Predicting health outcomes with intensive longitudinal data collected by mobile health devices: a functional principal component regression approach.

BACKGROUND: Intensive longitudinal data (ILD) collected in near real time by mobile health devices provide a new opportunity for monitoring chronic diseases, early disease risk prediction, and disease prevention in health research. Functional data analysis, specifically functional principal component analysis, has great potential to abstract trends in ILD but has not been used extensively in mobile health research. OBJECTIVE: To introduce functional principal component analysis (fPCA) and demonstrate its potential applicability in estimating trends in ILD collected by mobile heath devices, assessing longitudinal association between ILD and health outcomes, and predicting health outcomes. METHODS: fPCA and scalar-to-function regression models were reviewed. A case study was used to illustrate the process of abstracting trends in intensively self-measured blood glucose using functional principal component analysis and then predicting future HbA1c values in patients with type 2 diabetes using a scalar-to-function regression model. RESULTS: Based on the scalar-to-function regression model results, there was a slightly increasing trend between daily blood glucose measures and HbA1c. 61% of variation in HbA1c could be predicted by the three preceding months' blood glucose values measured before breakfast (P < 0.0001, [Formula: see text]). CONCLUSIONS: Functional data analysis, specifically fPCA, offers a unique tool to capture patterns in ILD collected by mobile health devices. It is particularly useful in assessing longitudinal dynamic association between repeated measures and outcomes, and can be easily integrated in prediction models to improve prediction precision.

Outcomes from Partner2Lose: a randomized controlled trial to evaluate 24-month weight loss in a partner-assisted intervention.

BACKGROUND: Partner support is associated with better weight loss outcomes in observational studies, but randomized trials show mixed results for including partners. Unclear is whether teaching communication skills to couples will improve weight loss in a person attempting weight loss (index participant). PURPOSE: To compare the efficacy of a partner-assisted intervention versus participant-only weight management program on 24-month weight loss. METHODS: This community-based study took place in Madison, WI. Index participants were eligible if they met obesity guideline criteria to receive weight loss counseling, were aged 18-74 years, lived with a partner, and had no medical contraindications to weight loss; partners were aged 18-74 years and not underweight. Couples were randomized 1:1 to a partner-assisted or participant-only intervention. Index participants in both arms received an evidence-based weight management program. In the partner-assisted arm, partners attended half of the intervention sessions, and couples were trained in communication skills. The primary outcome was index participant weight at 24 months, assessed by masked personnel; secondary outcomes were 24-month self-reported caloric intake and average daily steps assessed by an activity tracker. General linear mixed models were used to compare group differences in these outcomes following intent-to-treat principles. RESULTS: Among couples assigned to partner-assisted (n = 115) or participant-only intervention (n = 116), most index participants identified as female (67%) and non-Hispanic White (87%). Average baseline age was 47.27 years (SD 11.51 years) and weight was 106.55 kg (SD 19.41 kg). The estimated mean 24-month weight loss was similar in the partner-assisted (2.66 kg) and participant-only arms (2.89 kg) (estimated mean difference, 0.23 kg [95% CI, -1.58, 2.04 kg], p=0.80). There were no differences in 24-month average daily caloric intake (estimated mean difference 50 cal [95% CI: -233, 132 cal], p=0.59) or steps (estimated mean difference 806 steps [95% CI: -1675, 64 steps], p=0.07). The percentage of participants reporting an adverse event with at least possible attribution to the intervention did not differ by arm (partner-assisted: 9%, participant-only, 3%, p = 0.11). CONCLUSIONS: Partner-assisted and individual weight management interventions led to similar outcomes in index participants. TRIAL REGISTRATION: Clinicaltrials.gov NCT03801174, January 11, 2019.

An mHealth Intervention to Improve Medication Adherence and Health Outcomes Among Patients With Coronary Heart Disease: Randomized Controlled Trial.

BACKGROUND: The treatment of many chronic illnesses involves long-term pharmaceutical therapy, but it is an ongoing challenge to find effective ways to improve medication adherence to promote good health outcomes. Cardioprotective medications can prevent the enlargement of harmful clots, cardiovascular symptoms, and poor therapeutic outcomes, such as uncontrolled high blood pressure and hyperlipidemia, for patients with coronary heart disease. Poor adherence to cardioprotective medications, however, has been reported as a global health concern among patients with coronary heart disease, and it is particularly a concern in China. OBJECTIVE: This study aimed to evaluate the efficacy of a mobile health (mHealth) intervention using 2 mobile apps to improve medication adherence and health outcomes. METHODS: A randomized, placebo-controlled, 2-arm parallel study was conducted in a major university-affiliated medical center located in Chengdu, China. Participants were recruited by flyers and health care provider referrals. Each participant was observed for 90 days, including a 60-day period of mHealth intervention and a 30-day period of nonintervention follow-up. The study coordinator used WeChat and Message Express to send educational materials and reminders to take medication, respectively. Participants used WeChat to receive both the educational materials and reminders. Participants in the control group only received educational materials. This study received ethics approval from the Duke Health Institutional Review Board (Pro00073395) on May 5, 2018, and was approved by West China Hospital (20170331180037). Recruitment began on May 20, 2018. The pilot phase of this study was registered on June 8, 2016, and the current, larger-scale study was retrospectively registered on January 11, 2021 (ClinicalTrials.gov). RESULTS: We recruited 230 patients with coronary heart disease. Of these patients, 196 completed the baseline survey and received the intervention. The majority of participants were married (181/196, 92.4%), male (157/196, 80.1%), and lived in urban China (161/196, 82.1%). Participants' average age was 61 years, and half were retired (103/191, 53.9%). More than half the participants (121/196, 61.7%) were prescribed at least 5 medications. The mean decrease in medication nonadherence score was statistically significant at both 60 days (t179=2.04, P=.04) and 90 days (t155=3.48, P<.001). Systolic blood pressure and diastolic blood pressure decreased in the experimental group but increased in the control group. The mean decrease in diastolic blood pressure was statistically significant at both 60 days (t160=2.07, P=.04) and 90 days (t164=2.21, P=.03). The mean decrease in systolic blood pressure was significantly different in the groups at 90 days (t165=3.12, P=.002). CONCLUSIONS: The proposed mHealth intervention can improve medication adherence and health outcomes, including systolic blood pressure and diastolic blood pressure. TRIAL REGISTRATION: ClinicalTrials.gov NCT02793830; https://clinicaltrials.gov/ct2/show/NCT02793830 and ClinicalTrials.gov NCT04703439; https://clinicaltrials.gov/ct2/show/NCT04703439.

Telehealth for the Longitudinal Management of Chronic Conditions: Systematic Review.

BACKGROUND: Extensive literature support telehealth as a supplement or adjunct to in-person care for the management of chronic conditions such as congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM). Evidence is needed to support the use of telehealth as an equivalent and equitable replacement for in-person care and to assess potential adverse effects. OBJECTIVE: We conducted a systematic review to address the following question: among adults, what is the effect of synchronous telehealth (real-time response among individuals via phone or phone and video) compared with in-person care (or compared with phone, if synchronous video care) for chronic management of CHF, chronic obstructive pulmonary disease, and T2DM on key disease-specific clinical outcomes and health care use? METHODS: We followed systematic review methodologies and searched two databases (MEDLINE and Embase). We included randomized or quasi-experimental studies that evaluated the effect of synchronously delivered telehealth for relevant chronic conditions that occurred over ≥2 encounters and in which some or all in-person care was supplanted by care delivered via phone or video. We assessed the bias using the Cochrane Effective Practice and Organization of Care risk of bias (ROB) tool and the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We described the findings narratively and did not conduct meta-analysis owing to the small number of studies and the conceptual heterogeneity of the identified interventions. RESULTS: We identified 8662 studies, and 129 (1.49%) were reviewed at the full-text stage. In total, 3.9% (5/129) of the articles were retained for data extraction, all of which (5/5, 100%) were randomized controlled trials. The CHF study (1/5, 20%) was found to have high ROB and randomized patients (n=210) to receive quarterly automated asynchronous web-based review and follow-up of telemetry data versus synchronous personal follow-up (in-person vs phone-based) for 1 year. A 3-way comparison across study arms found no significant differences in clinical outcomes. Overall, 80% (4/5) of the studies (n=466) evaluated synchronous care for patients with T2DM (ROB was judged to be low for 2, 50% of studies and high for 2, 50% of studies). In total, 20% (1/5) of the studies were adequately powered to assess the difference in glycosylated hemoglobin level between groups; however, no significant difference was found. Intervention design varied greatly from remote monitoring of blood glucose combined with video versus in-person visits to an endocrinology clinic to a brief, 3-week remote intervention to stabilize uncontrolled diabetes. No articles were identified for chronic obstructive pulmonary disease. CONCLUSIONS: This review found few studies with a variety of designs and interventions that used telehealth as a replacement for in-person care. Future research should consider including observational studies and studies on additional highly prevalent chronic diseases.

Joule heating effects on electrokinetic flows with conductivity gradients.

Instability occurs in the electrokinetic flow of fluids with conductivity and/or permittivity gradients if the applied electric field is beyond a critical value. Understanding such an electrokinetic instability is significant for both improved transport (via the suppressed instability) and enhanced mixing (via the promoted instability) of liquid samples in microfluidic applications. This work presents the first study of Joule heating effects on electrokinetic microchannel flows with conductivity gradients using a combined experimental and numerical method. The experimentally observed flow patterns and measured critical electric fields under Joule heating effects to different extents are reasonably predicted by a depth-averaged numerical model. It is found that Joule heating increases the critical electric field for the onset of electrokinetic instability because the induced fluid temperature rise and in turn the fluid property change (primarily the decreased permittivity) lead to a smaller electric Rayleigh number.

Perceptions of Using Multiple Mobile Health Devices to Support Self-Management Among Adults With Type 2 Diabetes: A Qualitative Descriptive Study.

PURPOSE: This study identified facilitators and barriers pertaining to the use of multiple mobile health (mHealth) devices (Fitbit Alta® fitness tracker, iHealth® glucometer, BodyTrace® scale) that support self-management behaviors in individuals with type 2 diabetes mellitus (T2DM). DESIGN: This qualitative descriptive study presents study participants' perceptions of using multiple mobile devices to support T2DM self-management. Additionally, this study assessed whether participants found visualizations, generated from each participant's health data as obtained from the three separate devices, useful and easy to interpret. METHODS: Semistructured interviews were completed with a convenience sample of participants (n = 20) from a larger randomized control trial on T2DM self-management. Interview questions focused on participants' use of three devices to support T2DM self-management. A study team member created data visualizations of each interview participant's health data using RStudio. RESULTS: We identified two themes from descriptions of study participants: feasibility and usability. We identified one theme about visualizations created from data obtained from the mobile devices. Despite some challenges, individuals with T2DM found it feasible to use multiple mobile devices to facilitate engagement in T2DM self-management behaviors. DISCUSSION: As mHealth devices become increasingly popular for diabetes self-management and are integrated into care delivery, we must address issues associated with the use of multiple mHealth devices and the use of aggregate data to support T2DM self-management. CLINICAL RELEVANCE: Real-time patient-generated health data that are easily accessible and readily available can assist T2DM self-management and catalyze conversations, leading to better self-management. Our findings lay an important groundwork for understanding how individuals with T2DM can use multiple mHealth devices simultaneously to support self-management.

Beat the heat: Culex quinquefasciatus regulates its body temperature during blood feeding.

Mosquitoes are regarded as one of the most dangerous animals on earth. Because they are responsible for the spread of a wide range of both human and animal pathogens, research of the underlying mechanisms of their feeding behavior and physiology is critical. Among disease vector mosquitoes, Culex quinquefasciatus, a known carrier of West Nile virus and Western Equine Encephalitis, remains relatively understudied. As blood-sucking insects, adaptations (either at the molecular or physiological level) while feeding on warm blood are crucial to their survival, as overheating can result in death due to heat stress. Our research aims to determine how Cx. quinquefasciatus copes with the heat associated with warm blood meal ingestion and possibly uncover the adaptations this species uses to avoid thermal stress. Through the use of thermographic imaging, we analyzed the body temperature of Cx. quinquefasciatus while blood feeding. Infrared thermography has allowed us to identify a cooling strategy, evaporative cooling via the production of fluid droplets, and an overall low body temperature in comparison to the blood temperature during feeding. Understanding Cx. quinquefasciatus' adaptations and the strategies they employ to reduce their body temperature while blood feeding constitutes the first step towards discovering potential targets that could be used for their control.

Development of an RTD-Based Flowsheet Modeling Framework for the Assessment of In-Process Control Strategies.

Continuous manufacturing (CM) is an emerging technology which can improve pharmaceutical manufacturing and reduce drug product quality issues. One challenge that needs to be addressed when adopting CM technology is material traceability through the entire continuous process, which constitutes one key aspect of control strategy. Residence time distribution (RTD) plays an important role in material traceability as it characterizes the material spreading through the process. The propagation of upstream disturbances could be predictively tracked through the entire process by convolution of the disturbance and the RTD. The present study sets up the RTD-based modeling framework in a commonly used process modeling environment, gPROMS, and integrates it with existing modules and built-in tools (e.g., parameter estimation). Concentration calculations based on the convolution integral requires access to historical stream property information, which is not readily available in flowsheet modeling platforms. Thus, a novel approach is taken whereby a partial differential equation is used to propagate and store historical data as the simulation marches forward in time. Other stream properties not modeled by an RTD are determined in auxiliary modules. To illustrate the application of the framework, an integrated RTD-auxiliary model for a continuous direct compression manufacturing line was developed. An excellent agreement was found between the model predictions and experiments. The validated model was subsequently used to assess in-process control strategies for feeder and material traceability through the process. Our simulation results show that the employed modeling approach facilitates risk-based assessment of the continuous line by promoting our understanding on the process.

American Society for Transplantation and Cellular Therapy Pharmacy Special Interest Group Position Statement on Pharmacy Practice Management and Clinical Management for COVID-19 in Hematopoietic Cell Transplantation and Cellular Therapy Patients in the United States.

The coronavirus-19 (COVID-19) pandemic poses a significant risk to patients undergoing hematopoietic stem cell transplantation (HCT) or cellular therapy. The American Society for Transplantation and Cellular Therapy Pharmacy Special Interest Group Steering Committee aims to provide pharmacy practice management recommendations for how to transition clinical HCT or cellular therapy pharmacy services using telemedicine capabilities in the inpatient and outpatient settings to maintain an equivalent level of clinical practice while minimizing viral spread in a high-risk, immunocompromised population. In addition, the Steering Committee offers clinical management recommendations for COVID-19 in HCT and cellular therapy recipients based on the rapidly developing literature. As the therapeutic and supportive care interventions for COVID-19 expand, collaboration with clinical pharmacy providers is critical to ensure safe administration in HCT recipients. Attention to drug-drug interactions (DDIs) and toxicity, particularly QTc prolongation, warrants close cardiac monitoring and potential cessation of concomitant QTc-prolonging agents. Expanded indications for hydroxychloroquine and tocilizumab have already caused stress on the usual supply chain. Detailed prescribing algorithms, decision pathways, and specific patient population stock may be necessary. The COVID-19 pandemic has challenged all members of the healthcare team, and we must continue to remain vigilant in providing pharmacy clinical services to one of the most high-risk patient populations while also remaining committed to providing compassionate and safe care for patients undergoing HCT and cellular therapies.

Mobile Health Technology for Pediatric Symptom Monitoring: A Feasibility Study.

BACKGROUND: Pediatric blood and marrow transplant (PBMT) patients experience significant symptom distress. Mobile health (mHealth) technologies can be leveraged to improve understanding of the patient's symptom experience by providing continuous, real-time, in situ, patient-generated symptom data. This rich data stream can subsequently enhance symptom management strategies. However, limited research has been conducted in this area. OBJECTIVES: This pilot study seeks to (a) explore the feasibility of integrating mHealth technologies to monitor symptom data for PBMT patients and (b) evaluate the study design, measures, and procedures. METHODS: An exploratory longitudinal design was employed to assess the feasibility of monitoring 10 PBMT patients' symptoms using data from two mHealth technologies: (a) a smartphone mHealth application (app) to collect symptom data and (b) a wearable tracking device (Apple watch) to collect physiological data. Feasibility was measured as usability and acceptability. Monthly patient interviews and an end-of-study feasibility survey were employed and analyzed to further understand reasons for sustained interest in and attrition from the study. RESULTS: Overall usability of the wearable was 51%, and app was 56%. Children reported devices were easy to use and acceptable. The study demonstrated acceptability with an enrollment rate of 83% and an attrition rate of 30%, with 70% of the children remaining in the study for at least 40 days. DISCUSSION: This pilot study is among the first to explore the feasibility of using mobile technologies to longitudinally obtain patient-generated symptom data to enhance understanding of the PBMT symptom experience. In addition, it will improve our understanding of how these data present, interact, and cluster together throughout the posttransplant period.

Selecting Mobile Health Technologies for Electronic Health Record Integration: Case Study.

Mobile health (mHealth) technologies, such as wearable devices and sensors that can be placed in the home, allow for the capture of physiologic, behavioral, and environmental data from patients between clinic visits. The inclusion of these data in the medical record may benefit patients and providers. Most health systems now have electronic health records (EHRs), and the ability to pull and send data to and from mobile devices via smartphones and other methods is increasing; however, many challenges exist in the evaluation and selection of devices to integrate to meet the needs of diverse patients with a range of clinical needs. We present a case report that describes a method that our health system uses, guided by a telehealth model to evaluate the selection of devices for EHR integration.

Caring for Children With Medical Complexity With the Emergency Information Form.

BACKGROUND AND OBJECTIVE: The American Academy of Pediatrics recommends an emergency information form (EIF) for children with medical complexity (CMC) to facilitate emergency care. We sought to increase the EIF completion rate at our children's hospital's CMC clinic and to evaluate the effect on caregiver and emergency department (ED) provider opinion of preparation, comfort, and communication. METHODS: We used a pre/post-quality improvement design. The main outcomes were (1) the proportion of completed EIFs and (2) caregiver and ED provider opinion of preparation, comfort, and communication, using a Likert scale survey (1, low; 5, high). RESULTS: Emergency information form completion increased from 3.1% (4/133) before the intervention to 47.0% (78/166) after (P < 0.001). Twenty-three providers completed presurveys, and 8 completed postsurveys. Seventy-two caregivers completed presurveys, and 38 completed postsurveys (25 with ED visit and 13 without). There were no changes in preparation, comfort, or communication for caregivers who had an ED visit after the intervention. For those without a postintervention ED visit, caregiver median scores rose for preparation (4 [interquartile range {IQR}, 3-5] vs 5 [IQR, 4-5], P = 0.02) and comfort (4 [IQR, 2.25-5] vs 5 [IQR, 4-5], P = 0.05). After the intervention, ED providers had increased median communication scores (3 [IQR, 2.75-4.25] vs 5 [IQR, 4-5], P = 0.02), whereas scores of preparation and comfort were unchanged. CONCLUSION: A quality improvement project at a CMC clinic increased EIF completion, caregiver preparation and comfort, and ED provider communication in emergencies.

A Protocol to Assess Feasibility, Acceptability, and Usability of Mobile Technology for Symptom Management in Pediatric Transplant Patients.

BACKGROUND: Pediatric blood and marrow transplant (PBMT) patients experience significant symptom distress, and the use of mobile health (mHealth) technologies may enhance symptom management by providing patient-generated health data to foster personalized health strategies. OBJECTIVES: The aim of this study was to present a study protocol to explore feasibility, acceptability, and usability of integrating mHealth technologies to collect and monitor symptom data for PBMT patients. METHODS: An exploratory mixed-methods design is employed for 20 PBMT patients to monitor symptoms using real-time data from two mHealth devices: (a) a self-developed mHealth application and (b) a wearable tracking device. Patient-Reported Outcomes Measurement Information System surveys for fatigue, pain, and sleep disturbance are obtained monthly. Interviews are conducted to obtain further feasibility and usability data. RESULTS: The study began in October 2017; data collection should be completed in 2018. Feasibility and usability results to monitor and record symptom-related data daily via mobile devices will be reported. Patient-Reported Outcomes Measurement Information System surveys and interviews will further explore patients' symptoms and experiences with the mobile devices. DISCUSSION: This study will be among the first to explore the feasibility, acceptability, and usability of integrating multiple mHealth technologies to obtain patient-generated symptom data for the PBMT population. Results will enhance our understanding of how these data present, interact, and cluster together throughout the posttransplant period for these children and lead to symptom management strategies. Results will focus on a high-risk population that potentially stands to benefit from the use of mobile technologies.

A randomized phase II trial of MOVING ON: An intervention to increase exercise outcome expectations among breast cancer survivors.

OBJECTIVE: The objective of the study is to test theoretical intervention fidelity and feasibility of MOVING ON, a self-directed, home-based, randomized controlled trial to increase exercise outcome expectations (OEs) (what one expects to obtain or avoid as a result of a behavior or lack thereof), among breast cancer survivors. METHOD: Stage Ia to IIb survivors (n = 60) were given the MOVING ON intervention or control booklet. Data were collected through online surveys and an accelerometer at baseline, 4, 8, and 12 weeks postintervention. Fidelity was measured by questions assessing participant perceptions of MOVING ON (score ≥2) and direction of intervention effects. Feasibility was measured by recruitment rate (target of 60 participants in 6 months), retention (total attrition <17%), and acquisition of accelerometer data (% ≥subjective exercise data obtained). Analyses consisted of descriptive statistics, mixed models, and content analysis. RESULTS: Fidelity met a priori criteria (mean = 3.31, SD = 0.87). Outcome expectations increased 0.01 points, and weekly steps increased by 970 every 4 weeks in the intervention arm compared to the control arm. All effect sizes were small, ranging from 0.01 to 0.09. Target enrollment, achieved in 17 weeks, met a priori feasibility criteria. Retention (66%) and accelerometer data acquisition (60%) (compared to 73% of subjective exercise data) did not. CONCLUSION: MOVING ON influenced OEs as intended and was well received by participants. A fully powered study, of this low-cost, easy-to-implement intervention, is warranted. Intervention and measurement strategies used in MOVING ON can be incorporated in any study targeting OEs as a mediator of exercise or collecting exercise data with an accelerometer.

Customization of the TRU-PBMT App (Technology Recordings to better Understand Pediatric Blood and Marrow Transplant).

PURPOSE: Our investigative team is integrating mobile health technologies into pediatric blood and marrow transplant (PBMT) care. We aim to evaluate whether patient-generated health data can be used to monitor health status and enhance symptom management. While there are numerous health-related apps, none address the symptoms or care needs specific to PBMT patients. This article describes development of the Technology Recording to better Understand Pediatric Blood and Marrow Transplant (TRU-PBMT) mobile application. DESIGN AND METHODS: A one-time survey was distributed to PBMT clinicians, caregivers, and outpatients to elicit feedback and suggestions for the app's design. RESULTS: Feedback from clinicians (n = 23), caregivers (n = 5), and PBMT outpatients (n = 4) indicated the app would be acceptable and useable with this group of patients between eight and eighteen years of age. Suggestions from respondents included: making the app language and graphics more child-friendly; adding symptoms such as fatigue, mucositis, bleeding; and a visual stool chart. CONCLUSION: Patient, caregiver, and clinician feedback was valuable in creation of the TRU-PBMT app. We designed a pediatric friendly, PBMT-symptom-specific app, which we will test in future studies. IMPLICATIONS FOR PRACTICE: This app facilitates patient-generated health data collection and informs health care plans.

The Impact of Interventions that Integrate Accelerometers on Physical Activity and Weight Loss: A Systematic Review.

BACKGROUND: Regular physical activity is important for improving and maintaining health, but sedentary behavior is difficult to change. Providing objective, real-time feedback on physical activity with wearable motion-sensing technologies (activity monitors) may be a promising, scalable strategy to increase physical activity or decrease weight. PURPOSE: We synthesized the literature on the use of wearable activity monitors for improving physical activity and weight-related outcomes and evaluated moderating factors that may have an impact on effectiveness. METHODS: We searched five databases from January 2000 to January 2015 for peer-reviewed, English-language randomized controlled trials among adults. Random-effects models were used to produce standardized mean differences (SMDs) for physical activity outcomes and mean differences (MDs) for weight outcomes. Heterogeneity was measured with I 2. RESULTS: Fourteen trials (2972 total participants) met eligibility criteria; accelerometers were used in all trials. Twelve trials examined accelerometer interventions for increasing physical activity. A small significant effect was found for increasing physical activity (SMD 0.26; 95 % CI 0.04 to 0.49; I 2 = 64.7 %). Intervention duration was the only moderator found to significantly explain high heterogeneity for physical activity. Eleven trials examined the effects of accelerometer interventions on weight. Pooled estimates showed a small significant effect for weight loss (MD -1.65 kg; 95 % CI -3.03 to -0.28; I 2 = 81 %), and no moderators were significant. CONCLUSIONS: Accelerometers demonstrated small positive effects on physical activity and weight loss. The small sample sizes with moderate to high heterogeneity in the current studies limit the conclusions that may be drawn. Future studies should focus on how best to integrate accelerometers with other strategies to increase physical activity and weight loss.

Polymerase Interactions with Wobble Mismatches in Synthetic Genetic Systems and Their Evolutionary Implications.

In addition to completing the Watson-Crick nucleobase matching "concept" (big pairs with small, hydrogen bond donors pair with hydrogen bond acceptors), artificially expanded genetic information systems (AEGIS) also challenge DNA polymerases with a complete set of mismatches, including wobble mismatches. Here, we explore wobble mismatches with AEGIS with DNA polymerase 1 from Escherichia coli. Remarkably, we find that the polymerase tolerates an AEGIS:standard wobble that has the same geometry as the G:T wobble that polymerases have evolved to exclude but excludes a wobble geometry that polymerases have never encountered in natural history. These results suggest certain limits to "structural analogy" and "evolutionary guidance" as tools to help synthetic biologists expand DNA alphabets.

Feasibility and Smokers' Evaluation of Self-Generated Text Messages to Promote Quitting.

INTRODUCTION: Cigarette smoking is a leading cause of preventable mortality. Mobile technologies, including text messaging, provide opportunities to promote quitting. Many text messaging-based cessation interventions contain content created by experts. However, smokers may be best persuaded by receipt of text messages they created based on their reasons for quitting, assisted or not by a motivational facilitator. This study assessed the feasibility and participants' evaluation of two ways to self-generate smoking cessation messages delivered via cell-phone. METHODS: We enrolled smokers (N = 24) and randomized them to: (1) behavioral counseling assistance plus self-generated messages, or (2) self-generated messages only. Both groups wrote: (1) their reasons for wanting to quit and then (2) text messages related to their reason(s) for quitting, Messages were delivered as text messages as well as with a link to verbatim self-recorded audio message for 10 days. At follow-up, participants evaluated the intervention. RESULTS: Participants composed and recorded messages and evaluated them and the intervention favorably. The counseling+message group wrote an average of 7.66 (SD = 4.86) text messages while the message-only wrote an average of 6.66 (SD = 2.93) messages. Most participants felt that the messages were of appropriate length, including the frequency and timing of message delivery. CONCLUSION: It is feasible for smokers to self-generate motivational text and audio messages concerning reasons for quitting, even among smokers without an immediate desire to quit. Participants evaluated the messages and intervention favorably. Future research should test self-generated messages in larger trials of self- versus expert-generated message. IMPLICATIONS: This study assessed the feasibility and participants' evaluation of two ways to self-generate smoking cessation messages delivered via cell-phone. It is feasible for smokers to self-generate motivational text and audio messages concerning reasons for quitting, even among smokers without an immediate desire to quit. Participants evaluated the messages and intervention favorable. Future research should test self-generated messages in larger trials of self- versus expert-generated messages.

Piloting Augmented Reality Technology to Enhance Realism in Clinical Simulation.

We describe a pilot study that incorporated an innovative hybrid simulation designed to increase the perception of realism in a high-fidelity simulation. Prelicensure students (N = 12) cared for a manikin in a simulation lab scenario wearing Google Glass, a wearable head device that projected video into the students' field of vision. Students reported that the simulation gave them confidence that they were developing skills and knowledge to perform necessary tasks in a clinical setting and that they met the learning objectives of the simulation. The video combined visual images and cues seen in a real patient and created a sense of realism the manikin alone could not provide.