of a universal CL screening program. Additionally we evaluated risk factors associated with declining screening and subsequent delivery outcomes of women who accepted or declined screening. STUDY DESIGN: This was a retrospective cohort study of transvaginal CL screening at a single institution from July 1, 2011, through December 31, 2014. Institutional protocol recommended transvaginal CL measurement at the time of anatomic survey between 17-23 weeks in all women with singleton, viable pregnancies, without current or planned cerclage, with patients able to opt out. Patients with CL ≤20 mm were considered to have clinically significant cervical shortening and were offered treatment. We assessed acceptance rate, risk factors for declining CL screening, and the trend of acceptance of CL screening over time. We also calculated the prevalence of CL ≤25, ≤20, and ≤15 mm, and estimated the association between CL screening and spontaneous preterm birth. RESULTS: Of 12,740 women undergoing anatomic survey during the study period, 10,871 (85.3%; 95% confidence interval [CI], 84.7-85.9%) underwent CL screening. Of those, 215 (2.0%) had a CL ≤25 mm and 131 (1.2%) had a CL ≤20 mm. After the first 6 months of implementation, there was no change in rates of acceptance of CL screening over time (P for trend = .15). Women were more likely to decline CL screening if they were African American (adjusted odds ratio [aOR], 2.17; 95% CI, 1.93-2.44), obese (aOR, 1.18; 95% CI, 1.06-1.31), multiparous (aOR, 1.45; 95% CI, 1.29-1.64), age <35 years (aOR, 1.24; 95% CI, 1.08-1.43), or smokers (aOR, 1.42; 95% CI, 1.20-1.68). Rates of spontaneous preterm birth <28 weeks were higher in those who declined CL screening (aOR, 2.01; 95% CI, 1.33-3.02). CONCLUSION: Universal CL screening was implemented successfully with 85% of women screened. Overall incidence of short cervix was low and women with significant risk factors for preterm birth were more likely to decline screening. Patients who declined CL screening were more likely to be African American, obese, multiparous, age <35 years, and smokers. Rates of early, but not late, spontaneous preterm birth were significantly higher among women who did not undergo CL screening.

Degree of obesity at delivery and risk of preeclampsia with severe features.

BACKGROUND: The risk of preeclampsia increases as maternal body mass index (BMI) increases. The link between increasing maternal BMI and preeclampsia with severe features is less well-established. OBJECTIVE: To estimate the effect of increasing severity of obesity on risk of preeclampsia with severe features, stratified by early-onset and late-onset disease. STUDY DESIGN: We performed a retrospective cohort study of consecutive singleton live births at a tertiary care facility from 2004 to 2008. Women were included in the cohort if they delivered a singleton live birth and maternal height and weight was measured on admission. The primary exposure was maternal weight category on presentation for delivery, defined as normal (BMI 18.5-24.9; referent group, n = 1473), overweight (BMI 25-29.9, n = 3081), obese (BMI 30-39.9, n = 4196), and morbidly obese (BMI ≥40, n = 1446). The primary outcome was preeclampsia with severe features. Secondary outcome was early-onset preeclampsia with severe features at <34 weeks or late-onset preeclampsia with severe features at ≥34 weeks. Multivariable logistic regression was used to adjust for confounders. RESULTS: Of the 10,196 patients meeting inclusion criteria, 1119 developed preeclampsia. Of those, 881 (8.6%) women developed preeclampsia with severe features. Overall, the risk of preeclampsia with severe features was not significantly different in the 4 BMI categories. Of the 10,196 women in the cohort, 1072 delivered <34 weeks and 9124 delivered ≥34 weeks. When stratifying by gestational age at delivery, there was a statistically significant increased risk of developing late-onset preeclampsia with severe features at ≥34 weeks in overweight (4.5%, adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.0-2.1), obese (6.2%, aOR 2.0, 95% CI 1.4-2.8) and morbidly obese (6.8%, aOR 2.0, 95% CI 1.3-2.9) women compared with normal-weight women (2.9%). CONCLUSION: Increasing maternal weight was not associated with preeclampsia with severe features in the total cohort; however, overweight, obese, and morbidly obese women are at increased risk of developing late-onset preeclampsia with severe features.

Pregnancy in Women With Solid-Organ Transplants: A Review.

IMPORTANCE: Advances in solid-organ transplantation have allowed many women to reach reproductive potential, and pregnancy is no longer a rarity for these women. OBJECTIVE: To identify (1) potential complications to allograft function posed by pregnancy, (2) expected perinatal outcomes in women with solid-organ transplants, (3) risks of potential immunosuppressant regimens, (4) safety of lactation, and (5) contraceptive options for women with solid-organ transplants. EVIDENCE ACQUISITION: Single-center, registry data, and previous systematic reviews were evaluated in women with solid-organ transplants to identify the objectives of this review. In addition, recommendations from public health organizations were examined in regard to safety of medications and contraceptive methods. RESULTS: Women with solid-organ transplants are at risk for premature birth, low birth weight, cesarean delivery, and hypertensive disorders of pregnancy. Most immunosuppressant regimens are safe; however, mycophenolate mofetil should be avoided. Lactation with tacrolimus, cyclosporine, azathioprine, and prednisone appears safe. Long-acting reversible contraceptive methods are safe and effective for transplant recipients. CONCLUSIONS: Many successful pregnancies have been achieved in women following transplantation; however, optimal perinatal outcomes require stable allograft function. RELEVANCE: As more women are becoming pregnant after organ transplantation, a review of obstetric recommendations and perinatal outcome is warranted.

Increased likelihood of long-term gastrostomy tube dependence in head and neck cancer survivors without partners.

BACKGROUND: We evaluated factors associated with long-term dependence on percutaneous endoscopic gastrostomy (PEG) tubes. METHODS: One hundred fifty-four patients receiving treatment at the University of Alabama at Birmingham between 2002 and 2004 who underwent PEG tube placement were identified through retrospective review of medical records. Using binary logistic regression, we evaluated the association of various factors on long-term dependence on PEG tubes. RESULTS: A total of 25.3% of survivors remained PEG tube-dependent at 12 months. The odds of long-term PEG tube-dependence were greater for those who did not have partners compared with those who had partners (odds ratio [OR], 3.33; p = .004), for patients who received radiation therapy (OR, 6.21; p = .018), and for those who had a tracheotomy in place for longer than 30 days (OR, 4.328; p = .035). CONCLUSION: Data suggest that interventions targeted at reducing long-term dependence on PEG tubes take into account not only treatment-related factors, but also the important role that social support plays.

Completed versus aborted radical hysterectomy for node-positive stage IB cervical cancer in the modern era of chemoradiation therapy.

OBJECTIVE: Debate continues about optimal management of patients with node-positive stage I cervical cancer. Our objective was to determine if patient outcomes are affected by radical hysterectomy in the modern era of adjuvant chemoradiation. METHODS: Cervical cancer patients diagnosed from 2000 to 2008 were identified. Demographics, therapy, clinicopathologic data, progression free survival (PFS), overall survival (OS), total radiation exposure, and grade 3-4 complications were analyzed by student t, Mann-Whitney, Fisher's exact, Kaplan-Meier, and log rank tests. RESULTS: This single-institution review evaluated forty-one of 334 (13.4%) patients scheduled to undergo radical hysterectomy that had gross nodal disease diagnosed intraoperatively. 15 underwent aborted radical hysterectomy following lymphadenectomy; the remaining 26 underwent radical hysterectomy and lymphadenectomy. Eleven patients undergoing radical hysterectomy underwent whole pelvic radiation therapy (WPRT) while 8 (30.7%) patients underwent WPRT and postoperative vaginal brachytherapy (BT) for local treatment secondary to close margins. All patients undergoing aborted radical hysterectomy underwent WPRT and BT. With mean follow-up of 42.3 months, there were no significant differences in urinary, gastrointestinal, or hematologic complications between groups. When comparing those undergoing radical hysterectomy to aborted radical hysterectomy, there were no significant differences in local recurrence (11.5% vs 26.7%, p=0.39) or distant recurrence (19.2% vs. 33.3%, p=0.45), PFS (74.9 months vs 46.8 months, p=0.106), or OS (91.8 months vs 69.4 months, p=0.886). CONCLUSIONS: Treatment of patients with early stage cervical cancer and nodal metastasis may be tailored intraoperatively. Completion of radical hysterectomy and lymphadenectomy decreases radiation exposure without apparently compromising safety or outcome in the era of adjuvant chemoradiation.