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.

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.

A Glycemia Risk Index (GRI) of Hypoglycemia and Hyperglycemia for Continuous Glucose Monitoring Validated by Clinician Ratings

BACKGROUND

A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data.

METHODS

We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation.

RESULTS

The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals.

CONCLUSION

The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.

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.

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.

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-After Study (Preprint)

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.

Effect of ICT-Based Self-Management System DialBeticsLite on Treating Abdominal Obesity in the Specific Health Guidance in Japan: Randomized Controlled Trial. (Preprint)

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

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.

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.

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.

P3735Incidence of bicuspid aortic valve in 16,185 neonates by echocardiographic screening in a single institution: is it really congenial?

Background

Bicuspid aortic valve (BAV) has been reported to be the most common congenital heart disease with an incidence of 1 to 2% in the general population; however, its incidence in neonates is still unclear because most of the reported incidence data are based on surgical or autopsy cases in adults.

Purpose

To elucidate the true incidence of congenital isolated BAV in neonates by echocardiographic screening in a population-based study.

Methods

We examined a total of 16,185 full-term neonates (male, 48.9%) born in our institution during either of the following two periods: September 1986 to February 2008 and October 2014 to September 2017. Mean gestational age (range) was 39.4 (36 to 42) weeks, and mean birth weight (range) was 3075 (2268 to 4622) g. On the second day after birth, we performed echocardiography and colour-Doppler flow mapping in all subjects. BAV was classified into two types on the basis of morphologicfindings in the parasternal short axis view of the aortic valve: BAV with raphe harbouring two cusps and commissures, showing a congenital fusion of two underdeveloped cusps, and BAV without raphe, showing a fish mouth appearance in systolic images. BAV associated with other congenital heart diseases such as coarctation of the aorta was excluded from this study.

Results

BAV was identified in 14 neonates (0.09%), an incidence of 0.9 in 1,000 live births. Of the 14 BAV neonates, five had BAV with raphe, whereas nine had BAV without raphe. Of the five BAV neonates with raphe, four had fusion of the right and noncoronary cusps, whereas one had that of the right and left coronary cusps. No aortic regurgitation was detected except trivial one in only one neonate, and no significant valvar stenosis was detected.

Conclusion

The incidence of BAV in neonates was much lower than previously reported incidence data. An acquired fusion of the cusps may develop in later life, and eventually may result in increased incidence of functional BAV.

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.

Response to Comment on “Ghost cytometry”

Di Carlo et al . comment that our original results were insufficient to prove that the ghost cytometry technique is performing a morphologic analysis of cells in flow. We emphasize that the technique is primarily intended to acquire and classify morphological information of cells in a computationally efficient manner without reconstructing images. We provide additional supporting information, including images reconstructed from the compressive waveforms and a discussion of current and future throughput potentials.

Effect of Sympatholytic Therapy on Circadian Cardiac Autonomic Activity in Non-Diabetic Chronic Kidney Disease

Although beta-blockade itself is not a first choice for chronic kidney disease (CKD) patients, alpha-beta-blockers (ABB) do improve their prognoses. This study's aim was to evaluate the effect of beta-selective-blockers (BSB) and ABB on circadian cardiac autonomic activity in CKD patients.The study consisted of 496 non-diabetic individuals who underwent 24-hour Holter monitoring (149 CKD patients and 347 controls without CKD). Using heart rate variability analysis, we evaluated the proportion of NN50 and the high-frequency component (reflecting parasympathetic activity), and low- to high-frequency ratio (reflecting sympathovagal balance). These indices were evaluated by regression analysis incorporating gender, age, related comorbidities, and medications. BSB increased vagal activity only in the day-time and not the night-time in controls. In CKD patients, BSB was significantly related to higher vagal activity throughout the day and with lower sympathovagal balance at night. The night sympathovagal balance of CKD patients taking ABB was significantly higher than that of CKD patients taking BSB, which was the only significant difference between the effects of BSB and ABB.The sympatholytic therapy effect is different depending on CKD presence and whether patients are treated with BSB or ABB. In CKD patients without severe heart failure, BSB could be associated with higher parasympathetic activity and lower sympathovagal balance compared to ABB.

Ghost cytometry

Ghost imaging is a technique used to produce an object's image without using a spatially resolving detector. Here we develop a technique we term "ghost cytometry," an image-free ultrafast fluorescence "imaging" cytometry based on a single-pixel detector. Spatial information obtained from the motion of cells relative to a static randomly patterned optical structure is compressively converted into signals that arrive sequentially at a single-pixel detector. Combinatorial use of the temporal waveform with the intensity distribution of the random pattern allows us to computationally reconstruct cell morphology. More importantly, we show that applying machine-learning methods directly on the compressed waveforms without image reconstruction enables efficient image-free morphology-based cytometry. Despite a compact and inexpensive instrumentation, image-free ghost cytometry achieves accurate and high-throughput cell classification and selective sorting on the basis of cell morphology without a specific biomarker, both of which have been challenging to accomplish using conventional flow cytometers.

Design of and rationale for the Japan Diabetes compREhensive database project based on an Advanced electronic Medical record System (J-DREAMS)

The "Japan Diabetes compREhensive database project based on an Advanced electronic Medical record System" is a registry of patients with diabetes in Japan. The characteristics of this registry include a clinical information input process using the template function of an electronic medical record (EMR) system [the standard diabetes management template (SDMT)], a standardized exchangeable information storage format [the Standardized Structured Medical Information eXchange 2 (SS-MIX2)], and a secure and efficient information extraction process [Multipurpose Clinical Data Repository System (MCDRS)]. Together, these characteristics enable efficient data input during routine patient consultations, efficient and exact data extraction from each facility, and the integration of data across different facilities even though these data were generated by EMR systems from different vendors. The SDMT collects clinical information including the type of diabetes, body height and weight, blood pressure, lifestyle, and comorbidities. Completing this template triggers the automatic collection of other information such as fundamental information (sex, year and month of birth, and facility), prescription information, and laboratory examination results. As the information from every routine consultation is saved with an anonymized patient ID, linked data can be used as panel data allowing longitudinal investigations. The data obtained from the registry will allow analyses, for exmaple, mortality and morbidity risk, by various characteristics or drug types and may reveal unmet needs that inform future diabetes care.

Testing the Feasibility and Usability of a Novel Smartphone-Based Self-Management Support System for Dialysis Patients: A Pilot Study

Background

Diet and fluid restrictions that need continuous self-management are among the most difficult aspects of dialysis treatment. Smartphone applications may be useful for supporting self-management.

Objective

Our objective is to investigate the feasibility and usability of a novel smartphone-based self-management support system for dialysis patients.

Methods

We developed the Self-Management and Recording System for Dialysis (SMART-D), which supports self-monitoring of three mortality-related factors that can be modified by lifestyle: interdialytic weight gain and predialysis serum potassium and phosphorus concentrations. Data is displayed graphically, with all data evaluated automatically to determine whether they achieve the values suggested by the Japanese Society for Dialysis Therapy guidelines. In a pilot study, 9 dialysis patients used SMART-D system for 2 weeks. A total of 7 of them completed questionnaires rating their assessment of SMART-D’s usability and their satisfaction with the system. In addition, the Kidney Disease Quality of Life scale was compared before and after the study period.

Results

All 9 participants were able to use SMART-D with no major problems. Completion rates for body weight, pre- and postdialysis weight, and serum potassium and phosphorus concentrations were, respectively, 89% (SD 23), 95% (SD 7), and 78% (SD 44). Of the 7 participants who completed the usability survey, all were motivated by the sense of security derived from using the system, and 6 of the 7 (86%) reported that using SMART-D helped improve their lifestyle and self-management.

Conclusions

Using SMART-D was feasible, and the system was well regarded by patients. Further study with larger scale cohorts and longer study and follow-up periods is needed to evaluate the effects of SMART-D on clinical outcomes and quality of life.

Previous dropout from diabetic care as a predictor of patients' willingness to use mobile applications for self-management: A cross-sectional study

Aims/Introduction

Preventing dropout is crucial in managing diabetes. Accordingly, we investigated whether patients who had dropped out of diabetic care are suitable candidates for the use of mobile technologies – such as smartphone applications – to support self‐management (mHealth), which might help prevent dropout.

Materials and Methods

We carried out a cross‐sectional study in Tokyo, Japan. Patients aged 20 years or older who were clinically diagnosed as diabetic and who regularly visited the outpatient unit at the University of Tokyo Hospital were recruited between August 2014 and March 2015. Data were collected through face‐to‐face structured interviews, physical measurements and medical records. Participants were asked whether they were willing to use mHealth after being shown DialBetics – an mHealth application for diabetics – as an example, and about their history of dropout and previous mHealth experience. Data were analyzed by multivariate logistic regression models.

Results

Of 307 patients with type 1 and type 2 diabetes, 34 (11.1%) had previously dropped out from diabetic care. Multivariate analysis identified previous mHealth experience as a negative predictor of dropout (odds ratio 0.211, P = 0.023). Of those 34 patients, 27 (79.4%) expressed willingness to use mHealth, a significantly higher percentage than for those who had never dropped out (51.5%, P = 0.002). After adjusting for confounders, history of dropout remained a strong predictor of willingness (odds ratio 3.870, P = 0.004).

Conclusions

Patients who previously dropped out of diabetic care are suitable candidates for mHealth. Future studies must evaluate whether mHealth is effective for preventing repeated dropout and improving glycemic control among this population.

Manganese dioxide nanowires on carbon nanofiber frameworks for efficient electrochemical device electrodes

Hierarchically nanostructured composite electrodes were prepared by the electrodeposition of manganese dioxide nanowires (MnO₂ NWs) with 5–20 nm diameters on electrospun carbon nanofiber (CNF) webs with diameters of 250 and 650 nm.

Willingness of patients with diabetes to use an ICT-based self-management tool: a cross-sectional study

OBJECTIVES

To examine the prevalence of the willingness of patients with diabetes to use a self-management tool based on information and communication technology (ICT) such as personal computers, smartphones, and mobile phones; and to examine the patient characteristics associated with that willingness.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional interview survey of 312 adults with diabetes at a university hospital in an urban area in Japan. Participants were classified into 2 groups: those who were willing to use an ICT-based self-management tool and those who were unwilling. Multiple logistic regression analysis was used to identify factors associated with the willingness, including clinical and social factors, current use of ICT, self-management practices, self-efficacy, and diabetes-related emotional distress.

RESULTS

The mean age of the 312 participants was 66.3 years (SD=11.5) and 198 (63%) were male. Most of the participants (93%) had type 2 diabetes. Although only 51 (16%) currently used ICT-based self-management tools, a total of 157 (50%) expressed the willingness to use such a tool. Factors associated with the willingness included: not having nephropathy (OR=2.02, 95% CI 1.14 to 3.58); outpatient visits once a month or more (vs less than once a month, OR=2.13, 95% CI 1.13 to 3.99); current use of personal computers and/or smartphones (OR=4.91, 95% CI 2.69 to 8.98); and having greater diabetes-related emotional distress (OR=1.10, 95% CI 1.01 to 1.20).

CONCLUSIONS

Approximately half of the patients showed interest in using an ICT-based self-management tool. Willing patients may expect ICT-based self-management tools to complement outpatient visits and to make self-management easier. Starting with patients who display the willingness factors might optimize programs based on such tools.

Machine-Learning-Based Prediction of a Missed Scheduled Clinical Appointment by Patients With Diabetes

BACKGROUND

About 10% of patients with diabetes discontinue treatment, resulting in the progression of diabetes-related complications and reduced quality of life.

OBJECTIVE

The objective was to predict a missed clinical appointment (MA), which can lead to discontinued treatment for diabetes patients.

METHODS

A machine-learning algorithm was used to build a logistic regression model for MA predictions, with L2-norm regularization used to avoid over-fitting and 10-fold cross validation used to evaluate prediction performance. Data associated with patient MAs were extracted from electronic medical records and classified into two groups: one related to patients' clinical condition (X1) and the other related to previous findings (X2). The records used were those of the University of Tokyo Hospital, and they included the history of 16 026 clinical appointments scheduled by 879 patients whose initial clinical visit had been made after January 1, 2004, who had diagnostic codes indicating diabetes, and whose HbA1c had been tested within 3 months after their initial visit. Records between April 1, 2011, and June 30, 2014, were inspected for a history of MAs.

RESULTS

The best predictor of MAs proved to be X1 + X2 (AUC = 0.958); precision and recall rates were, respectively, 0.757 and 0.659. Among all the appointment data, the day of the week when an appointment was made was most strongly associated with MA predictions (weight = 2.22).

CONCLUSIONS

Our findings may provide information to help clinicians make timely interventions to avoid MAs.

Validating the use of photos to measure dietary intake: the method used by DialBetics, a smartphone-based self-management system for diabetes patients

Background

The accuracy of estimating nutritional intake and balance from photos of meals has not been well documented. However, DialBetics (DB)-our diabetes self-management support system, which is based on information and communication technologies-relies on the photos that type 2 diabetes patients take of their meals with smartphones. Therefore, we designed a study to evaluate this accuracy.

Methods

We prepared 61 dishes whose actual amount/value of total energy and each nutrient were known: protein, fat, carbohydrates, dietary fiber and salt. Their balance-the protein-fat-carbohydrate ratio-was also known, constituting the weighed food record (WFR). Smartphone photos of those dishes were taken, and three registered dietitians evaluated each dish from those photos, naming the dish and estimating the amount of each nutrient in it, plus the dish's balance. These estimated DB and WFR values were compared using the Wilcoxon matched-pairs rank-sum test; intraclass correlation coefficients (ICCs) were calculated. Agreement between the two values for each dish was assessed by Bland-Altman analysis.

Results

There were significant ICCs-0.84 for fat (95 % confidence interval 0.75-0.90) and 0.93 for carbohydrates (0.88, 0.96)-but no statistically significant differences between DB and WRF for other nutrients or balance. Bland-Altman analysis showed that differences between the two values were random and not biased against nutrient intake; 95 % limits of agreement were acceptable although wide (energy -198 to 210 kcal/dish; carbohydrates -22.7 to 25.8 g/dish).

Conclusion

DB's diet evaluation by photos is reliable with apparent potential for assessing diets.

DialBetics With a Multimedia Food Recording Tool, FoodLog: Smartphone-Based Self-Management for Type 2 Diabetes

BACKGROUND

Diabetes self-management education is an essential element of diabetes care. Systems based on information and communication technology (ICT) for supporting lifestyle modification and self-management of diabetes are promising tools for helping patients better cope with diabetes. An earlier study had determined that diet improved and HbA1c declined for the patients who had used DialBetics during a 3-month randomized clinical trial. The objective of the current study was to test a more patient-friendly version of DialBetics, whose development was based on the original participants' feedback about the previous version of DialBetics.

METHOD

DialBetics comprises 4 modules: data transmission, evaluation, exercise input, and food recording and dietary evaluation. Food recording uses a multimedia food record, FoodLog. A 1-week pilot study was designed to determine if usability and compliance improved over the previous version, especially with the new meal-input function.

RESULTS

In the earlier 3-month, diet-evaluation study, HbA1c had declined a significant 0.4% among those who used DialBetics compared with the control group. In the current 1-week study, input of meal photos was higher than with the previous version (84.8 ± 13.2% vs 77.1% ± 35.1% in the first 2 weeks of the 3-month trial). Interviews after the 1-week study showed that 4 of the 5 participants thought the meal-input function improved; the fifth found input easier, but did not consider the result an improvement.

CONCLUSIONS

DialBetics with FoodLog was shown to be an effective and convenient tool, its new meal-photo input function helping provide patients with real-time support for diet modification.

Long-Term Pancreas Allograft Survival in Simultaneous Pancreas-Kidney Transplantation by Era

Data collected by the United Network for Organ Sharing from all approved United States transplant programs were analyzed; the data included 20,290 adult diabetic patients who received primary pancreas transplants between October 1987 and December 2014. Simultaneous pancreas-kidney (SPK) transplantation has become the major therapeutic option for diabetes patients. The number of SPKs per year has not increased since 1999; it leveled off or decreased slightly each year. Recipients in the most recent period, 2010-2014, were more likely than recipients in any of the other periods to be non-white, older, male, to have had diabetes longer, to have higher body mass indices; and in this group there were more donor-recipient human leukocyte antigen mismatches. Donors in the 2010-2014 period were more likely to be younger and male and less likely to be white. Pancreas graft survival rates were highest in the 2010-2014 period (one-year graft survival 89.7%) vs. those for 1987-1989 (74.6%), 1990- 1994 (77.5%), 1995-1999 (82.9%), 2000-2004 (84.4%), and 2005-2009 (85.5%); the five-year rates were 72.7% for 2010-14 vs. 60.0%, 64.3%, 69.0%, 70.9%, and 73.9% for the other periods, respectively. There was no decreased risk of graft failure for recent-era transplants compared with those of 1987-1989, except for those in 2005-2009. By year of transplant, the adjusted hazard ratios [with 95% confidence intervals (CI)] for overall loss of grafts surviving over one year in eras 1990-1994, 1995-1999, 2000-2004, 2005-2009, and 2010-2014 were, respectively, 0.85 (CI 0.66-1.09), 0.85 (CI 0.66- 1.09), 0.87 (CI 0.67-1.13), 0.71 (CI 0.54-0.93), and 0.86 (CI 0.64-1.15). Chronic rejection caused 44.9% of graft losses between one and five years and 51.5% after five years. There is a need for a means to identify early markers of chronic rejection-and to control it-to improve long-term survival.

Comparative Study of the Routine Daily Usability of FoodLog: A Smartphone-based Food Recording Tool Assisted by Image Retrieval

The health care field is focusing considerable attention on dietary control, which requires that individuals record what they eat. We have developed a novel smartphone application called FoodLog, a multimedia food recording tool that allows users to take photos of their meals and to produce textual food records. Unlike conventional smartphone-based food recording tools, FoodLog allows users to employ meal photos to help them to input textual descriptions based on image retrieval. In this study, we conducted usability experiments to evaluate the routine daily use of FoodLog systems with and without image-based assistance. We produced 2 food recording tools: FoodLog with image-based assistance (FL-I) and FoodLog with text input only (FL-T). We recruited 18 university students (age = 18-24 years), all of whom performed food recording for the first time. The participants used FoodLog on a daily basis for 1 month. In the subjective evaluation, FL-I had higher average scores for questions related to ease of use, fun, frequency of browsing, and intention to continue. In particular, the latter 3 factors received significantly higher scores with FL-I than with FL-T. In the quantitative evaluation, the daily average number of meal events and food records did not differ significantly between FL-I and FL-T. A detailed analysis of the individual records showed that 1 participant produced 3 times as many records using FL-I compared with FL-T. The subjective assessment showed that our new tool, which fully exploits the use of images, is a promising method for food recording.

DialBetics: A Novel Smartphone-based Self-management Support System for Type 2 Diabetes Patients

Numerous diabetes-management systems and programs for improving glycemic control to meet guideline targets have been proposed, using IT technology. But all of them allow only limited-or no-real-time interaction between patients and the system in terms of system response to patient input; few studies have effectively assessed the systems' usability and feasibility to determine how well patients understand and can adopt the technology involved. DialBetics is composed of 4 modules: (1) data transmission module, (2) evaluation module, (3) communication module, and (4) dietary evaluation module. A 3-month randomized study was designed to assess the safety and usability of a remote health-data monitoring system, and especially its impact on modifying patient lifestyles to improve diabetes self-management and, thus, clinical outcomes. Fifty-four type 2 diabetes patients were randomly divided into 2 groups, 27 in the DialBetics group and 27 in the non-DialBetics control group. HbA1c and fasting blood sugar (FBS) values declined significantly in the DialBetics group: HbA1c decreased an average of 0.4% (from 7.1 ± 1.0% to 6.7 ± 0.7%) compared with an average increase of 0.1% in the non-DialBetics group (from 7.0 ± 0.9% to 7.1 ± 1.1%) (P = .015); The DialBetics group FBS decreased an average of 5.5 mg/dl compared with a non-DialBetics group average increase of 16.9 mg/dl (P = .019). BMI improvement-although not statistically significant because of the small sample size-was greater in the DialBetics group. DialBetics was shown to be a feasible and an effective tool for improving HbA1c by providing patients with real-time support based on their measurements and inputs.

A smartphone-based medication self-management system with realtime medication monitoring

BACKGROUND

Most patients cannot remember their entire medication regimen and occasionally forget to take their medication.

OBJECTIVES

The objective of the study was to design, develop, and demonstrate the feasibility of a new type of medication self-management system using smartphones with real-time medication monitoring.

METHODS

We designed and developed a smartphone-based medication self-management system (SMSS) based on interviews of 116 patients. The system offered patients two main functions by means of smartphones: (1) storage and provision of an accurate, portable medication history and medication-taking records of patients; and (2) provision of a reminder to take medication only when the patient has forgotten to take his/her medication. These functions were realized by two data input methods: (a) reading of prescription data represented in two-dimensional barcodes using the smartphone camera and getting the photographic images of the pills; and (b) real-time medication monitoring by novel user-friendly wireless pillboxes.

RESULTS

Interviews suggested that a pocket-sized pillbox was demanded to support patient's medication-taking outside the home and pillboxes for home use should be adaptable to the different means of pillbox storage. In accordance with the result, we designed and developed SMSS. Ten patients participated in the feasibility study. In 17 out of 47 cases (36.2%), patients took their medication upon being presented with reminders by the system. Correct medication-taking occurrence was improved using this system.

CONCLUSIONS

The SMSS is acceptable to patients and has the advantage of supporting ubiquitous medication self-management using a smartphone. We believe that the proposed system is feasible and provides an innovative solution to encourage medication self-management.

Development and clinical study of mobile 12-lead electrocardiography based on cloud computing for cardiac emergency

To improve emergency services for accurate diagnosis of cardiac emergency, we developed a low-cost new mobile electrocardiography system "Cloud Cardiology®" based upon cloud computing for prehospital diagnosis. This comprises a compact 12-lead ECG unit equipped with Bluetooth and Android Smartphone with an application for transmission. Cloud server enables us to share ECG simultaneously inside and outside the hospital. We evaluated the clinical effectiveness by conducting a clinical trial with historical comparison to evaluate this system in a rapid response car in the real emergency service settings. We found that this system has an ability to shorten the onset to balloon time of patients with acute myocardial infarction, resulting in better clinical outcome. Here we propose that cloud-computing based simultaneous data sharing could be powerful solution for emergency service for cardiology, along with its significant clinical outcome.

Smoking cessation increases short-term risk of type 2 diabetes irrespective of weight gain: the Japan Public Health Center-Based Prospective Study

Objective

The effect of smoking cessation on the risk of diabetes has been reported previously. However, it is unknown whether the association is influenced by weight gain and other potential risk factors.

Methods

The Japan Public Health Center-Based Prospective Study established in 1990 for Cohort I and in 1993 for Cohort II provided data, and 25,875 men and 33,959 women were analyzed. The response rate to the baseline questionnaire was 80.9%, and 68.4% of the respondents participated both the 5- and 10-year follow-up surveys. Smoking cessation was noted during the initial five years and the development of diabetes was reported in the subsequent five years.

Results

An increased risk was observed among individuals who newly quit smoking compared with never smokers among men (odds ratio (OR) = 1.42, 95% CI = 1.03–1.94) and women (OR = 2.84, CI = 1.53–5.29). The risk of developing diabetes among male new quitters who gained 3 kg or more during the 5-year follow-up did not substantially differ from the risk among male never smokers with less than 3 kg of weight gain or no weight gain, while an increased risk was observed among male new quitters with less or no weight gain (OR = 1.46, 95%CI 1.00–2.14). An insignificant increased risk was observed among male new quitters with a family history of diabetes compared with male never smokers with a family history of diabetes. The risk was more than twice as high for male new quitters who used to smoke 25 or more cigarettes per day compared with never smokers (OR = 2.15, 95%CI: 1.34–3.47).

Discussion

An increased risk of diabetes was implied among individuals who quit smoking. However, the increased risk was not implied among those who gained weight over the 5-years of follow-up. Those who had major risk factors for diabetes or who smoked heavier had a higher risk.

Long-term pancreas allograft survival in simultaneous pancreas-kidney transplantation by era

Data collected by UNOS from all approved US transplant programs were analyzed. The analysis was based on data for 22,075 diabetic patients who received a pancreas transplant between January 1995 and December 2011. Simultaneous pancreas-kidney (SPK) transplantation was the major therapeutic option for diabetes patients. SPK had better survival than pancreas transplantation alone (PTA) or pancreas-after-kidney (PAK) transplantation. The 5-year pancreas graft survival rate for SPK, PAK, and PTA was 71.3%, 56.6%, and 53.0%, respectively. When long-term SPK pancreas graft survival was examined by transplant era, there was no survival improvement after 1995. The effect of year of transplant was estimated using Cox proportional hazard models. The 5-year pancreas graft survival rate in the eras 1995-1998, 1999-2002 and 2003-2006 were 69.2%, 69.8%, and 72.4%, respectively. For those whose graft survived over one year, the 5-year graft survival rate in those eras was 83.5%, 83.4%, and 85.2%, respectively. The adjusted hazard ratio for overall graft loss by year of transplant for the grafts that survived more than one year in the eras 1999-2002 and 2003-2006 was 1.08 (95% confidence interval [CI], 0.94-1.24) and 0.95 (95% CI, 0.82-1.11), respectively. The survival rate of long-term pancreas grafts remained almost unchanged over time.

Factors affecting operational tolerance after pediatric living-donor liver transplantation: impact of early post-transplant events and HLA match

Pediatric recipients of living-donor liver transplants (LDLT) can often discontinue immunosuppression (IS). We examined factors affecting development of operational tolerance (OT), defined as off IS for >1 year, in this population. A historic cohort analysis was conducted in 134 pediatric primary semi-allogeneic LDLT. Multivariate logistic regression analysis was used. The frequency of peripheral regulatory T cells (Tregs) was determined at >10 years post-Tx by FACS analysis. IS was successfully discontinued in 84 tolerant patients (Gr-tol), but not in 50 intolerant patients (Gr-intol). The Gr-intol consisted of 24 patients with rejection (Gr-rej) and 26 with fibrosis of grafts (Gr-fib). The absence of early rejection [odds ratio (OR) 2.79, 95% CI 1.11-7.02, P = 0.03], was a positive independent predictor, whereas HLA-A mismatch (0.18, 0.03-0.91, P = 0.04) was a negative predictor. HLA-DR mismatches did not affect OT. The Treg frequency was significantly decreased in Gr-intol (4.9%) compared with Gr-tol (7.6%) (P = 0.003). There were increased levels of tacrolimus in the first week in Gr-Tol (P = 0.02). Although HLA-B mismatch (8.73, 1.09-70.0, P = 0.04) was a positive independent predictor of OT, its clinical significance remains doubtful. In this large cohort of pediatric LDLT recipients, absence of early rejection, HLA-A match and the later predominance of Tregs are factors associated with OT.

IL28B polymorphism may guide pegylated interferon plus ribavirin therapy even after curative treatment for hepatitis C virus-related hepatocellular carcinoma

The present study was designed to determine the predictive factors for the viral response to pegylated interferon-alpha plus ribavirin combination therapy (PEGIFN/RBV) administered after curative treatment for hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC). The study group was 78 patients treated between January 2005 and January 2009. The sustained viral response (SVR) rate was 25.8% (15/58) in patients infected with HCV-genotype 1 and 55.0% (11/20) in those with genotype 2. Among the 78 patients, 32 (41.0%) could not complete the treatment protocol, and this was because of HCC recurrence in 17 (53%) of them. Multivariate analysis identified partial early viral response (pEVR) as the only independent determinant of SVR [odds ratio (OR) 14.73, P = 0.013] for patients with genotype 1. Multivariate analysis identified male gender (OR 8.72, P = 0.001) and interleukin-28B (IL-28B) genotype (rs8099917) TT (OR 7.93, P = 0.007) as independent predictors of pEVR. Multivariate analysis also identified IL-28B genotype GG+TG (OR 14.1, P = 0.021) and α-fetoprotein >30 (OR 5.4, P = 0.031) as independent predictors of null response. Patients with SVR showed a better survival rate than those without SVR (P = 0.034). The second HCC recurrence rate tended to be lower in patients with SVR than in those without SVR (P = 0.054). With regard to the prognosis of patients with SVR, it is desirable to achieve SVR with interferon therapy even when administered after HCC treatment. IL-28B genotype is a potentially useful marker for the response to PEGIFN/RBV therapy administered after curative treatment of HCV-related HCC.

Living-donor liver transplantation at the University of Tokyo, 1996-2011: the impact of HLA matching and a positive crossmatch on long-term survival and tolerance

OBJECTIVE

We analyzed a single center's experience during 16 years of living-donor liver transplantation (LDLT). The impacts of HLA mismatches and positive crossmatches on long term outcomes and tolerance were evaluated.

METHODS

This study was of primary LDLTs of consecutive patients from January 1996 to December 2011; re-transplants were not included. Long-term survival was compared by primary disease, number of HLA mismatches, and crossmatches. Demographics and complications after transplantation between pediatric recipients who achieved clinical operational tolerance and those who did not were compared.

RESULTS

One-year liver graft survival rates for adult and pediatric cases were 90.4% and 91.9%, respectively; the 5-year rates were 83.1% and 89.2%, respectively; the 10-year rates were 79.7% and 89.2%, respectively; and 15-year rates were 65.9% and 83.8%, respectively. For the grafts that survived more than one year, the 10-year rates for adult and pediatric cases were 88.2% and 97.0%, respectively. The 10-year rates for adult LDLT in 0 mismatches, 1-2 mismatches, 3-4 mismatches, and 5-6 mismatches were 79.2%, 86.8%, 77.4%, and 69.4%, respectively. Although the survival rates were not significantly different, the survival rates were lowest in LDLT recipients with 5-6 HLA mismatches. Ten-year liver graft survival rates for adult LDLT with negative T-cell crossmatch, and positive T-cell crossmatch were 80.0% and 71.1%, respectively. The 1-year liver graft survival rates for adult LDLT with negative B-cell crossmatch, and positive B-cell crossmatch were 90.6% and 88.2%, respectively. None of the factors--age of recipients and donors, primary disease, donor gender, relationship of donors to recipients, positive crossmatches, or number of HLA mismatches--was significantly different between COT and non-COT recipients, except for recipient gender (p = 0.01); in COT cases, there were more female recipients (88.9%) than male (11.1%). Post-transplant complications--acute rejection rate in one year post-transplant, biliary complications rate, and vascular complication rate--were not significantly different between COT and non-COT recipients.

CONCLUSIONS

High long-term survival was achieved by both adult and pediatric recipients. Even higher survival can be achieved by improving early graft loss. Further studies are necessary to determine the impact of HLA mismatches and positive crossmatches on long-term outcomes and tolerance.