the use of high-throughput pyrosequencing.2 In contrast with the findings of Bhatt et al. (Aug. 8 issue),3 we were unable to identify sequences of Bradyrhizobium enterica, but in samples of tissue obtained during active cord colitis syndrome, we noticed overgrowth of Bacteroides fragilis, which was barely detectable after successful therapy (Table 1). B. fragilis is a commensal bacterium that has been shown to induce chronic colitis in animal studies by secreting an enterotoxin.4 Our observation suggests that cord colitis syndrome is not caused by a single microbe but may reflect the overgrowth of a variety of organisms. The finding of increased levels of B. enterica in cord colitis syndrome may therefore represent a local phenomenon, since nearly all patients were treated at the same institution, as noted by the authors.1,3 Gregor Gorkiewicz, M.D. Slave Trajanoski, Ph.D. Christoph Högenauer, M.D. Medical University of Graz Graz, Austria christ[email protected] No potential conflict of interest relevant to this letter was reported.

the cord colitis syndrome could be associated with microorganisms other than B. enterica. The authors present data indicating that B. fragilis could be a cause of cord colitis syndrome in the patient. Although a clear antibioticinduced reduction in the relative abundance of B. fragilis is shown, in association with clinical remission, some additional issues could be addressed to confirm a potential causal relation. In our experience, it is important to distinguish mucosa-associated organisms from those that infect host tissue. The ability to make this distinction is affected by the choices made with regard to sample handling and processing. An approach in which frozen samples are used, as described by Gorkiewicz et al., will not necessarily restrict the analysis to tissue-residing organisms. Instead, a more complex, stool-like microbial community is expected, such as the one that is described.2 In addition, to clearly demonstrate the infection of tissue with B. fragilis or other organisms, histopathological analysis would be essential, as would follow-up with the use of fluorescence in situ hybridization and microscopy.

1. Herrera AF, Soriano G, Bellizzi AM, et al. Cord colitis syn-

Ami S. Bhatt, M.D., Ph.D.

drome in cord-blood stem-cell transplantation. N Engl J Med 2011;365:815-24. 2. Kump PK, Gröchenig HP, Lackner S, et al. Alteration of intestinal dysbiosis by fecal microbiota transplantation does not induce remission in patients with chronic active ulcerative colitis. Inflamm Bowel Dis 2013;19:2155-65. 3. Bhatt AS, Freeman SS, Herrera AF, et al. Sequence-based discovery of Bradyrhizobium enterica in cord colitis syndrome. N Engl J Med 2013;369:517-28. 4. Rhee KJ, Wu S, Wu X, et al. Induction of persistent colitis by a human commensal, enterotoxigenic Bacteroides fragilis, in wildtype C57BL/6 mice. Infect Immun 2009;77:1708-18. DOI: 10.1056/NEJMc1311318

Dana–Farber Cancer Institute Boston, MA

Francisco M. Marty, M.D. Brigham and Women’s Hospital Boston, MA

Matthew Meyerson, M.D., Ph.D. Dana–Farber Cancer Institute Boston, MA [email protected] Since publication of their article, the authors report no further potential conflict of interest. 1. Herrera AF, Soriano G, Bellizzi AM, et al. Cord colitis syn-

The Authors Reply: Gorkiewicz et al. report on a patient who presented in Austria with the clinical and histopathologic features of cord colitis syndrome and who responded to antibacterial treatment, as previously reported.1 We agree that

drome in cord-blood stem-cell transplantation. N Engl J Med 2011;365:815-24. 2. Human Microbiome Project Consortium. Structure, function and diversity of the healthy human microbiome. Nature 2012;486:207-14. DOI: 10.1056/NEJMc1311318

Ask, Don’t Tell — Mobile Phones to Improve HIV Care To the Editor: Almost all health care is voluntary: patients choose when to engage in care, when to take their medicine (if they choose to take it), and whether to return for follow-up visits. In human immunodeficiency virus (HIV) in-

fection and other chronic diseases, the benefits of medication adherence for the patient and public health are tremendous. Mobile health — the use of mobile devices such as cell phones to improve health outcomes and health care services

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n e w e ng l a n d j o u r na l


m e dic i n e

— has been shown to be effective in promoting Richard T. Lester, M.D. adherence to treatment for HIV infection. The University of British Columbia Centre for Disease Control World Health Organization has strongly recom- Vancouver, BC, Canada [email protected] mended text messaging as a reminder tool to inDisclosure forms provided by the author are available with the crease adherence to antiretroviral therapy. full text of this letter at However, the potential of mobile health is much greater than just reminders. A random- 1. Lester RT, Ritvo P, Mills EJ, et al. Effects of a mobile phone message service on antiretroviral treatment adherence in ized, controlled trial in Kenya that showed the short Kenya (WelTel Kenya1): a randomised trial. Lancet 2010;376: effectiveness of text messaging to improve out- 1838-45. comes of HIV treatment used weekly interactive 2. Hardy H, Kumar V, Doros G, et al. Randomized controlled trial of a personalized cellular phone reminder system to encheck-ins to ask patients how they were doing, hance adherence to antiretroviral therapy. AIDS Patient Care with follow-up phone calls to those reporting a STDS 2011;25:153-61. problem.1 This model involved a weekly text 3. Chung MH, Richardson BA, Tapia K, et al. A randomized trial comparing the effects of counseling and alarm message to patients with a single word — controlled device on HAART adherence and virologic outcomes. PLoS Med “Mambo?” (“How are you?”). The intention was 2011;8(3):e1000422. to promote self-care rather than issue timed 4. Pop-Eleches C, Thirumurthy H, Habyarimana JP, et al. Mophone technologies improve adherence to antiretroviral medication reminders. The patients reported bile treatment in a resource-limited setting: a randomized controlled that they felt cared for and supported. Clinic trial of text message reminders. AIDS 2011;25:825-34. staff indicated that the intervention made their 5. Mbuagbaw L, Thabane L, Ongolo-Zogo P, et al. The CamerMobile Phone SMS (CAMPS) trial: a randomized trial of text work more effective and efficient, since they oon messaging versus usual care for adherence to antiretroviral could focus on patients who needed and wanted therapy. PLoS One 2012;7(12):e46909. their help. Text-messaging services with frequent DOI: 10.1056/NEJMc1310509 medication reminders increase costs and result Correspondence Copyright © 2013 Massachusetts Medical Society. in user fatigue.2 In separate trials, neither medication alarm devices3 nor daily text-message reinstructions for letters to the editor minders4 improved adherence. The provision of health information through Letters to the Editor are considered for publication, subject mobile phones offers the opportunity to improve to editing and abridgment, provided they do not contain material that has been submitted or published elsewhere. health literacy. But does it translate into improved Please note the following: adherence? Although this may be possible, effecin reference to a Journal article must not exceed 175 tiveness has not yet been shown in controlled • Letters words (excluding references) and must be received within studies. A randomized, controlled trial showed 3 weeks after publication of the article. that longer motivational text messages with • Letters not related to a Journal article must not exceed 400 words of encouragement were no more effective words. at improving adherence than short messages.4 A • A letter can have no more than five references and one figure separate trial of motivational messaging showed or table. no effect on adherence.5 Imagine that patients • A letter can be signed by no more than three authors. are feeling sick, and a unidirectional text-messag- • Financial associations or other possible conflicts of interest must be disclosed. Disclosures will be published with the ing service keeps telling them they are imporletters. (For authors of Journal articles who are responding tant and cared for. It is better to show patients to letters, we will only publish new relevant relationships you care, rather than just tell them. that have developed since publication of the article.) My experience and interpretation of the evi- • Include your full mailing address, telephone number, fax dence support an “Ask, don’t tell” approach. Alnumber, and e-mail address with your letter. though patients may eventually tire of being • All letters must be submitted at reminded and told things they had not specifiLetters that do not adhere to these instructions will not be cally asked about, they do not seem to tire of considered. We will notify you when we have made a decision being asked how they are doing. Instead, they about possible publication. Letters regarding a recent Journal feel cared for. Patients also do not seem to tire article may be shared with the authors of that article. We are of having access to their health care providers in unable to provide prepublication proofs. Submission of a letter constitutes permission for the Massachusetts Medical times of need; this is the true power of having Society, its licensees, and its assignees to use it in the Journal’s their health in their own hands through their various print and electronic publications and in collections, mobile phones. revisions, and any other form or medium. 1868

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Ask, don't tell - mobile phones to improve HIV care.

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