The Association Between Mobile App Use and Change in Functional Capacity Among Cardiac Rehabilitation Participants: Cohort Study.

BACKGROUND: Cardiac rehabilitation (CR) is underused in the United States and globally, with participation disparities across gender, socioeconomic status, race, and ethnicities. The pandemic led to greater adoption of telehealth CR and mobile app use. OBJECTIVE: Our primary objective was to estimate the association between CR mobile app use and change in functional capacity from enrollment to completion in patients participating in a CR program that offered in-person, hybrid, and telehealth CR. Our secondary objectives were to study the association between mobile app use and changes in blood pressure (BP) or program completion. METHODS: We conducted a retrospective cohort study of participants enrolled in CR at an urban CR program in the United States. Participants were English speaking, at least 18 years of age, participated in the program between May 22, 2020, and May 21, 2022, and downloaded the CR mobile app. Mobile app use was quantified by number of exercise logs, vitals logs, and education material views. The primary outcome was change in functional capacity, measured by change in 6-minute walk distance (6MWD) from enrollment to completion. The secondary outcome was change in BP from enrollment to completion. We estimated associations using multivariable linear or logistic regression models adjusted for age, sex, race, ethnicity, socioeconomic status by ZIP code, insurance, and primary diagnosis for CR referral. RESULTS: A total of 107 participants (mean age 62.9, SD 13.02 years; 90/107, 84.1% male; and 57/105, 53.3% self-declared as White Caucasian) used the mobile app and completed the CR program. Participants had a mean 64.0 (SD 54.1) meter increase in 6MWD between enrollment and completion (P<.001). From enrollment to completion, participants with an elevated BP at baseline (≥130/80 mmHg) experienced a significant decrease in BP (systolic BP -11.5 mmHg; P=.002 and diastolic BP -7.7 mmHg; P=.003). We found no significant association between total app interactions and change in 6MWD (coefficient -0.03, 95% CI -0.1 to 0.07; P=.59) or change in BP (systolic coefficient 0.002, 95% CI -0.03 to 0.03; P=.87 and diastolic coefficient -0.005, 95% CI -0.03 to 0.02; P=.65). There was no significant association between total exercise logs and change in 6MWD (coefficient 0.1, 95% CI -0.3 to 0.4; P=.57) or total BP logs and change in BP (systolic coefficient -0.02, 95% CI -0.1 to 0.06; P=.63 and diastolic coefficient -0.02, 95% CI -0.09 to 0.04; P=.50). There was no significant association between total app interactions and completion of CR (adjusted odds ratio 1.00, 95% CI 0.99-1.01; P=.44). CONCLUSIONS: CR mobile app use as part of an in-person, hybrid, or telehealth CR program was not associated with greater improvement in functional capacity or BP or with program completion.

Uterine activity in labour and the risk of neonatal encephalopathy: a case control study.

OBJECTIVE: To determine the relationship between intrapartum contraction frequency, rest interval duration, and cervical dilation speed and the risk of neonatal hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN: This was a retrospective case-control study conducted in a maternity hospital in Dublin, Ireland. Babies born without major congenital anomalies between September 2006 and November 2017 at ≥ 35 + 0 weeks' gestational age were eligible. Cases were diagnosed with moderate-severe HIE. The controls were the first eligible baby born before and after each case with normal Apgar scores and not admitted to the neonatal unit. Intrapartum uterine activity was assessed by automated analysis of external tocography recordings. Cervical dilation was assessed by linear interpolation between vaginal examination measurements. The speed of cervical dilation was expressed as the times from 4 to 6 cm, >6 cm to the start of pushing, and from pushing to delivery. RESULTS: Intrapartum tocographs results were available in 49 of 88 cases and 121 of 176 controls. The median contraction rate in cases was 7.7 (Interquartile range [IQR]: 6.6-9.0) compared to 7.0 in controls (IQR: 6.2-7.9) (p = 0.021). The median rest interval duration was 56 s (IQR: 38-76) in cases and 62 s (IQR: 50-79) in controls (p = 0.058). Cases took longer to progress from > 6 cm to the start of pushing (cases: 02:58 [01:14-04:49], controls: 01:48 [00:51-03:34], p = 0.020) and from pushing to delivery (cases: 00:34 [00:24-01:10], controls: 00:27 [00:13-00:56], p = 0.036). CONCLUSIONS: Higher contraction frequencies and slower progress towards the end of labour are both independently associated with the risk of moderate-severe HIE. Inter-contraction rest interval duration as measured by external tocography does not provide additional accuracy.

Fetal heart rate patterns in labor and the risk of neonatal encephalopathy: A case control study.

OBJECTIVE: To describe the accuracy of intrapartum fetal heart rate abnormalities as defined by National Institute of Health and Care Excellence guidelines to predict moderate-severe neonatal encephalopathy of apparent hypoxic-ischemic etiology. STUDY DESIGN: A case-control study of HIE risk factors was conducted. Eligible babies were born in a single maternity hospital in Dublin, Ireland between September 2006, and November 2017 at ≥35 + 0 weeks' gestational age. Cases were eligible babies with moderate-severe neonatal encephalopathy of definite or apparent hypoxic-ischemic etiology. Controls were eligible babies born before and after each case with normal Apgar scores. The included subjects who had intrapartum fetal heart rate recordings were identified. Pattern features (baseline rate, variability, accelerations, decelerations [early, late, variable, prolonged], bradycardia, sinusoidal pattern) were manually identified blind to all clinical details by one of the authors. Each 15-minute segment was then algorithmically categorized (uninterpretable, normal, suspicious, pathological). RESULTS: Of 88 cases and 176 controls, 71 cases (81%) and 146 controls (83%) were admitted to the delivery suite in labor. From that group, intrapartum FHR traces longer than 15 min were available for 52 (73%) cases and 118 (83%) controls. The FHR pattern feature with the largest area under the receiver operating characteristic curve was the maximum number of consecutive segments in which the baseline was >160 bpm (0.71 [95% confidence interval: 0.62-0.80]). The category variable with the highest area under the curve was the number of suspicious segments (0.76 [95% confidence interval: 0.67-0.84]). A tri-variate logistic regression model incorporating the total number of segments, the number of "suspicious" segments classed, and the number of "pathological" segments achieved an area under the curve of 0.78 (95% confidence interval: 0.70-0.86). With 95% specificity, this model correctly identified 17 cases (33%) at a median time before delivery of 2 h and 18 min (interquartile range: 01:19-04:40). CONCLUSIONS: The power of fetal heart rate analysis to predict neonatal encephalopathy is hampered by poor specificity given the rarity of the outcome. When analyzing a suspicious trace, it is beneficial to consider the overall duration of the suspicious pattern.

Clinical Outcomes and Qualitative Perceptions of In-person, Hybrid, and Virtual Cardiac Rehabilitation.

PURPOSE: Cardiac rehabilitation (CR) is evolving to include both in-person and virtual delivery. Our objective was to compare, in CR patients, the association of in-person, hybrid, and virtual CR with change in performance on the 6-min walk test (6MWT) between enrollment and completion. METHODS: Patients enrolled in CR between October 22, 2019, and May 10, 2021, were categorized into in-person, hybrid, or virtual groups by number of in-person and virtual visits. All patients received individualized exercise training and health behavior counseling. Cardiac rehabilitation was delivered to patients in the hybrid and virtual cohorts using synchronous video exercise and/or asynchronous telephone visits. Measurements at CR enrollment and completion included the 6MWT, blood pressure (BP), depression, anxiety, waist-to-hip ratio, and cardiac self-efficacy. RESULTS: Of 187 CR patients, 37/97 (38.1%) were in-person patients and 58/90 (64.4%) were hybrid/virtual patients ( P = .001). Compared to in-person (51.5 ± 59.4 m) improvement in the 6MWT was similar in hybrid (63.4 ± 55.6; P = .46) and virtual (63.2 ± 59.6; P = .55) compared with in-person (51.5 ± 59.4). Hybrid and virtual patients experienced similar improvements in BP control and anxiety. Virtual patients experienced less improvement in depression symptoms. There were no statistically significant changes in waist-to-hip ratio or cardiac self-efficacy. Qualitative themes included the adaptability of virtual CR, importance of relationships between patients and CR staff, and need for training and organizational adjustments to adopt virtual CR. CONCLUSIONS: Hybrid and virtual CR were associated with similar improvements in functional capacity to in-person. Virtual and hybrid CR have the potential to expand availability without compromising outcomes.

A wavelet-based algorithm for automated analysis of external tocography: How does it compare to human interpretation?

BACKGROUND: Studies which use external tocography to explore the relationship between increased intrapartum uterine activity and foetal outcomes are feasible because the technology is safe and ubiquitous. However, periods of poor signal quality are common. We developed an algorithm which aims to calculate tocograph summary variables based on well-recorded contractions only, ignoring artefact and excluding sections deemed uninterpretable. The aim of this study was to test that algorithm's reliability. METHODS: Whole recordings from labours at ≥35 weeks of gestation were randomly selected without regard to quality. Contractions and rest intervals were measured by two humans independently, and by the algorithm using two sets of models; one based on a series of pre-defined thresholds, and another trained to imitate one of the human interpreters. The absolute agreement intraclass correlation coefficient (ICC) was calculated using a two-way random effects model. RESULTS: The training dataset included data from 106 tocographs. Of the tested algorithms, AdaBoost showed the highest initial cross-validated accuracy and proceeded to optimization. Forty tocographs were included in the validation set. The ICCs for the per tocograph mean contraction rates were; human B to human A: 0.940 (0.890-0.968), human A to initial models: 0.944 (0.898-0.970), human A to trained models 0.962 (0.927-0.980), human B to initial models: 0.930 (0.872-0.962), human B to trained models: 0.948 (0.903-0.972). CONCLUSIONS: The algorithm described approximates interpretation of external tocography performed by trained humans. The performance of the AdaBoost trained models was marginally superior compared to the initial models.

Sensitivity and specificity of the Pap smear for glandular lesions of the cervix and endometrium.

OBJECTIVE: To investigate the sensitivity and specificity of the Pap smear for detection of adenocarcinoma in situ of the cervix (AIS), endocervical adenocarcinoma (ECAC) and endometrial adenocarcinoma (EAC) as well as the overall specificity of the smear for detection of glandular lesions in general. STUDY DESIGN: Computer records of the laboratory of the QE II Health Sciences Center, Halifax, were searched for patients who had AIS, ECAC or EAC diagnosed on histology between June 1, 1999, and May 31, 2001 and who had had a Pap smear within the preceding year. Computer records were also searched for patients who had a Pap smear result consisting of suspicious or positive for AIS or adenocarcinoma (AC) with subsequent tissue diagnosis during the same time. The histologic and cytologic findings were correlated. RESULTS: One hundred percent of patients with AIS, 80% with ECAC and 22% with EAC on histology had positive findings on a Pap smear performed within a year of the histologic diagnosis. One hundred percent of patients with a Pap smear result consisting of suspicious or positive for AIS or AC and follow-up histology had a lesion on histology: 13% AIS, 13% ECAC, 37% EAC, 23% other AC, 10% high grade squamous lesion and 0.3% low grade squamous lesion. CONCLUSION: This study confirmed the good overall specificity of the Pap smear for glandular lesions in general. It also confirmed the good sensitivity for glandular lesions of the cervix and the poor sensitivity for glandular lesions of the endometrium. It thus confirmed that the Pap smear is not an effective screening tool for endometrial AC, and that the quest for alternative screening methods should continue.

Maternal or fetal heart rate? Avoiding intrapartum misidentification.

Electronic fetal monitoring technology is capable of monitoring and recording maternal heart rate (MHR) patterns that mimic fetal heart rate (FHR) patterns. The ability to distinguish one from the other requires knowledge of FHR and MHR characteristics and monitoring technology. Application of this knowledge may prevent fetal injury and death. This article reviews heart rate monitoring technology and the similarities and differences between MHR and FHR baselines, accelerations, and decelerations. Three case reports are described in which the MHR was mistaken for the FHR prior to the diagnosis of fetal demise. Guidelines to confirm fetal life and prevent misidentification are proposed.