Unexpected Effects of a System-Distributed Mobile Application in Maternity Care: A Randomized Controlled Trial

BACKGROUND

As pregnant mothers increasingly engage in shared decision making regarding prenatal decisions, such as induction of labor, the patient's level of activation may influence pregnancy outcomes. One potential tool to increase patient activation in the clinical setting is mobile applications. However, research is limited in comparing mobile apps with other modalities of patient education and engagement tools.

AIM

This study was designed to test the effectiveness of a mobile app as a replacement for a spiral notebook guide as a patient education and engagement tool in the prenatal clinical setting.

METHOD

This randomized controlled trial was conducted in the Women's Health Clinic and Family Health Clinic of three hospitals. Repeated-measures analysis of covariance was used to test intervention effects in the study sample of 205 patients.

RESULTS

Mothers used a mobile app interface to more frequently record information about their pregnancy; however, across time, mothers using a mobile app reported a significant decrease in patient activation.

DISCUSSION

The unexpected negative effects in the group of patients randomized to the mobile app prompt these authors to recommend that health systems pause before distributing their own version of mobile apps that may decrease patient activation.

CONCLUSION

Mobile apps can be inherently empowering and engaging, but how a system encourages their use may ultimately determine their adoption and success.

Influence of Provider Communication on Women's Delivery Expectations and Birth Experience Appraisal: A Qualitative Study

BACKGROUND AND OBJECTIVES

Although current research suggests that patient-provider prenatal communication and expectation-setting affects women's outcomes, more needs to be understood about the kinds of communication experiences that shape women's expectations, the nature of expectations that women hold, and how those expectations influence their appraisal of labor and delivery. The goal of this study is to draw connections between provider communication, birth experience expectations, and birth experience appraisals.

METHODS

Recently delivered mothers (n=36) were recruited at a mid-Atlantic community hospital. Using a grounded theory approach, interviews were systematically analyzed to uncover how participants perceived provider communication during their prenatal care, how participants described their expectations of the birth experience, and how expectations affected appraisals of the experience.

RESULTS

Mothers recognize providers' use of patient-centered communication in messages of empowerment, emotional support, explanation, decision making, and elicitation. Findings posit that it is the inflexibility or flexibility of expectations that may determine mothers' appraisals of the birth experience.

CONCLUSIONS

Mothers continue to rely on providers as partners in health care. Through patient-centered communication, providers can help mothers develop flexible expectations of the birth experience, which in turn can result in positive appraisals of delivery.

Mobile application as a prenatal education and engagement tool: A randomized controlled pilot

OBJECTIVES

Research has shown that mobile applications provide a powerful alternative to traditional paper diaries; however, little data exists in comparing apps to the traditional mode of paper as a patient education and engagement tool in the clinical setting. This study was designed to compare the effectiveness of a mobile app versus a spiral-notebook guide throughout prenatal care.

METHODS

This randomized (n=173) controlled pilot was conducted at an East Coast community hospital. Chi-square and repeated-measures analysis of variance was used to test intervention effects in the sample of 127 pregnant mothers who completed their prenatal care in the healthcare system.

RESULTS

Patients who were distributed the mobile application used the tool to record information about pregnancy more frequently (p=.04) and developed greater patient activation (p=.02) than patients who were distributed notebooks. No difference was detected on interpersonal clinical communication.

CONCLUSION

A mobile application successfully activated a patient population in which self-management is a critical factor.

PRACTICE IMPLICATIONS

This study shows that mobile apps can prompt greater use and result in more activated patients. Findings may be translated to other patient populations who receive recurring care for chronic disease.

Electronic health records improve clinical note quality

BACKGROUND AND OBJECTIVE

The clinical note documents the clinician's information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes.

MATERIALS AND METHODS

A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes.

RESULTS

The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval.

CONCLUSIONS

The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

QNOTE: an instrument for measuring the quality of EHR clinical notes

BACKGROUND AND OBJECTIVE

The outpatient clinical note documents the clinician's information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole.

MATERIALS AND METHODS

Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ.

RESULTS

The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04).

CONCLUSIONS

We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.

Characterization of a Rac1 signaling pathway to cyclin D(1) expression in airway smooth muscle cells

We examined the importance of the Rho family GTPase Rac1 for cyclin D(1) promoter transcriptional activation in bovine tracheal myocytes. Overexpression of active Rac1 induced transcription from the cyclin D(1) promoter, whereas platelet-derived growth factor (PDGF)-induced transcription was inhibited by a dominant-negative allele of Rac1, suggesting that Rac1 functions as an upstream activator of cyclin D(1) in this system. Rac1 forms part of the NADPH oxidase complex that generates reactive oxygen species such as H(2)O(2). PDGF stimulated a substantial increase in intracellular reactive oxygen species, as measured by the fluorescence of dichlorofluorescein-loaded cells, and this was blocked by the glutathione peroxidase mimetic ebselen. Pretreatment with ebselen, catalase, and the flavoprotein inhibitor diphenylene iodonium each attenuated PDGF- and Rac1-mediated cyclin D(1) promoter activation, while having no effect on the induction of cyclin D(1) by mitogen-activated protein kinase/extracellular signal-regulated kinase (ERK) kinase-1 (MEK1), the upstream activator of ERKs. Antioxidant treatment also inhibited PDGF-induced cyclin D(1) protein expression and DNA synthesis. Overexpression of an N-terminal fragment of p67(phox), a component of NADPH oxidase which interacts with Rac1, attenuated PDGF-induced cyclin D(1) promoter activity, whereas overexpression of the wild-type p67 did not. Finally, Rac1 was neither required nor sufficient for ERK activation. Taken together, these data suggest a model by which two distinct signaling pathways, the ERK and Rac1 pathways, positively regulate cyclin D(1) and smooth muscle growth.

Medical clinic referral letters. Do they say what they mean? Do they mean what they say?

Consecutive general practitioner referrals to three general medical clinics were examined prospectively to assess whether the reason for referral was being correctly interpreted by consultants. The resultant data revealed that although this was not always the case, such misunderstandings did not appear to affect subsequent management. Explicit reasons for referral in the referral letter however could improve both the quality and value of out-patient consultations.

The importance of bicarbonate in large volume anesthetic preparations. Revisiting the tumescent formula

BACKGROUND

The tumescent local anesthetic approach is now being used more widely in dermatologic surgery. Although the original formula contains 12.5 mEq sodium bicarbonate per 50 mL of lidocaine, traditionally buffered solutions contain 1 mEq per 10 mL.

OBJECTIVE

This study examines the effects of changing the concentrations of sodium bicarbonate in the tumescent formula.

METHODS

Various concentrations of sodium bicarbonate in tumescent anesthetic preparations were measured for pH.

RESULTS

Tumescent anesthetic preparations containing 5 mEq/L have a more physiologic pH (7.41) than the classic formula of 12.5 mEq/L (7.73). Clinical use of this reduced sodium bicarbonate solution showed no difference from the original formula.

CONCLUSIONS

Sodium bicarbonate can be used in a 1 mEq per 10 mL of lidocaine ratio similar to other buffered anesthetic solutions. This solution is physiologic in pH. However, some thought should also be given to the pKa of lidocaine, which is at pH 7.9. To achieve this even higher concentration (20 mEq/L) bicarbonate must be added to the tumescent solution. Thought must be given to these concepts when tumescent solutions are used in large volumes.

Differential expression of adenine nucleotide translocator isoforms in mammalian tissues and during muscle cell differentiation

The adenine nucleotide translocator (ANT) catalyzes the exchange of ADP and ATP across the mitochondrial internal membrane. Its three isoforms, ANT1, ANT2, and ANT3 are coded by differentially regulated nuclear genes. The patterns of expression of these genes in human, bovine, and mouse tissue are similar. ANT1 is highly expressed in heart and skeletal muscle and is induced during myoblast differentiation. It is coordinately regulated with the nuclear gene for the mitochondrial ATP synthase beta subunit, with which it shares the positive muscle cis element, the OXBOX. ANT2 is either absent or weakly expressed in all tissues. ANT3 is ubiquitously expressed in all tissues, and its transcript level is proportional to the level of oxidative metabolism. The tissue-specific expression of the ANT gene family thus provides insight into the molecular basis of the differential reliance of mammalian tissues on oxidative phosphorylation.

Southeast Asian mitochondrial DNA analysis reveals genetic continuity of ancient mongoloid migrations

Human mitochondrial DNAs (mtDNAs) from 153 independent samples encompassing seven Asian populations were surveyed for sequence variation using the polymerase chain reaction (PCR), restriction endonuclease analysis and oligonucleotide hybridization. All Asian populations were found to share two ancient AluI/DdeI polymorphisms at nps 10394 and 10397 and to be genetically similar indicating that they share a common ancestry. The greatest mtDNA diversity and the highest frequency of mtDNAs with HpaI/HincII morph 1 were observed in the Vietnamese suggesting a Southern Mongoloid origin of Asians. Remnants of the founding populations of Papua New Guinea (PNG) were found in Malaysia, and a marked frequency cline for the COII/tRNA(Lys) intergenic deletion was observed along coastal Asia. Phylogenetic analysis indicates that both insertion and deletion mutations in the COII/tRNA(Lys) region have occurred more than once.

Radio aid to ships at sea

OBJECTIVE

To review the first 30 months' experience in providing medical advice by radio to the masters of vessels in the Indian and Southern Oceans. The Department of Emergency Medicine at Fremantle Hospital has provided this service since October 1987.

DESIGN

Details of all cases were collected prospectively.

SETTING

The master of the ship communicates with the senior medical staff in the Department of Emergency Medicine by telex or radio-telephone.

RESULTS

Seventy-five patients were discussed in 30 months. They were aboard 68 ships from 17 nations. Forty-eight patients has spontaneous illnesses, of which 41 were classified as medical and 7 surgical. Twenty-seven patients sustained injury. The most frequent medications advised by the doctor were analgesics and antibiotics. In 12% of cases, the doctor recommended that the ship change course significantly in order to discharge the patient to medical care. In another 11% of cases the patient was discharged at an unscheduled but nearby port, although not all of these diversions were urgent.

CONCLUSIONS

Despite the difficulties in assessing a patient one cannot see, most illnesses can be diagnosed with a reasonable degree of certainty and useful treatment can be instituted aboard ship. Improving communication systems make the task easier, but variation in the contents of the pharmaceutical cabinets aboard ships is a problem.

Alpha 1-antitrypsin deficiency-associated panniculitis: case report and review of the literature

Alpha 1-antitrypsin is the primary serum proteinase inhibitor. Alpha 1-antitrypsin deficiency, especially the ZZ genotype, has been linked mainly to emphysema and cirrhosis; it is also associated with paniculitis. A case of alpha 1-AT-associated panniculitis was documented in a 13-year-old girl in whom a deficiency of the enzyme was known to be present from infancy. This is unusual, since alpha 1-AT panniculitis previously was described in older patients without prior knowledge of the duration of the deficiency. Our patient developed erythematous, subcutaneous nodules subsequent to trauma, which later developed into deep, painless ulcers. We report this case so that the condition may be suspected in patients with panniculitis. The diagnosis may be confirmed by measuring quantitative alpha 1-AT serum levels and by enzyme genotyping. The treatment of choice is dapsone.

OXBOX, a positive transcriptional element of the heart-skeletal muscle ADP/ATP translocator gene

Three positive transcriptional control regions have been identified in the promoter of the human heart-skeletal muscle adenine nucleotide translocator gene (ANT1). By transfecting promoter-chloramphenicol acetyltransferase fusion constructs into C2C12 myogenic cells, each positive region was found to increase transcription 2-3-fold. The first region spans from -123 to -674 base pairs (bp), the second from -2.6 to -3.1 kilobases, and the third from -3.1 to -8.8 kilobases. Linker-scanning mutants generated using the polymerase chain reaction and modified oligonucleotides have identified the OXBOX (5'-GGCTCTAAAGAGG) as the positive element within the -123 to -674-bp region. This element enhances transcription in muscle cells but not in HeLa cells, suggesting that it is muscle-specific. Gel retardation experiments have revealed a factor from C2C12 cells which specifically binds to a 40-bp piece of the ANT1 promoter containing the OXBOX. Since the OXBOX is also found in the promoter of the human ATP synthase beta subunit gene, it is the first tissue-specific element identified which could coordinately regulate mitochondrial oxidative phosphorylation genes.

Neoplastic transformation is associated with coordinate induction of nuclear and cytoplasmic oxidative phosphorylation genes

Neoplastic transformation was found to have a marked effect on the expression of nuclear DNA (nDNA)- and mitochondrial DNA (mtDNA)-encoded oxidative phosphorylation (OXPHOS) genes. Examining three pairs of human diploid fibroblasts and their SV 40-transformed counterparts revealed that mRNAs for the nuclear-encoded ATP synthase beta and the adenine nucleotide translocator (ANT) isoform 1 and 2 genes were markedly induced, whereas the mRNA for the ANT isoform 3 gene remained unchanged. The mRNA levels for the mtDNA-encoded 12 S rRNA, ND2, ATPase6+8, COIII, ND5+6, and Cytb genes were also increased, whereas the mtDNA number declined. Similar analysis of a cervical carcinoma (HeLa), fibrosarcoma (HT1080), and an Epstein-Barr virus (EBV)-transformed lymphoblastoid line (EBV-L) revealed that all three ANT isoforms were also expressed in these cells. Hence, changes in the expression of OXPHOS genes may be a common feature of transformed cells.

Amerindian mitochondrial DNAs have rare Asian mutations at high frequencies, suggesting they derived from four primary maternal lineages

The mitochondrial DNA (mtDNA) sequence variation of the South American Ticuna, the Central American Maya, and the North American Pima was analyzed by restriction-endonuclease digestion and oligonucleotide hybridization. The analysis revealed that Amerindian populations have high frequencies of mtDNAs containing the rare Asian RFLP HincII morph 6, a rare HaeIII site gain, and a unique AluI site gain. In addition, the Asian-specific deletion between the cytochrome c oxidase subunit II (COII) and tRNA(Lys) genes was also prevalent in both the Pima and the Maya. These data suggest that Amerindian mtDNAs derived from at least four primary maternal lineages, that new tribal-specific variants accumulated as these mtDNAs became distributed throughout the Americas, and that some genetic variation may have been lost when the progenitors of the Ticuna separated from the North and Central American populations.

A human muscle adenine nucleotide translocator gene has four exons, is located on chromosome 4, and is differentially expressed

The human heart-skeletal muscle adenine nucleotide translocator (ANT1) gene was isolated and sequenced. It spans 5.8 kilobases and contains four exons. The 5'-nontranscribed region contains typical CCAAT and TATA sequences, a 22-nucleotide pair inverted repeat and a 13-nucleotide pair sequence homologous to a similar region in the ATP synthase beta subunit gene. The region surrounding the first exon and intron is G+C-region surrounding the first exon and intron is G+C-rich, and the intron contains three Sp1 binding motifs. ANT1 was assigned to chromosome 4 using both flow-sorted chromosomes and segregating human-mouse hybrid cells. Additional ANT sequences were found on at least two other chromosomes. ANT1 transcripts were present at high levels in human heart and skeletal muscle but were almost undetectable in liver, kidney, and brain. By contrast, fibroblast ANT (ANT2) mRNAs were present in all five tissues. The unique nature and arrangement of the ANT1 transcriptional control elements may account for this differential expression.

Mitochondrial DNA mutation associated with Leber's hereditary optic neuropathy

Leber's hereditary optic neuropathy is a maternally inherited disease resulting in optic nerve degeneration and cardiac dysrhythmia. A mitochondrial DNA replacement mutation was identified that correlated with this disease in multiple families. This mutation converted a highly conserved arginine to a histidine at codon 340 in the NADH dehydrogenase subunit 4 gene and eliminated an Sfa NI site, thus providing a simple diagnostic test. This finding demonstrated that a nucleotide change in a mitochondrial DNA energy production gene can result in a neurological disease.

Familial mitochondrial encephalomyopathy (MERRF): genetic, pathophysiological, and biochemical characterization of a mitochondrial DNA disease

A large MERRF pedigree permitted the direct testing of the predictions for a mitochondrial DNA (mtDNA) mutation. A mtDNA mutation was demonstrated by proving maternal inheritance and by identifying specific deficiencies in muscle energetics and mitochondrial respiratory complexes I and IV. mtDNA heteroplasmy (a mixture of mutant and wild-type mtDNAs) was demonstrated by showing variation in the mitochondrial energetic capacity between family members. The phenotypic consequences of differential tissue-specific reliance on mitochondrial ATP was shown by correlating individual respiratory deficiency with the nature and severity of patients' clinical manifestations. The observed spectrum of clinical manifestations resulting from this heteroplasmic mtDNA mutation implies that mtDNA disease may be much more prevalent than previously anticipated.

Cell-mediated cytotoxicity expressed by lymphoid cells from rats with asbestos-induced peritoneal mesothelioma towards rat fetal cell

Cell-mediated immunity (CMI) directed towards rat fetal cells was evaluated in Fischer F344 young inbred male rats having asbestos-induced peritoneal mesothelioma. The tumors were induced by exposure to Canadian chrysotile B fibers and the CMI delineated by the injury and destruction brought about to 6- to 10-day-old primary fetal cell cultures by the so-called educated peripheral blood lymphoid-cells (PBLC) obtained from the cancer-bearing rats. A significant cytotoxicity was found to be expressed by the PBLCs, suggesting that during the development of mesothelioma, a cellular retrodifferentiation occurs, thereby educating the effectors to recognize a common determinant existing in both the tumor and fetal cells. Educated PBLCs were produced from rats having endodermal tissue cancers (adenocarcinomas of the small bowel, colon and pancreas) and were found to also be cytotoxic to the fetal cultures, yet no injury was apparently inflicted upon cultured mesothelioma target cells by these effectors. These results suggested that the tumor education was specific and that probably a unique and different fetal component was being recognized by the effector cells obtained from the rats with lesions arising either in the mesodermal or endodermal tissue. Further support for this concept was the failure of an antibody, specific to an oncofetal protein existing in endodermal lesions, to apparently recognize any common oncogenic proteins in the mesothelioma. Preliminary studies have also been accomplished which suggests the existence of natural killing immune responses existing to the mesothelioma target cells.(ABSTRACT TRUNCATED AT 250 WORDS)