correspondence
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
[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
n engl j med 369;19 nejm.org november 7, 2013
1867
The
n e w e ng l a n d j o u r na l
of
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 NEJM.org.
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 authors.NEJM.org.
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
n engl j med 369;19 nejm.org november 7, 2013