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Journal Description

JMIR Preprints contains pre-publication/pre-peer-review preprints intended for community review. With the exception of selected submissions to the JMIR family of journals (where the submitting author opted in for open peer-review, and which are displayed here as well for open peer-review), there is no editor assigning peer-reviewers.

Submissions are open for anybody to peer-review. Once two peer-review reports of reasonable quality have been received, we will send these peer-review reports to the author, and may offer transfer to a partner journal, which has its own editor or editorial board.

The submission fee for that partner journal (if any) will be waived, and transfer of the peer-review reports may mean that the paper does not have to be re-reviewed. Authors will receive a notification when the manuscript has enough reviewers, and at that time can decide if they want to pursue publication in a partner journal.

If authors want to have the paper only considered/forwarded to specific journals, e.g. JMIR, PLOS, PEERJ, BMJ Open, Nature Communications etc) after peer-review, please specify this in the cover letter. Simply rank the journals and we will offer the peer-reviewed manuscript to these editors in the order of your ranking.

If authors do NOT wish to have the preprint considered in a partner journal (or a specific journal), this should be noted in the cover letter.

JMIR Preprints accepts manuscripts at no costs and without any formatting requirements (but if you intend the submission to be published eventually by a specific journal, it is of advantage to follow their instructions for authors). Authors may even take a WebCite snapshot of a blog post or "grey" online report. However, if the manuscript is already peer-reviewed and formally published elsewhere, please do NOT submit it here (this is a preprint server, not a postprint server!).

 

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    Peer-Review 2.0: Welcome to JMIR Preprints, an Open Peer-Review Marketplace for Scholarly Manuscripts

    Authors List:

    Abstract:

    JMIR Preprints is a preprint server and "manuscript marketplace" with manuscripts that are intended for community review. Great manuscripts may be snatched up by participating journals which will make offers for publication.There are two pathways for manuscripts to appear here: 1) a submission to a JMIR or partner journal, where the author has checked the "open peer-review" checkbox, 2) Direct submissions to the preprint server. For the latter, there is no editor assigning peer-reviewers, so authors are encouraged to nominate as many reviewers as possible, and set the setting to "open peer-review". Nominated peer-reviewers should be arms-length. It will also help to tweet about your submission or posting it on your homepage. For pathway 2, once a sufficient number of reviews has been received (and they are reasonably positive), the manuscript and peer-review reports may be transferred to a partner journal (e.g. JMIR, i-JMR, JMIR Res Protoc, or other journals from participating publishers), whose editor may offer formal publication if the peer-review reports are addressed. The submission fee for that partner journal (if any) will be waived, and transfer of the peer-review reports may mean that the paper does not have to be re-reviewed. Authors will receive a notification when the manuscript has enough reviewers, and at that time can decide if they want to pursue publication in a partner journal. For pathway 2, if authors do not wish to have the preprint considered in a partner journal (or a specific journal), this should be noted in the cover letter. Also, note if you want to have the paper only considered/forwarded to specific journals, e.g. JMIR, PLOS, PEERJ, BMJ Open, Nature Communications etc), please specify this in the cover letter. Manuscripts can be in any format. However, an abstract is required in all cases. We highly recommend to have the references in JMIR format (include a PMID) as then our system will automatically assign reviewers based on the references.

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Latest Submissions Open for Peer-Review:

  • The Impact of Internet Health Information on the Physiotherapist-Patient Relationship: the Case of the Lebanese Community.

    From: Journal of Medical Internet Research

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: With the evolution of the internet and communication media, endless information are made available for all individuals, most of the time free of charge. The health care field seems to be o...

    Background: With the evolution of the internet and communication media, endless information are made available for all individuals, most of the time free of charge. The health care field seems to be of high interest for patients who surf the net for pathology definitions, symptoms, treatments and medications mostly before visiting a health practitioner. No matter the quantity of information found on the internet, the quality and credibility of this information is sometimes questionable, leading to undesirable health outcomes or resulting in inappropriate requests for clinical interventions. Few researches on physiotherapy were generally conducted and almost none in Lebanon and none targeted specifically the impact of internet use for medical information research. Objective: This research attempts to examine the effect of searching for health related information by patients over the internet on the physiotherapist-patient relationship, exploring particularly how the online medical information can affect the physiotherapist-patient relationship and the patients’ acceptance of the physiotherapist’s medical approach. Methods: This research adopts a positivist and deductive approach, based on similar studies conducted in the context of other health care specialties. A questionnaire-based survey was sent using communication media to a representative sample population and data was computerized and analyzed using SPSS program to be able to analyze the results and accept or reject H1 and H2. Results: According to the order of physiotherapist in Lebanon2, 1935 physiotherapists are currently registered at the order and working within the Lebanon territory. Our sample is 92 physiotherapists, chosen from those registered at the OPTL, distributed in Lebanon, using an acceptable error of 10% and a confidence level of 95%. Eighty six percent of the physiotherapists valued the recent increase of health information on the internet. Eighty percent found the time to discuss that information with their patients. Seventy three percent believed that the latter positively affects the physiotherapist-patient relationship and eighty one percent said that it positively engages patients in the treatment plan. For H1, 32% of the variation in the physiotherapist-patient relationship was caused by seeking health information on the internet, and in H2: 27.2% of the variation in the acceptance of the physiotherapist’s medical plan was caused by seeking health information on the internet. Conclusions: This study is the first of its kind in the physiotherapy field in general and in Lebanon specifically, aiming to explore the impact of the medical information research on the internet and how it affects the physiotherapist-patient relationship. This study can help raising PTs awareness on how to use appropriate skills to assist their patients in facing information overflow and achieving good health outcomes.

  • A Mobile and Web-Based Clinical Decision Support and Monitoring System for Diabetes Mellitus Patients in Primary Care: A Study Protocol for a Randomized Controlled Trial

    From: JMIR Research Protocols

    Date Submitted: Sep 29, 2016

    Open Peer Review Period: Sep 30, 2016 - Oct 14, 2016

    Background: Physicians’ utilization rates of diagnosis, treatment and monitoring guidelines for diabetes mellitus (DM) is very low. Because of time constraints, overpopulation of patients and comple...

    Background: Physicians’ utilization rates of diagnosis, treatment and monitoring guidelines for diabetes mellitus (DM) is very low. Because of time constraints, overpopulation of patients and complexity of guidelines, alternative solutions are required. Rapidly evolving e-health technology will be a solution to such problems in terms of clinical decision support and monitoring systems (CDSMS). Objective: The purpose of the study is to develop a user-friendly, comprehensive, fully integrated web and mobile-based CDSMS for DM diseases screening, diagnosis, treatment and monitoring for the use of physicians and patients in primary care and to determine the effectiveness of the system. Methods: Methods: CDSMS will be based on evidence-based guidelines for DM diseases. Web and mobile-based application will be developed. The remote monitoring of patient data collected through mobile applications will be provided. The system will be physician –assisted. A database containing patient data will be created. The developed CDSMS will be tested in two stages. In the first stage, the usability, understandability and adequacy of the application will be determined. 5 family physicians will use the developed application for at least their 16 DM patients. Then, necessary adjustments in the application will be made in accordance with the feedback of the interviews with physicians and patients. In the second phase, the system will be validated. A parallel single blind randomized controlled trial will be implemented. 10 physicians and their 439 patients are involved in the study. According to the results of screening which is done using developed CDSMS, DM diagnosed patients will be recruited for trial from the primary care centers by the physicians. The recruited patients will register to the CDSMS with their accounts given by their physicians. Eligible participants will be assigned to intervention and control groups with simple randomization. The significance level will be accepted as p<0,05. In the intervention group, the system recommendations on diagnosis, treatment and monitoring will be carried out as the final decision given by the physician. In the control group, physicians will treat DM patients as the general routine. Patients in both groups will be monitored for 6 months. Patient data on 0th and 6th month will be compared. Clinical and laboratory outcomes will be face-to-face assessed, others will be online self-assessed. Results: Primary outcomes include HbA1c, Fasting Blood Glucose and Postprandial Blood Glucose levels. Secondary outcomes include body mass index, diabetes-related emotional burden and interpersonal distress sub-scales, self-efficacy for diabetes self-care: blood glucose monitoring, physical activity, nutrition, medication-taking, diabetes self-care: blood glucose self-monitoring, medication-taking, smoking and alcohol using and physical activity, depression, anxiety, stress levels. This study is a part of a project which currently underway with funding support from The Scientific and Technological Research Council of Turkey. Study results are expected to be published in the middle of 2018. Conclusions: Among the fields of medical expertise providing health services to DM patients, the developed system using evidence-based guidelines will be the first example.

  • Internet-based cognitive behaviour therapy for stress, anxiety and depressive symptoms among perinatal women: A systematic review and meta-analysis

    From: Journal of Medical Internet Research

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: A growing number of meta-analyses have supported the application of Internet-based cognitive behaviour therapy (iCBT) for psychological disorders across different populations, but relative...

    Background: A growing number of meta-analyses have supported the application of Internet-based cognitive behaviour therapy (iCBT) for psychological disorders across different populations, but relatively few meta-analyses have concentrated on perinatal women. Objective: This meta-analysis evaluated the efficacy of iCBT in improving stress, anxiety and depressive symptoms among perinatal women. Methods: Ten electronic databases were used to search for published and unpublished trials. Cochrane Collaboration’s tool for assessing risk of bias was utilised to measure methodological quality. Meta-analysis was performed using RevMan software. Among the 789 studies identified, nine randomised controlled trials were selected, involving 1,626 participants across seven countries. Results: More than half (63%) of the selected studies had a low risk of bias with no to moderate heterogeneity. Results revealed that iCBT significantly improved stress (d = 0.70, n = 6), anxiety (d = 0.32, n = 7) and depressive symptoms (d = 0.63, n = 8,) of the intervention group compared to those of the control group at post-intervention. Significant subgroup differences according to different control conditions and supportive types were found on stress symptoms. Conclusions: This review revealed that iCBT significantly improve stress, anxiety, and depressive symptoms among perinatal women with small to medium effects. Future effectiveness studies should establish the essential components, format and approach of iCBT with optimal levels of human support to maximize a long-term effect.

  • Non-participation in Videoconferencing-based Treatment for Alcohol Use Disorder

    From: Journal of Medical Internet Research

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: We recently conducted an effectiveness study randomized controlled pilot trial concerning videoconferencing-based treatment for alcohol use disorder (AUD). In short, the aim was to test if...

    Background: We recently conducted an effectiveness study randomized controlled pilot trial concerning videoconferencing-based treatment for alcohol use disorder (AUD). In short, the aim was to test if optional videoconferencing increases adherence and effect in treatment for AUD. Due to a lower patient- and participation rate than anticipated arose the opportunity and need to examine why the patients declined to participate in the effectiveness study. Objective: To examine non-participants’ barriers against participating in an effectiveness study randomized controlled pilot trial and to examine differences between participants and non-participants. Objective: To examine non-participants’ barriers against participating in an effectiveness study randomized controlled pilot trial and to examine differences between participants and non-participants. Methods: The design of this study was mixed methods; an analysis of barriers against participating using an anonymous questionnaire filled out by non-participants, and a comparative analysis of participants and non-participants using data from a clinical database. Results: 43 non-participants filled out the questionnaire. Two categories were derived: scientific barriers, which were barriers against the scientific study in general, and technical barriers, which were barriers against using a laptop and/or videoconferencing in specific. 6 patients stated scientific barriers: of these, 6 patients declined to participate in a research project, and 1 patient also declined to participate in a randomization. 27 patients stated technical barriers: of these, 22 patients declined to use videoconferencing, 12 declined to learn how to use a laptop, and 13 declined to spend time learning it. Non-participants who had technical barriers to participating in the study were older, more often female and part of the work force than those who did not have technical barriers. 13 patients elaborated on technical barriers. 9 patients found it impersonal, preferred personal contact, and would rather attend face-to-face treatment at the clinic. There were no significant differences between participants and non-participants according to socio-demographics, alcohol measures, and composite scores. Conclusions: Patients’ barriers against participating in the effectiveness study were mainly concerned with the technology. They declined to participate because they refused to receive treatment via videoconferencing. Clinical Trial: The regional health research ethics committee system in Southern Denmark, S-20110052

  • Techniques for Improving Communication of Emotional Content in Text-only Online Therapeutic Communications – A Systematic Review

    From: Journal of Medical Internet Research

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: Online typed exchanges are increasingly used by professionals to provide emotional support to patients. Although some empirical evidence exists to suggest that various strategies may be us...

    Background: Online typed exchanges are increasingly used by professionals to provide emotional support to patients. Although some empirical evidence exists to suggest that various strategies may be used to convey emotion during online typed exchanges, there has been no critical review of these data. Objective: The objective of this review was to identify the techniques used to convey emotion in written or typed online communication and assess the empirical evidence regarding impact on communication and psychological outcomes. Methods: An electronic search of databases including Medline, CINAHL, PsycINFO, Embase and the Cochrane Library was conducted to identify literature published between 1990 and 2015. Searches were also conducted using Google Scholar, manual searching of reference lists of identified articles and manual searching of tables of contents for selected relevant journals. Data extraction and coding were completed by two reviewers. Publications were assessed against the eligibility criteria and excluded if they: were duplicates; were not published in English; were published before 1990; referenced animal/non-human subjects; did not describe original research; were not journal articles; or did not empirically test the effect of one or more non-verbal communication techniques (for instance smilies, emoticons, emotional bracketing, voice accentuation, trailers (ellipsis) and pseudowords) as part of online, web-based or typed communication on communication-related variables including: message interpretation, social presence, the nature of the interaction (e.g. therapeutic alliance), consumer perceptions of the interaction (e.g. participant satisfaction), or psychological outcomes including depression, anxiety and distress. Results: A total of 4617 unique publications were identified. Of these, four publications met the eligibility criteria and were included in a narrative synthesis. All four studies addressed the effect of smilies or emoticons on participant responses, message interpretation or social presence of the writer. It was found that smilies and emoticons were able to convey a limited amount of emotion. No studies addressed other techniques for conveying emotion in written communication. No studies addressed the effects of any techniques on the nature of the interaction (e.g. therapeutic alliance), consumer perceptions of the interaction (e.g. participant satisfaction) or psychological outcomes (depression, anxiety or distress). Conclusions: There is a need for greater empirical attention to the effects of the various proposed techniques for conveying emotion in online or typed communications in order to inform health service providers regarding best-practice online communication skills.

  • Clinical Trial Electronic Portals for Expedited Safety Reporting: Current Issues and Desired Features

    From: JMIR Cancer

    Date Submitted: Sep 27, 2016

    Open Peer Review Period: Sep 28, 2016 - Nov 23, 2016

    Background: Use of electronic clinical trial portals has increased in recent years to assist with sponsor-investigator communication, safety reporting, and clinical trial management. Electronic porta...

    Background: Use of electronic clinical trial portals has increased in recent years to assist with sponsor-investigator communication, safety reporting, and clinical trial management. Electronic portals can help reduce time and costs associated with processing paperwork and add security measures; however, there is a lack of information on clinical trial investigative staff’s perceived challenges and benefits of using portals. Objective: The Clinical Trials Transformation Initiative (CTTI) sought to (1) identify challenges to investigator receipt and management of investigational new drug (IND) safety reports at oncologic investigative sites and coordinating centers and (2) facilitate adoption of best practices for communicating and managing IND safety reports using electronic portals consistent with the United States (US) Food and Drug Administration’s (FDA) guidance, the IND safety rule, and CTTI recommendations. Methods: CTTI, a public-private partnership to improve the conduct of clinical trials, distributed surveys and conducted interviews in an opinion-gathering effort to record investigators’ and research staff views on electronic portals in the context of the new safety reporting requirements described in the FDA’s final rule (Code of Federal Regulation 21.312). Results: The top challenge investigators/staff identified in using individual sponsor portals was remembering several, complex, individual passwords to access each site. Also, certain time-consuming tasks (e.g., downloading reports) are due to slow sites or difficulties associated with particular operating systems or software. To improve user experiences, respondents suggested that portals function independently of browsers and operating systems, have intuitive interfaces with easy navigation, and incorporate additional features that would allow users to filter, search, and batch safety reports. Conclusions: Results indicate that an ideal system for sharing expedited IND safety information is through a central portal used by all sponsors. Until this is feasible, electronic reporting portals should at least have consistent functionality. CTTI has issued recommendations to improve the quality and use of electronic portals.

  • Telehealth interventions to support self-management of long-term conditions: a systematic meta-review of diabetes, heart failure, asthma, chronic obstructive pulmonary disease and cancer.

    From: Journal of Medical Internet Research

    Date Submitted: Sep 26, 2016

    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. This meta-review synthesises evidence for te...

    Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. This meta-review synthesises evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Objective: The objectives of this review were a) to assess the impact of telehealth interventions to support self-management on disease control and healthcare utilisation, and b) to identify components of telehealth support and their impact on disease control and the process of self-management. Methods: We performed a meta-review (a systematic review of systematic reviews) of randomised controlled trials (RCTs) of telehealth interventions to support self-management in six exemplar long-term conditions. Seven databases were searched from January 2000 to May 2016 and studies screened against eligibility criteria. Reviews were weighted by quality (R-AMSTAR), size and relevance). Results were combined in a narrative synthesis and using Harvest Plots. Results: Fifty-three systematic reviews, comprising 232 unique RCTs, were included. Reviews concerned diabetes (type 1 (n=6), type 2 (n=11), mixed (n=19)), heart failure (n=9), asthma (n=7), COPD (n=7) and cancer (n=3). Findings varied between and within disease areas. The highest weighted reviews showed blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycaemic control in type-2, but not type-1, diabetes; telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure; but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multi-faceted interventions were associated with greater improvements in diabetes, heart failure and asthma. Conclusions: While not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth represents a safe option for delivery for self-management support, particularly in conditions such as heart failure and type 2 diabetes where the evidence base is more developed. Larger scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.

  • Student Evaluation of a Distance Learning Module Using The Sigu Questionnaire

    From: Journal of Medical Internet Research

    Date Submitted: Sep 26, 2016

    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Infectious diseases remain a public health concern in Brazil. To achieve success in this process and to implement surveillance and public policy action, it is necessary to have health prof...

    Background: Infectious diseases remain a public health concern in Brazil. To achieve success in this process and to implement surveillance and public policy action, it is necessary to have health professionals that are highly trained and updated with the latest skills. The Brazilian government, through the Open University of SUS (UNA-SUS), in partnership with public universities in several states, offers specialization courses, further training and extension courses with free access, in the distance learning (DE) modality. In order to assess the DE courses offered by the institution, UNA-SUS/UFMA created the SIGU questionnaire, a subsystem that facilitates the processing and interpretation of data that is collected when students assess course’s modules. Objective: This study aimed to analyze students’ perceptions regarding didactic and pedagogical aspects related to the content and activities, educational resources, and tutoring in the Communicable Disease module in two distance learning (DE) postgraduate courses at UNA-SUS/UFMA. Methods: The authors analyzed a sample of 319 students, enrolled in two Postgraduate in Family Health classes (class of 2013 and 2014), and two Postgraduate Classes in Primary Care (two classes of 2014), who had completed the Communicable Diseases module and responded to evaluation questions through the SIGU questionnaire, an auxiliary system for processing and interpreting assessments of distance education modules offered by UNA-SUS/UFMA. By way of a statistical analysis, evaluation variables were dichotomized into either a positive outcome (“great” and “good”) or a negative outcome (“bad” and “insufficient”). Data were analyzed using SPSS (Version 18); the significance level was set at 5% (P < .05). Results: After analyzing the data, the authors observed that 99% of the students evaluated the module positively. With regard to the evaluation of the content and activities developed in the module, 53% (169), 43.6% (139), and 3.4% (11) of students evaluated the item workload of the course educational units as great, good, and bad, respectively. The highest rated item was tutor performance, with a rating of “great” from 229 (71.8%) of the students. Conclusions: Overall, the results contributed to the improvement of DE courses offered by UNA-SUS/UFMA from the perspectives of controlling dropout rates and the development of public health services offered in Brazil.

  • A feasibility pilot randomised control trial to test the effectiveness of a website to promote physical activity in people with type 2 diabetes living in remote or rural locations

    From: JMIR Diabetes

    Date Submitted: Sep 20, 2016

    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Previous research supports the use of web-based interventions to promote physical activity in diabetes management. However previous interventions have found poor levels of engagement or ha...

    Background: Previous research supports the use of web-based interventions to promote physical activity in diabetes management. However previous interventions have found poor levels of engagement or have not included health professionals and people with diabetes in the design of the tool. Objective: The present study aims to identify whether a web based virtual trainer can increase physical activity in people diagnosed with Type 2 Diabetes living in remote or rural locations. Methods: Focus groups including patients with diabetes and health professionals were run to identify key concepts, ideas and design of a physical activity website. This site was tested with a six month pilot study which adopted a three armed approach. Participants were randomised into; CG- control group who received written diabetes specific physical activity advice, InfoG- a web-based group who received the information online and InterG- an interactive web-based group who received online information plus interactive features such as an activity log, personalised advice and goal setting. Results: A website was designed based on patient and health professional ideas for effective physical activity promotion. This website was tested with 31 participants, 61% male, who were randomised into the groups. Website logins decreased over time: 4.5 times (month one) falling to three times (month six). Both the InfoG (134.6 (± 123.9) to 154.9 (± 144.2) mins) and CG (118.9 (± 103.8) to 126.1 (± 93.4) mins, d=0.07) increased time spent in moderate vigorous physical activity but decreased in the InterG (131.9 (± 126.2) to 116.8 (± 107.4) mins). Conclusions: Access to online diabetes specific physical information was effective in promoting physical activity in people with type 2 diabetes, access to interactive features was not associated with increases in activity Clinical Trial: ISRCTN96266587

  • Epidemiology of patient harms in New Zealand general practices: Records review study

    From: JMIR Research Protocols

    Date Submitted: Sep 25, 2016

    Open Peer Review Period: Sep 26, 2016 - Oct 10, 2016

    Knowing where and why harm occurs in general practice will assist patients, doctors and others make informed decisions about the risks and benefits of treatment options. Research to date has been un...

    Knowing where and why harm occurs in general practice will assist patients, doctors and others make informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety. We therefore aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their healthcare, from the whole-of-health-system lens afforded by electronic general practice patient records. ‘Harm’ is defined as disease, injury, disability, suffering and death, arising from the health system. The study design is a stratified, two-level cluster, retrospective records review study. Both general practices and patients will be randomly selected so that the study’s results will apply nationally, after weighting. Stratification by practice size and rurality will allow comparisons between six study groups (large, medium-sized, small; urban, and rural practices). Records of equal numbers of patients from each study group will be included in the study because there may be systematic differences in patient harms in different types of practices. Eight general practitioner investigators will review three years of electronic general practice health records (consultation notes, prescriptions, investigations, referrals, and summaries of hospital care) from 9000 patients registered in 60 general practices. Double reviews will check the concordance of reviewers’ assessments. Study data will comprise demographic data of all 9000 patients and reviewers’ assessments of whether patients experienced harm arising from healthcare. Where patient harm is identified, their types, preventability, severity, and outcomes will be coded using MedDRA 18.0 and measured. The design of this complex study is presented with discussion on data collection methods, sampling weightings, power analysis and statistical approach. Lessons from a feasibility study are reported.

  • Attachment style and Internet addiction

    From: Journal of Medical Internet Research

    Date Submitted: Sep 25, 2016

    Open Peer Review Period: Sep 25, 2016 - Nov 20, 2016

    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Overall, the estimated prevalence of computer game and Internet addiction is between 3 and...

    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Overall, the estimated prevalence of computer game and Internet addiction is between 3 and 5%. Considering the fact that there is ample evidence for the relationship between attachment style and substance abuse, it stands to reason that attachment theory can also make an important contribution to the understanding of the pathogenesis of Internet addiction. Accordingly, the aim of this study was to examine people’s tendency toward pathological Internet usage in relation to their attachment style. Method: An online survey was conducted. Sociodemographic data, attachment style (Bielefeld questionnaire partnership expectations), symptoms of Internet addiction (scale for online addiction for adults), used Internet services and online relationship motives (Cyper relationship motive Scale) were assessed. In order to confirm the findings, a study using the Rorschach test was also conducted. Results: In total N = 245 subjects were recruited. Participants with insecure attachment style showed a higher tendency to pathological Internet usage compared to securely-attached participants. An ambivalent attachment style was particularly associated with pathological Internet usage. Escapist and social-compensatory motives played an important role for insecurely attached subjects. However, there were no significant effects with respect to online services and applications used. Results of the analysis of the Rorschach protocol with N = 16 subjects corroborated these results. Users with pathological Internet use frequently showed signs of infantile relationship structures in the context of social groups. This refers to the results of the online survey, in which interpersonal relationships were the result of an insecure attachment style. Conclusions: In summary, pathological Internet use was a function of insecure attachment and limited interpersonal relationships.

  • Perceptions of Mobile Health Technology of Midlife Adults with Chronic Conditions

    From: JMIR mHealth and uHealth

    Date Submitted: Sep 23, 2016

    Open Peer Review Period: Sep 24, 2016 - Nov 19, 2016

    Background: The growth in mobile health (mHealth) technology is intersecting the demographic shift to an aging society. This presents unprecedented opportunity to maximize healthy aging. Regular physi...

    Background: The growth in mobile health (mHealth) technology is intersecting the demographic shift to an aging society. This presents unprecedented opportunity to maximize healthy aging. Regular physical activity (PA) and adequate nutrition are major determinants of health, and enhance physical functioning and mental health necessary to preserve independence. A common form of communication among younger adults, mobile technology offers benefits to promote health. Objective: To assess the perceptions of midlife adults with chronic conditions in terms of use, usefulness, and ease of use of mHealth technology to promote PA. Methods: Midlife adults, age 50-64 years (n=20) diagnosed with one or more chronic conditions were randomly selected from a list generated at an academic-affiliated Internal Medicine clinic in the Midwest. Verbal consent was obtained. An adapted version of the Pew Health Survey (2012) addressing mHealth technology use to promote PA was administered by phone. Results: The majority of respondents were female, and Caucasian. Midlife women were more likely than men to access the Internet for health information. Participants were less likely to use social media sites to discuss or seek health information. They were most likely to use technology to discuss health issues with friends and family, with clinicians remaining a central resource. Despite the small sample size, these results are consistent with previous findings of all adults across the continuum. Conclusions: These findings indicate overall positive perceptions of mHealth technology among midlife adults with chronic conditions. This information will be useful to inform future mHealth interventions for healthy aging. The ultimate goal of this research is to promote health behaviors, thereby reducing the burden of chronic conditions for aging adults and society.

  • The SENSOR Study: A mixed-methods study of SElf-management checks to predict exacerbatioNs of Pseudomonas aeruginosa in patients with long-term reSpiratORy conditions.

    From: JMIR Research Protocols

    Date Submitted: Sep 23, 2016

    Open Peer Review Period: Sep 24, 2016 - Oct 8, 2016

    There are an estimated three million people in the UK with COPD and the incidence of Bronchiectasis is estimated at around 0.1% but is more common in COPD and severe asthma. Both COPD and Bronchiectas...

    There are an estimated three million people in the UK with COPD and the incidence of Bronchiectasis is estimated at around 0.1% but is more common in COPD and severe asthma. Both COPD and Bronchiectasis are characterised by exacerbations in which bacteria play a central role. Pseudomonas aeruginosa (PA) is isolated from sputum samples from 4–15% of adults with COPD and is more likely to be isolated from patients with severe disease. Earlier detection of exacerbations may improve morbidity and mortality by expediting treatment. Aseptika Ltd (Cambridgeshire, UK) has developed a system for patients to self-monitor important physiological measurements including levels of physical activity, peak flow, FEV1 and biomarkers for PA in sputum. We aim to test this system in twenty participants with PA colonisation, and ten controls with Haemophilus influenzae(HI). We plan to recruit 30 adult participants with COPD or non-CF Bronchiectasis who have previously cultured PA or HI during an exacerbation in the last six months. They must produce sputum on most days and should have been stable for four weeks prior to entry. Daily data collected will include symptoms, healthcare usage, medication, weight, FEV1, physical activity level, blood pressure, oxygen saturation and temperature. Sputum and urine samples will be provided daily. These data will be analysed to assess predictive value in detecting upcoming exacerbations. Qualitative data will be gathered through self-administered questionnaires and semi-structured interviews to gather information on participants coping and their use of the technology involved.

  • Automated Adherence Reminders for High Risk Children with Asthma: Research Protocol

    From: JMIR Research Protocols

    Date Submitted: Sep 23, 2016

    Open Peer Review Period: Sep 23, 2016 - Oct 7, 2016

    Background: The use of inhaled corticosteroid (ICS) medications has been shown to improve asthma control and reduce asthma-related morbidity and mortality. Two recent randomized trials demonstrated d...

    Background: The use of inhaled corticosteroid (ICS) medications has been shown to improve asthma control and reduce asthma-related morbidity and mortality. Two recent randomized trials demonstrated dramatic improvements in ICS adherence by monitoring adherence with electronic sensors and providing automated reminders to participants to take their ICS medications. Given their lower levels of adherence and higher levels of asthma-related emergency department (ED) visits, hospitalizations, and death, urban minority populations could potentially benefit greatly from these types of interventions. Objective: The principle objective of this study will be to evaluate the feasibility, acceptability, and limited efficacy of a text message reminder intervention to enhance ICS adherence in an urban minority population of children with asthma. We will also assess trajectories of ICS adherence in the two months following asthma hospitalization. Methods: Participants will include children ages 2-13 who are currently admitted to the Children’s Hospital of Philadelphia (CHOP) for asthma and their parent or legal guardian. Participants will be assigned to intervention and control arms using a 1:1 randomization scheme. The intervention arm will receive daily text message reminders for a 30-day intervention phase following hospitalization. This will be followed by a 30-day follow-up phase, in which all participants may choose whether or not to receive the text messages. Feasibility will be assessed by measuring (1) retention of the participants through the study phases and (2) perceived usefulness, acceptability, and preferences regarding the intervention components. Limited efficacy outcomes will include percent adherence to prescribed ICS regimen and change in parent-reported asthma control. We will perform an exploratory analysis to assess for discrete trajectories of adherence using group-based trajectory modeling (GBTM). Results: Study enrollment began in December 2015 and the intervention and follow-up phases are ongoing. Results of the data analysis are expected to be available by December 2016. Conclusions: This study will add to the literature by providing foundational feasibility data on which elements of a mobile health text-message reminder intervention may need to be modified to suit the needs and constraints of high-risk urban minority populations. Clinical Trial: Clinicaltrials.gov: NCT02615743; https://www.clinicaltrials.gov/ct2/show/study/NCT02615743?view=results; archived with WebCite® at http://www.webcitation.org/6ji59rAXN

  • Designing patient-centered text messaging interventions for increasing physical activity among participants with Type II Diabetes: Qualitative results from the Text to Move intervention

    From: Journal of Medical Internet Research

    Date Submitted: Sep 21, 2016

    Open Peer Review Period: Sep 22, 2016 - Nov 17, 2016

    Background: The Text to Move (TTM) study was a six-month 2-parallel group randomized controlled trial of individuals with type II diabetes (T2DM) to increase physical activity, measured by a pedometer...

    Background: The Text to Move (TTM) study was a six-month 2-parallel group randomized controlled trial of individuals with type II diabetes (T2DM) to increase physical activity, measured by a pedometer. The intervention arm received twice daily text messages for 6 months that were tailored to the participant’s stage of behavior change as defined by the Transtheoretical Model of Behavior Change. Objective: The purpose of this follow-up study was to collect feedback from participants in the TTM program and explore their views on text messaging as a health promotion tool. Categorizing the perceived barriers and facilitators to the TTM program will help inform the design of future technology-based studies to maximize participant engagement. Methods: We assessed participants’ attitudes regarding their experience with text messaging, focusing on perceived barriers and facilitators, through two focus groups and telephone interviews. All interviews were audio-recorded, transcribed verbatim, coded and analyzed using a grounded theory approach. Results: The response rate was 67.4% (31/46 participants). The average age was 51 and 61% were male. The majority of individuals were English speakers and married, had completed at least 12th grade and approximately half of all participants were employed full-time. Overall, participants were satisfied with the TTM program and recalled the text messages as educational, informational, and motivational. Program involvement increased the sense of connection with their healthcare center. The wearing of pedometers and daily step count information served as motivational reminders and created a sense of accountability through the sentinel effect. However, there was frustration concerning the automation of the text message program, including the repetitiveness, predictability of text time delivery, and lack of customization and interactivity of text message content. Participants recommended personalization of texting content and frequency as well as more contact time with personnel for a stronger sense of support, including greater surveillance and feedback based on their own results and comparison to other participants. Conclusions: Participants in a theory-based text messaging intervention identified key facilitators and barriers to program efficacy that should be incorporated into future texting interventions to optimize participant satisfaction and outcomes. Clinical Trial: clinicaltrials.gov/ct2/show/NCT01569243

  • Cognitive and Psychosocial Assessment After Mechanical Ventilation in Intensive Care - Does an Experience of Delirium Make a Difference: The CAPA Study Protocol

    From: JMIR Research Protocols

    Date Submitted: Sep 17, 2016

    Open Peer Review Period: Sep 19, 2016 - Oct 3, 2016

    Background: In the Intensive Care Unit (ICU) critical illness delirium occurs in the context of multiple co-morbidities, multi-organ failure, and invasive management techniques, such as mechanical ven...

    Background: In the Intensive Care Unit (ICU) critical illness delirium occurs in the context of multiple co-morbidities, multi-organ failure, and invasive management techniques, such as mechanical ventilation, sedation and lack of sleep. Delirium is characterized by an acute confusional state defined by fluctuating mental status, inattention and, either disorganised thinking or an altered level of consciousness. The impact of delirium in ICU on the long-term cognitive and psychosocial function of patients who experience it is of crucial interest. Preliminary data suggest strong association between ICU delirium and long-term cognitive impairment. Objective: We aim to explore the relationship of delirium in ICU to adverse outcomes. We are doing so by following mechanically ventilated patients for a yearafter their ICU discharge. We aim to collect data on their long-term cognition andpsychosocial function. Methods: We are conducting this study by enrolling patients in two tertiary Intensive Care Units in Australia. We aim to recruit 200 patients who have been mechanically ventilated for more than 24 hours. Data is collected at three time points following discharge from ICU: at discharge patients are administered the Mini Mental State Examination (MMSE); at 6 months after ICU discharge they are administered the Impact of Events Scale Revised (IES-R) and the Telephone Inventory for Cognitive Status (TICS); and again at 12 months after ICU discharge patients are administered the TICS and IES-R, as well as the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE), which is administered Results: We aim to assess long-term cognition and psychosocial function as our primary outcomes. We will investigate mortality as a secondary outcome. The study is enrolling until end of September 2016 and data collection will conclude at the end of September 2017. The analysis and results are expected to be available by March 2018 Conclusions: We aim to assess long-term cognition and psychosocial function as our primary outcomes. We will investigate mortality as a secondary outcome. The study is enrolling until end of September 2016 and data collection will conclude at the end of September 2017. The analysis and results are expected to be available by March 2018. Conclusion: Delirium during mechanical ventilation has been linked with longer ICU and hospital stay and associated financial burden; a higher risk of long-term cognitive impairment, including dementia; poor functional outcomes and quality of life; and decreased survival. Delirium during mechanical ventilation in ICU is not well understood, and this study will advance knowledge of the comprehensive long-term effects on cognitive and psychosocial function. Clinical Trial: Trial Registration: ACTRN12616001116415

  • Exploration of Deaf people’s health information sources and techniques for information delivery in Cape Town: A qualitative study for the design and development of a mobile health application

    From: JMIR Human Factors

    Date Submitted: Sep 15, 2016

    Open Peer Review Period: Sep 18, 2016 - Oct 2, 2016

    Background: Many cultural and linguistic Deaf people in South Africa face disparity when accessing health information because of social and language barriers. The number of certified South African Sig...

    Background: Many cultural and linguistic Deaf people in South Africa face disparity when accessing health information because of social and language barriers. The number of certified South African Sign Language interpreters is also insufficient to meet the demand of the Deaf population in the country. Our research team, in collaboration with Deaf communities in Cape Town, devised a mobile health application called SignSupport to bridge the communication gaps in healthcare contexts. We consequently plan to extend our work with a Health Knowledge Transfer System to provide Deaf people with accessible, understandable, and accurate health information. We conducted an explorative study to prepare the groundwork for the design and development of the system. Objective: We aim to: investigate the current modes of health information distributed to Deaf people in Cape Town; identify the health information sources Deaf people prefer and their reasons; and define effective techniques for delivering understandable information to generate the groundwork for the mobile health application development with and for Deaf people. Methods: A qualitative methodology using semi-structured interviews with sensitizing tools was used in a community-based co-design setting. Twenty-three Deaf people and 10 health professionals participated in this study. Inductive and deductive coding was used for the analysis. Results: Deaf people currently have access to 4 modes of health information distribution through: Deaf and other relevant organizations, hearing health professionals, personal interactions, and the mass media. Their preferred and accessible sources are those delivering information in signed language and with communication techniques that match Deaf people’s communication needs. Accessible and accurate health information can be delivered to Deaf people by 3 effective techniques: using signed language including its dialects, through health drama, and accompanying the information with pictures and concise text. Conclusions: We can apply the knowledge gained from this exploration to build the groundwork of the mobile health information system. We see an opportunity to design a Health Knowledge Transfer System to assist the information delivery during the patient-health professional interactions in primary health care settings. Deaf people want to understand the information relevant to their diagnosed disease and its self-management. The 3 identified preferred techniques will be applied to deliver health information through a mobile application.

  • Statin and fibrate for Diabetic Retinopathy-Systematic Review

    From: JMIR Diabetes

    Date Submitted: Sep 14, 2016

    Open Peer Review Period: Sep 15, 2016 - Nov 10, 2016

    Background: Diabetes mellitus is a metabolic chronic disease characterized by increased rates of blood glucose. High blood sugar can promote changes of acute and chronic form. When blood glucose is ch...

    Background: Diabetes mellitus is a metabolic chronic disease characterized by increased rates of blood glucose. High blood sugar can promote changes of acute and chronic form. When blood glucose is chronically increased, it triggers a cascade of reactions culminating in the final products of non- enzymatic glycosylation called AGE (Advanced Glycosylation End Product). [1.2] Currently the oxidative stress and dyslipidemias are also considered as metabolic conditions for the increase of the AGE. [3.4] Diabetic retinopathy is characterized by wall vascular proteins glycosylation that leads to vessels permeability increase and consequently exudation. They may also lead to vascular occlusion leading to retinal ischemia. Ischemic areas producing angiogenic factors proliferating vessels culminating in the disease proliferative phase. When the protein AGE joins any of its receptors in the vascular endothelium occurs the release of tissue factor that triggers the extrinsic pathway of coagulation, protein C inhibition and increased production of Endothelin 1 that together lead to diminishing light of the vessel and increase the permeability of the vascular wall by decreasing fibrinolytic activity and platelet aggregation leading to the formation of microaneurysms , oozing, tissue ischemia, calling angiogenic factors culminating in angiogenesis. Data from World Health Organization( WHO) claim 33000 new cases of diabetic macular edema, 86000 new cases of proliferative diabetic retinopathy and 12000 a 14000 new cases of blindness by diabetic retinopathy per year in United States. [5] According to the CDC the number of diabetics who reported decreased vision increased from 1.7 to 4,000,000 of 1997 until 2011 [6] so it is considered a public health problem. Although the photocoagulation persists as a treatment of choice she makes sequels of visual field loss and impairment of night vision so irreversible by ablar retinal tissue. In this way, to find a systemic medication to provide efficiency and effectiveness preventing the onset and progression of diabetic retinopathy would be of great value because it would prevent the manipulation of the eye and with the chance to act in a preventive manner across vascular endothelium. Objective: To find a systemic medication to provide efficiency and effectiveness preventing the onset and progression of diabetic retinopathy would be of great value because it would prevent the manipulation of the eye and with the chance to act in a preventive manner across vascular. In this way, the objective of this study is to evaluate the efficacy and effectiveness of statins and/or fibrates in the diabetic retinopathy incidence and progression. . Methods: Methods/design This protocol is registered in PROSPERO (Inter-national prospective register of systematic reviews) at the National Institute for Health Research and the Centre for Reviews and Dissemination (CRD) at the University of York. It was developed according to the Cochrane Handbook of Interventions Reviews [7] and was reported according to the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P).[8] Type of studies For this Systematic Review, only randomised clinical trials will be included. Given the progressive nature of the clinical situation, cross-over designs will not be considered. Type of patients Patients with type 1 or 2 diabetes, with or without non proliferative retinopathy (for treatment and prevention, respectively) will be considered. Patients with proliferative retinopathy wil be excluded. Type of interventions Any type of statins and/or fibric acids given in isolation or in association, at any dose or duration course will be considered. Type of outcome measures Primary outcomes 1. Incidence of diabetic retinopathy will be considered for prevention proposal at any time point and progression of Diabetic retinopathy, that will be defined as mild non-proliferative, or more severe diabetic retinopathy, from the Early Treatment Diabetic Retinopathy Study (ETDRS) final scale of 35 grade or greater, based on evaluation of stereoscopic color fundus photographs of the eyes of participants who did not have retinopathy at baseline on the ETDRS scale. However, other criteria may be considered on a case by case basis.[9] 2. Progression of diabetic retinopathy at any time point. This will be defined as progression of two steps or greater from baseline on the ETDRS scale based on the development of stereoscopic color fundus photographs of participants' eyes who had diabetic retinopathy at baseline. However, other criteria may be considered on a case by case basis. Secondary outcomes Decrease of visual acuity (any decrease) in both eyes by Snellem charts technique or Logmar; Adverse events, including death, myopathy, liver enzymes alterations, hepatitis induced by drugs; Rate of patients with necessity of laser therapy; Quality of life measured by any tecnique. Methods for search Electronic search We will systematically search the databases: MEDLINE (via Pubmed), EMBASE (via Elsevier), LILACS (via Biblioteca Virtual em Saúde - BVS) and CENTRAL (via Wiley) using search strategy including MESH terms and free-text terms related to “diabetic retinopathy”, “hypolipidemic agents”, “statin”, “fibrates” and drugs within these class and “hypolipidemic agents”. No limit for data, language and status of the publication (conference abstracts, full-text, ongoing studies) will be used. The aditional search will be conducted in Clinicaltrial.gov. Handsearch We will assess reference lists of all included studies and review articles for additional references. We will contact authors of identified trials and ask them about other published and unpublished studies. We will also contact manufacturers and specialists in the area. Selection of studies Two authors (VM and CGF) independently will select the texts and qualify according to the criteria for inclusion and exclusion exposing the reasons for deletion. A third reviewer (RR) will solve any disagreement. We will exclude duplicates and collate multiple reports of the same study so that each study rather than each report will be the unit of interest in the review. We will record the selection process in sufficient detail to fulfill a PRISMA flow diagram and a characteristics of excluded studies table.[10] Data extraction and management [10] We will use a standard data collection form for extracting study characteristics and outcome data. Two reviewers (VM and CGF) will extract the following study characteristics: • Methods: study design, total duration study and run in, number of study centres and location, study setting, withdrawals, date of study; • Participants: N, mean age, age range, gender, severity of condition, diagnostic criteria, inclusion criteria, exclusion criteria; • Interventions: intervention, comparison, concomitant medications, excluded medications; • Outcomes: primary and secondary outcomes specified and collected, time points reported; • Notes: funding for trial, notable conflicts of interest of trial authors; One reviewer [VM] will copy the data from the data collection form into the Review Manager (VerMan 5.3) file [10]. We will double check that the data is entered correctly by comparing the study reports with how the data is presented in the systematic review. A second reviewer will double-check study characteristics for accuracy against the trial report. The same two reviewers (VM and CGF) will independently judge the risk of bias for each study using the criteria outlined. Assesment of risk of bias in included studies According to the following domains: (a) random sequence generation; (b) allocation concealment; (c) blinding of participants and personnel; (d) blinding of outcome assessment; (e) incomplete outcome data; (f) selective outcome reporting; and other bias. Each domain will be judge as: high risk, low risk or unclear risk of bias. We will summarise the risk of bias judgements across different studies for each of the domains listed. We will consider blinding separately for different key outcomes where necessary e.g. for unblinded outcome assessment, risk of bias for all-cause mortality may be very different than for a patient- reported quality of life scale. [10] When considering treatment effects, we will take into account the risk of bias for the studies that contribute to that outcome. Data synthesis We will carry all as is possible to statistical meta-analysis Review Manager version5-3 [11], if we are not able to analyze due to a lack of data or high heterogeneity, we will report the result narratively. Measures of treatment effect Will be analyzed dichotomous data as risk ratio (RR) and continuous data as mean difference (MD) or standardized mean difference (SMD). Will be undertaken meta-analyses only where this is meaningful i.e. if the treatments participants and the underlying clinical question are similar enough for pooling to make sense. If multiple trial arms are reported in a single trial, it will be included only the relevant arms. If two comparisons (e.g. drug X versus placebo and drug Y versus placebo) must be included into the same meta-analysis, we will have the control group to avoid double counting.[10] Dealing with missing data We will contact authors or study sponsors in order to verify key study characteristics and obtain missing numerical outcome data where possible (e.g. when a study is identified as abstract only). If outcome data are missing in both intervention groups, but reasons for these are both reported and balanced across group, then important bias would not be expected unless the reasons have different implications in the compared groups. In dichotomus study, the potential impact of missing depends on the frequency or risk of outcomes. In continuous outcomes, the potential impact increses with the proportion of participants with missing data. [12] Assessment of heterogeneity We will assess heterogeneity by using chi-squared and I-squared statistics. Will be considered heterogeneous if chi-squared value is lower than 0.10 and I-squared value is greater than 50 %. An I-squared value greater than 50% will be considered as substantial heterogeneity and, in this case, random effect model will be use rather than fixed effect model. The reason of heterogeneity will be investigated trought subgroup and sensitivity analysis. [12] Assessment of reporting bias If there are 10 or more studies in the meta-analysis, we will assess reporting biases using funnel plots and visually interpret for the funnel plot asymmetry. [12] Subgroup analysis and investigation of heterogeneity Subgroup analysis for the primary outcomes considering the following group will be conducted: the different types of diabetes and the different kinds of hypolipemic drugs (statins, fibrates) and doses. [12] Sensitivity analysis Sensitivity analyses will be conducted to determine the impact of exclusion of studies with overall lower methodological quality (high risk of bias). We will consider as low methodological quality those studies judged as low quality for at least one of main domains of Risk of Bias Table (generation of randomization sequence, allocation concealment and blinding).[12] Results: We will generate two summary of findings table using all primary outcomes for each key-question of this review: development and progression of diabetic retinopathy. We will use the five GRADE criteria (study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the pre-specified outcomes. We will use methods and recommendations described in Section 8.5 and Chapter 12 of the Cochrane Handbook (Higgins 2011) [13] and using GRADEpro software[14].We will justify all decisions to down- or up-grade the quality of studies using footnotes and make comments to aid reader's understanding of the review where necessary. We will consider whether there is any additional outcome information that was not able to be incorporated into meta-analyses and note this in the comments and state if it supports or contradicts the information from the meta-analyses. Conclusions: Dyslipidemia is one well- known risk factor for the development of vascular disease in diabetics. However, the effects of statins and/or fibrates use have not been addressed by a systematic review yet. The findings of this review will provide an evidence-based recommendation for patients and health care professionals that deal with this severe and prevalent complication of diabetes. Clinical Trial: PROSPERO: CRD42016029746

  • Smartphone Application Use for Diabetes Management: Evaluating Patient Perspectives

    From: JMIR Diabetes

    Date Submitted: Sep 12, 2016

    Open Peer Review Period: Sep 13, 2016 - Nov 8, 2016

    Background: Finding novel ways to engage patients in chronic disease management has led to an increased in interest in the potential of mobile health technologies in the management of diabetes. There...

    Background: Finding novel ways to engage patients in chronic disease management has led to an increased in interest in the potential of mobile health technologies in the management of diabetes. There are currently a wealth of smartphone applications (apps) available for free download or purchase. However, the usability and desirability of these apps has not been extensively studied. These are important considerations as, at a very practical level these apps must be accepted by the patient population if they are to be utilized. Objective: The purpose of this study was to gain insight into patient experiences with use of smartphone applications (“apps”) for management of type 1 diabetes. Methods: Adults with type 1 diabetes who previously or currently used apps to manage their diabetes were eligible to participate. Participants (n=12) completed a questionnaire in which they were required to list the names of preferred apps and indicate which app functions they had used. They were given opportunity to comment on app functions they perceived to be missing from the current technology. Participants were also asked whether they had previously paid for an app and whether they would be willing to do so. Results: The apps most commonly listed by participants as the best apps they had encountered included IBG star and MyFitnessPal. Blood glucose tracking, carbohydrate counting, and activity tracking were the most commonly use features. 100% of participants indicated that they had not encountered any one app that included all of the functions that they used. Ability to synchronize with a glucometer or insulin pump was the most common function participants stated was missing from app technology. 10% of participants had previously paid for a diabetes related app and 90% of participants indicated they would be willing to pay. Conclusions: In spite of dissatisfaction with the currently available apps, there is interest in using these tools for diabetes management. Adapting existing technology to better meet the needs of this patient population may allow these apps to become more widely utilized.

  • Does usage of an e-health intervention reduce the risk of excessive gestational weight gain?

    From: Journal of Medical Internet Research

    Date Submitted: Sep 13, 2016

    Open Peer Review Period: Sep 13, 2016 - Nov 8, 2016

    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Online interventions have the potential for delivering innovative, interactive excess...

    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Online interventions have the potential for delivering innovative, interactive excessive GWG prevention to large numbers of people. Objective: This study creates a novel measure of online intervention usage patterns and examines whether online intervention usage is associated with reduced risk of excessive GWG. Methods: The online intervention was theory based and emphasized the active ingredients of weight gain tracking and behavioral goal-setting and self-monitoring. One-thousand three hundred and thirty-five (898 intervention and 437 control) relatively diverse and healthy pregnant women were randomly assigned to the intervention arms or control arm. Usage patterns were examined for both intervention and control arm participants using Latent Class Analysis. A modified Poisson regression approach was used to estimate the relative risk of excessive total or weekly GWG for women with different usage patterns. Results: Five usage patterns best characterized the usage of the intervention arm participants. Three usage patterns best characterized control arm participants’ usage. Control arm usage patterns were not associated with excessive GWG, whereas intervention arm usage patterns were associated with excessive GWG. Conclusions: The control and intervention arm usage pattern characterization is a unique methodological contribution to process evaluations for self-directed, online interventions. Clinical Trial: NCT01331564, ClinicalTrials.gov, www.clinicaltrials.gov

  • A call to digital health practitioners: New guidelines can help improve the quality of digital health evidence

    From: JMIR mHealth and uHealth

    Date Submitted: Sep 10, 2016

    Open Peer Review Period: Sep 12, 2016 - Nov 7, 2016

    In the recent years, there has been rapid increase in the number of mobile phone supported health interventions and accompanying literature assessing the efficacy of these interventions. The quality o...

    In the recent years, there has been rapid increase in the number of mobile phone supported health interventions and accompanying literature assessing the efficacy of these interventions. The quality of reporting of this evidence has been largely variable. Though the field has expanded in its scope and scale, the quality of the supporting evidence is still in its infancy. The mHealth Evidence Reporting and Assessment (mERA) checklist, led by the WHO, and developed in partnership with several institutions, aims to standardize the quality of mHealth evidence reporting. mERA was published as an original manuscript in the British Medical Journal in March 2016. The attached commentary provides a brief overview of the checklist, with a call to the digital help community to use the checklist in the reporting of evidence on digital health interventions.

  • The Sugarsquare study: a multicenter randomized controlled feasibility trial concerning a web-based patient portal for parents of a child with type 1 diabetes

    From: Journal of Medical Internet Research

    Date Submitted: Sep 10, 2016

    Open Peer Review Period: Sep 11, 2016 - Nov 6, 2016

    Background: Raising a child with type 1 diabetes (T1D) faces parents with the task of combining the demands of the disease-management with everyday parenting, which is associated with increased levels...

    Background: Raising a child with type 1 diabetes (T1D) faces parents with the task of combining the demands of the disease-management with everyday parenting, which is associated with increased levels of distress. To support parents, a web-based patient portal Sugarsquare was developed, delivering online parent-professional communication, peer support and disease information. Objective: The first aim of this study was to assess the feasibility of conducting a multicenter, randomized controlled trial concerning Sugarsquare in a population of parents of a child with T1D. The second aim was to assess the feasibility of implementing Sugarsquare in clinical practice. Methods: Hundred and five parents of 105 children with T1D under the age of 13 participated in a 6-month multicenter randomized controlled feasibility trial and were randomly assigned to an experimental (usual care + Sugarsquare) or a control group (usual care). Attrition rates and user statistics were gathered throughout the study-period for feasibility of the trial and the implementation. To determine potential efficacy of Sugarsquare, parenting stress (PSI-SF) was assessed at baseline (T0) and after six months (T1). Results: Enrollment refusal rate (58%), baseline attrition rate (25%) and post-randomization attrition rate during follow-up (26%) were all average. User statistics in the experimental group showed high practicability, integration in all users, moderate acceptability and demand in parents and high acceptability and demand in healthcare professionals. Reporting higher levels of parenting stress at baseline was related to higher frequency of logging in by parents (ρ=.282, p=.030) on Sugarsquare and higher parents’ number of page views (ρ=.304, p=.019). No significant differences in change in parenting stress between experimental and control group were found (F=.49, p=.49). Conclusions: Conducting a trial concerning an Internet intervention in a population of parents of a child with T1D can be considered feasible. Implementing Sugarsquare in clinical practice was found to be partly feasible, given the moderate demand and acceptability in parent users and lack of potential efficacy. Parents who reported higher levels of parenting stress used Sugarsquare more often. Although usage did not lead to a decrease in parenting stress, results indicate that online provision of care is suitable for parents of a child with T1D, who are in need for additional support. Future research should clarify whether incorporating targeted interventions in Sugarsquare will lead to less psychosocial problems. Factors potentially contributing to successful implementation are suggested. Clinical Trial: The study described in this paper is registered under NTR3643 (Dutch Trial Register).

  • The Rise Of New Alcoholic Games Among Adolescents: The Consequences At The Emergency Department

    From: JMIR Serious Games

    Date Submitted: Aug 30, 2016

    Open Peer Review Period: Sep 9, 2016 - Nov 4, 2016

    Background: This article can be considered as a result of three different works. The first one consists on a questionnaire regarding the behaviors about alcohol consumption among young people; the sec...

    Background: This article can be considered as a result of three different works. The first one consists on a questionnaire regarding the behaviors about alcohol consumption among young people; the second one consists on an analysis of the scientific literature about this topic and finally the third one is the analysis of the shelters at the Emergency Department of acute alcoholic intoxication. The link between all these works is the existence of an abuse of alcohol by young people, the spread documented in the literature and the questionnaire on new practices of alcohol consumption and therefore a prevalence of young people in shelters at Emergency Department for reasons attributable to alcoholic behaviors. In scientific literature, there are many papers on the abuse of alcohol and binge drinking, but those are not describing enough how alcohol consumption happens in adolescence and there are no sufficient data about new drinking modes such as Neknomination or Vodka Eyeballing. 1. Today, analyzing scientific journals in PubMed Embase databases, there are no significant publications referring to the relationship between clinical sequelae for Neknomination and access to the emergency room as a result of the various alcoholic games. There are many projects and protocols relating to the Italian and European generic problem of alcohol consumption in adolescents (1) but despite some methodological differences, which can make it difficult to compare data among surveys, in general there are no discrepancies in the consumption trends among young Italians. 2. It is important to inform and educate parents and clinicians about the spread of new alcohol consumption modalities in adolescents, their risk and impact for Emergency Medicine. 3. The quantification of the cases, the knowledge of the clinical significance of the different modes of abuse chronic or acute intoxication of alcohol among teenagers, represent the central point for the development of a control system being aware not only of the distribution of the most dangerous alcohol consumption, but also of their evolution, focusing on Neknomination and new methods of recruitment (games alcohol, "binge roulette" etc.), and the increase of occasional consumption. The new trends related to consumption patterns found among teenagers are leading to a very high number of episodes of drunkenness. There are many risk factors related to alcohol abuse by young people and often the conclusions found in literature are conflicting: the age at which the first taste of alcohol occurs and the context in which this happens, seem to be related to the influence of the Web and "alcohol socialization" social networks with different methods and rules. Another risk factor in the relationship between adolescents and alcohol is the marketing of alcoholic beverages in the web not only throughout advertising but also by social influence model, which is characterized as "social norm and" life skills ". 4. The phenomenon of Neknomination can be seen as the translation on the web of the association between binge drinking (intake of large amounts of alcohol in a short period of time) and happy hour: video publishing on the web seems to be a way to get in a group or to be socially accepted by schoolmates. The amount of alcohol taken in these events is high and since the "game" lasts a few minutes, the boys get the same effects of binge drinking. (2). Other social consequences caused by alcohol can be road and domestic accidents, legal problems, financial problems and gambling. As for young people, alcohol abuse can lead to develop dangerous behaviors such as multiple consumption, unprotected sex, which can cause diseases and unwanted pregnancies, and driving while intoxicated. 5. The strategic role of Emergency Services is to identify and monitor a problem since its debut, to support the planning and to coordinate the implementation of interventions, ensuring operator training. At this stage, considering the literature data and previous experience in Veneto region and Padua, we have assessed the characteristics and extent of the phenomenon of alcohol consumption in young people and adolescents (risk analysis, definition scenarios), in order to identify the best methods to track trends over time; to define in detail the operations to be performed in the Emergency Department, the organization of interventions in the hospital acceptance phase, the alarm mode, the training of the operators involved, the communication between operators and the population (planning). 6. The communication with the public, with the media, and with schools plays a decisive role in this situation to gain timely and reliable information and to obtain cooperation by limiting the effects of the problem in place. It becomes necessary to invest in developing strategies of specific routes that meet the new styles of consumption of alcohol in adolescents, promoting healthy lifestyles, with specific interventions and coordinated between the different health care specialists enabling differentiated access to care pathways, and developing closer collaboration with general practitioners). The excessive and sometimes pathological use of Internet is currently rising among young people in many industrialized countries in Asia, North America and Europe. Recently, the use of internet has spread so rapidly among adolescents to become a serious public health problem, and many authors have started writing about "Internet addiction." It is estimated that 95% of adolescents connects on-line every day in different places and with different devices: computers, cell phones, smartphones, tablets or e-book readers. The effect of social networks on the health of adolescents and in general the influence of this lifestyle today remains controversial, especially when teens become more independent in their decisions (academic, educational and social / recreational) and are increasingly exposed to the trends of social media. While this may seem apparently harmless, it can actually profoundly affect the behaviors of teenagers and young adults. A study analyzed the profiles of MySpace of 400 adolescents and found that 56% contained references to alcohol and among them 49% spoke explicitly of alcohol use (5). Today's teenagers are increasingly inclined to take and share regularly "selfies" on social networking sites like Twitter, Youtube, Facebook, Instagram, snapchat etc., where each user is represented by its profile. Internet sites such as video-sharing platforms can significantly influence the behavior of adolescents and forms of communication between peers. For example, YouTube, which has become property of Google since 2006, is currently the most popular video sharing site in the world, with over one billion users per month. Some of the most popular videos on YouTube are music videos, each of which generates millions of views and comments. However, YouTube also has self-produced material that can be highly subject to interpretation by the users. While some viewers may be savvy enough to display the various video or advertising with detachment and critical spirit, others may be deeply influenced by the spirit of escape, fun and thrill described in some video. (6) The ease of communication between the various teenagers, that is the true success of social networks, not only affects the school environment, family or friends, but, thanks to the virtual network, it also extends globally, allowing one to share instantly a photo, a video or a simple "state". This attitude of ostentation can unfortunately also lead to pressures from peers and pathological conditioning that could adversely affect the behavior of the boy, pushing him toward a potentially reckless behavior (7). It is fast becoming clear that the widespread use of social networks can lead to a "viral phenomenon", where the emulation of dangerous acts spreads very rapidly throughout the world. The importance of these sources of influence becomes evident when looking at the various psychophysical changes typical of adolescence and it is therefore necessary for them to be taken into consideration by medical professionals, given their significant impact on the health not only of the same teenagers but also on that of society as a whole. Previous studies report that many factors can contribute to substance abuse and its evolution during adolescence, including a greater emphasis on independence, the presence of established habits in the family and peer influence. In a descriptive longitudinal study, D'Amico et al. They analyzed the various habits of adolescents, identifying a strong connection between alcohol abuse and other substances consumption such as tobacco and marijuana, demonstrating also a greater propensity to alcohol abuse in people of Hispanic and African American descendence(8). It was then considered that the general assumption of most descriptive models of peer pressure is based on the perception that adolescents have about the consumption of alcoholic beverages by friends, identified as predictor of long-term substance abuse in adolescents and youth in pre-adolescent(9-10) In relation to sexual maturity as it applies to teenagers, it is worth mentioning that the early use of alcohol is an important risk factor in relation to risky sexual activity among young people, whose health and well-being are so compromised by potential exposure to HIV and other sexually transmitted infectious diseases, as well as other potential negative consequences, including unwanted pregnancies. (12). Objective: This study encourages health care providers to pay attention to these new behavioral trends of substance abuse, especially alcohol, related to the use of internet and future surveys should identify potential markers of a problematic use of social networks, including the identification of groups at risk of abuse and should aim to establish a potential prevention strategy in terms of awareness and education that could help to avoid potentially fatal episodes. Methods: METHODS AND MATERIALS Purpose and design of the study This research is an observational study, retrospective longitudinal type single-center study conducted at the Hospital-University of Padua. The study aims to evaluate the influence of the web and social networks in the daily life of adolescents, who access to the Emergency Department of the main hospital of Padua, by questionnaires about the consumption of alcohol. The processing of the answers to these questionnaires allowed us to better understand the most problematic aspects that interfere in the mode of alcohol intake in young people. Admissions for acute alcohol intoxication of adolescents aged between 15 and 20 years old to the Emergency Department. The data obtained were compared with the meta-analysis, the review and the case studies reported in the literature when present. Organizational chart of the study The survey presented in this work let focus the attention of medical professionals, teachers and parents on a rapidly growing phenomenon among adolescents: the rapid development of Internet and with it the social networks. The survey was conducted according to the procedures listed below and then described in detail. 1. In the first part of the study 70 (Attachments) questionnaires were distributed at the entrance of the hospital while attending the emergency department in the period 2013-2015 to the sample of subjects in this study. Data obtained in this way were added to the questionnaires distributed in secondary schools and in health education classes. 2. The estimate of the impact of social networks on the health and daily lives of adolescents was assessed with 50 questionnaires (Attachments). The tool used to gather information is a questionnaire drawn up by a group of multidisciplinary research with Spanish colleagues, partially supplemented by a few questions about smoking and alcohol, placed on the initiative of the national coordinating corpse. To enable a better sharing of these tools, web pages have been created. If accepted, the guy with the consent of the parents, depending on age, will fill out a questionnaire validated for individual pediatric age groups (PedsQL Measurement Model). The questionnaires were processed by the principal investigator and collaborators in compliance with privacy laws. The anonymous questionnaires The information was gathered by analyzing the behavior described in the questionnaire (Attachment). They were alcohol consumption, considering various types of drinks such as spirits, liqueurs, aperitifs, wine or beer, and the use of cigarettes. The age of first use and its frequency were evaluated for each drug of abuse. In order to understand just how dominant the role of social media is in the daily lives of adolescents, they were asked to express an opinion on the importance of the influence of the web among their peers. To increase the validity of the responses, the questions about the use of substances were laid whereas the boy / girl has consumed the substance previously, for example, "How old were you when you..?" with the option "Never drank ..." and "How many times have you made use of...?" with the option to choose how to answer "one time", "2x", "3 or 5 times", "5 or more times, " and never". The questions refer to the last 30 days and events or places such as parties, clubs, bars where there is an increased risk of drinking alcohol in large quantities. In particular, to investigate the spread of binge drinking, he was asked respondents how many times they had consumed five or more drinks within 2 hours during the last 30 days, offering as an option to answer "Never, Once, 2 times , 3-5 times More than 5 times "and inviting to quantify the number of drinks consumed. To try to identify the best luxuries habits of adolescents surveyed, they were asked if they were aware of similar behavior present in their circle of friends or family members ("No member of the family makes use of alcohol, at least one component / both components make routine use of more than one alcoholic drink during or outside meals "). To assess the consequences of substance abuse from a clinical point of view, it was asked if the subjects were aware of the new games as NekNomination alcohol, Vodka Eyeballing etc., if they had ever attended and whether they had ever repented. Symptoms assessed were the most frequent associated to drunkenness or "tremors and incoordination, Altered behavior, increased talkativeness and sociability, language vague, uncertain gait, Abnormal reflexes, Altered perception of reality, Absence of perceptions, sense of death. " Other symptoms evaluated were: "I had a headache and chills, I threw up, I passed out / I had memory lapses" and eventual access to the emergency department. To correlate the recent tendency to alcohol abuse among adolescents and traffic accidents of persons testing positive blood alcohol, it asked respondents whether conducessero motorized vehicles, if they were aware of the alcohol limit foreseen by the Highway Code in Italy, if they had never taken alcohol for two hours prior to taking the lead and if they had never driven in conditions considered by them to little clarity. In the event that they had traffic accidents related to alcohol consumption, we were assessed the following clinical signs reported: "Bruises and minor trauma, Head injuries, fractures, hemorrhages, Abnormal breathing, loss of consciousness." From the standpoint of psycho-sociological was asked the boys surveyed what were the reasons that pushed them to the consumption of alcoholic beverages (To please myself, to please others, I think that alcohol makes me more fun, To not to feel excluded from the group) and what would change in their daily lives if they stopped drinking alcohol (Nothing, I divertirei less, I would not see the same people, I would try other busts). Finally, it was considered, in the same manner as the consumption of alcohol, smoking habits, invited the parties to express themselves about the age at which they started smoking, the frequency and amount of consumption of cigarettes and the duration of exposure to secondhand smoke daily allowance (Never, Occasionally, less than an hour a day, 1-5 hours a day). Evaluation of the phenomenon in a hospital: the Emergency Department Inclusion criteria of patients, data collection Among the 1,224,768 arrived at the emergency room of the Hospital of Padua since 2006, I have been examined 473,531 accesses in the years 2013-2015, selected retrospectively through the computer system Qlik. Including access to the emergency department, through Qlik, they were selected 3742 patients aged between 15 and 30 years old came to the emergency room of the Hospital of Padua hospitalized for acute alcohol intoxication associated with illness or trauma from 2006 to 2015. They were analyzed folders SDO and the database contains the access mode in the emergency department (only, ambulance, etc.), the diagnosis entry, the characteristics (sex, age, nationality), the circumstances of the fact, and the surveys required by ER doctors and in-hospital monitoring (monitoring PS, OBI, hospitalization, operating room, intensive care) and between tests was particularly considered the value of blood alcohol. It was therefore not possible to record the total complexity of emergencies ULSS 16, since the subjects under the age of 15 years have access to the Pediatric Emergency Department and a proportion of patients> 15 years comes to the emergency room of the nearby St. Anthony Hospital. Of these patients were analyzed folders DEA. Comparing the missing data with the computer program Galileo 1.4.3.107, DB 41, considering the anamnesis (directly or by friends) and symptoms attributable to alcohol consumption (consistent with the history of alcohol- positive: vomiting, altered reflexes , impaired vision, perception of shapes, colors, sizes, serious impairment of physical or mental condition, marked difficulty in standing or walking, hallucinations, cessation of reflexes, incontinence and coma). Data entered in spreadsheets Office Excel 2007 were analyzed using SAS 9.2 (SAS Institute Inc., Cary, NC, USA) for Windows. For categorical variables (gender, diagnosis closing observation period, days of the week, BAC and age) we have been reported the number of patients per category and the percentage of the variable considered. The variable age was reported in classifying subgroups (15-20 years, 20-25 years and 25-30 years). The variable "blood alcohol" has been divided into classes according to the classification scheme in art. 5 of Decree-Law no. 151/2003, conv. with Law no. 214 of 1 August 2003 (<0.5 g / L, 0.5g / L-0.8g / L, 0.8g / L-1.5g / L,> 1.5g / L). The association between categorical variables was evaluated using the chi-square test or the Fisher exact test. Considering significant p values less than or equal to 0.05. For continuous asymmetric (Duration of hospital stay, weight standard DGR) they were calculated Minimum, Maximum, Median and Quantiles; They were then compared between the sexes with the nonparametric Wilcoxon. Economic evaluation Based on the questionnaires, it was decided to select 225 belonging to the age group 15-20 years, because they were considered the main beneficiaries of the new trends about alcohol consumption. Of the 225 patients aged 15-20 years examined in 2013-2015, using the computer program Galileo 1.4.3.107, DB 41, were considered treatment programs care of a sample of 38 patients, hospitalized in OBI (Observation short intensive ) of which is considered the type of transport by which have come to the emergency department (118 - Ambulance 118 - other means, ambulatory), the access time (from 20 to 24, 24 to 8, from 8 to 20), recovery time. They were then evaluated clinical care processes of samples of patients: 1. inpatient OBI with its performance laboratoristiche and hospital. 2. Patients traumatized (DRG-486 other surgeries for multiple significant trauma, DRG 487-multiple other injuries relevant) and hospitalized with at least 5 days in hospital who had attended the neknomination or other games under the influence of alcohol content. Folders via SDO and the analysis of the therapy welfare of patients have been completed not only the provision of medical and surgical but also all related activities and diagnostic and laboratory allowing to outline the economic value of some cases more or less complex. The path of hospital inpatients or undergoing observation short, allowed the identification of categories or types of patients similar in intensity of consumption of resources and clinically significant in relation to the extent of the trauma or the type of cause of hospitalization associated to ' acute alcohol intoxication. Results: The extent of the phenomenon "Alcohol abuse and alcohol new games" The results for the 120 questionnaires (70 PS and 50 in schools) administered to young teenagers in the province of Padua (Attachments) show that the average respondent’s age is 17 years, 38% of respondents were male while 62% female. The questionnaires refer mainly to people attending secondary schools, especially high schools and technical institutes. 66 respondents (55%) claim to have been 13-14 years old when consumed (and not only tasted) in full his first alcoholic drink, while 41 (34%) say they have started to 15-16 years.Respondents were asked to indicate what was the type of alcoholic beverage consumed by them most: most drinking beer (42 subjects, 35%), 47 respondents (39%) consume aperitifs and digestives (Spritz Aperol, Campari, Amari ), 16 (13%) wine and 10 (8%) makes use of spirits and liquors (Vodka, Gin, Rum, Scotch, Wisky ..). The teens surveyed were then invited to express themselves about the habitual consumption of alcoholic beverages: 100 (83%) do not disapprove drinking one or two glasses regularly while 20 (17%) do not disapprove getting drunk once a week. Referring to the practices of extreme intoxication described in the questionnaire (in the eyes -vodka eyeballing- vodka, drink upside down, strong sucking from a straw, make a cocktail with mouthwash and hand sanitizer-drink hand sanitizer) 109 subjects (91% ) deny having ever participated and 11 (9%) say they have sucked strong from a straw. Despite the denial, 55 respondents (46%) admit to have seen video of guys getting drunk with extreme ways in social media like Youtube, Facebook and Instagram. As regards the NekNomination, 95 respondents (79%) are aware of this practice. Almost all, 112 (93%), denies having ever taken part, although 52 subjects (43%) know of at least one friend who took part in the past (figure 1). In the period from January 2006 to April 2015 a total of 1,224,768 accesses to the Emergency Department (ED) of the main hospital in Padua (Azienda Ospedaliera di Padova) have been recorded, of which 473,531 from January 2012 to April 2015. Of these recent data triage code was assigned as follow: white, 51%; yellow, 26%; red (critical), 4%; green, 18%. (figure 2)By analyzing these patients we considered 3 ages: 1) from 15 to 20 2) from 20 to 25 3) from 25 to 30. The data were further analyzed on the basis of sex. The categorizations by sex and age group are described in (FIGURE 3) for the period 2006-2012, (FIGURE 4) for 2013-2015. The age group between 15 and 30 years is a demographic group with a high incidence of requests for blood alcohol tests (BAC) at the Emergency Department. This age group is responsible for 37% of the total requests, while it represents only 14% of the resident population. (P <0.001). For comparison the report was for the age group 30 to 45: 29 % of BAC compared with 21 % of the population; for the age group from 45 to 60 years: 23 % of BAC compared with 22 % of the population(FIGURE 5).It was ascertained that the number increases considerably over the weekend and that the percentage difference between the sexes is minimal: on Saturday the admission for acute alcohol are 21% of the full week for both females (60) than for males (113). On Sunday the females are 73 (23%) and 132 Males (24%). Interestingly on Thursday the female patients admitted to the Emergency Department for acute alcohol intoxication are as many those admitted on Saturday, i.e. 56 (19%)(FIGURE 6)Subdividing the same patients by age, we note that: -15-20 Years: patients with acute alcohol intoxication accessing ED mainly on weekends with a peak abundance of 50 (22%) on Saturday, and 65 (29%) on Sunday. A certain proportion also focuses in correspondence of Thursday (29 subjects, 13%). -20-25 Years: the large number of such patients is distributed over the week. Wednesday and Thursday is the large number of 43 (14%) and 60 (19%) respectively. Over the weekend we do not have concentrations as high as for the youngest group, registering peaks of 62 patients (20%) on Saturday and 78 patients (25%) on Sunday. (FIGURE 7).Discharge diagnosis patients 15-20 years Among the 830 patients analyzed in the period from 2013 to 2015, of special interest are the 225 belonging to the age group 15-20 years, because they are believed to be those mainly exposed to new mode of intake of drinks with a high alcohol content. Table I summarises the diagnosis at discharge in this sub-group. In the years 2013-2015 blood alcohol content has been tested for 830 patients aged 15 to 30 years (TABLE II).In all the bands of age considered, the majority of patients had levels of ethyl alcohol in the blood greater than 1.5 g / L: 172 (21%) in the age 15-20, 262 (42%) aged 20- 25 and 232 (4%) in range aged 25-30. As shown in Figure 8, the other classes of blood alcohol levels are poorly represented in the age groups 20-25 and 25-30, while a significant percentage of patients aged 15-20 years (36, 10%) is admitted to Emergency Department for acute intoxication of alcohol, with values of ethyl alcohol of blood comprised between 0.8 g / L and 1.5 g / L. Of the 225 patients (135 males and 90 females) aged between 15 and 20 years, admitted to the Emergency Department of the Hospital of Padua for acute alcohol intoxication in the years 2013 to 2015 were analyzed blood alcohol levels obtained from Central Laboratory of the Hospital of Padua. Of these patients, 70 (31%) admitted that they have participated in new alcohol consumption based games. In particular, 14 (19%) reported having taken part in NekNomination, 53 (76%) to "other alcohol games" (among which beer pong, alcohol enema, flip cup were included) and 4 (5%) to VodkaEyeballing. table III. Of all 225 patients the blood alcohol concentration was analyzed and the data was then examined by individual years and by age. Blood concentration of ethanol (BAC Blood Alcohol Concentration) was grouped following the classification scheme outlined by Italian legislation (art. 5 of Decree no. 151/2003, converted in Law no. 214 of August 1, 2003), as described in Table IV. All values are > 0 g/L.Statistical analysis performed with the Chi Square test (Z2) does not identify significant changes over the years analyzed (p> 0.05). In all years 2013, 2014 and 2015 there is a high prevalence of patients whose values fall into the category of BAC> 1.5 g / L: 61 (75%) in 2013, 78 (76%) in 2014 and 33 (81% ) in 2015. The second value range blood alcohol most represented in the studied years is 0.8-1.5 g / L: 12 (13%) in 2013, 16 (15%) in 2014, and 8 (19%) in 2015. In 2015 (the data refer to the months from January to April), all the examined patients 15-20 years have blood alcohol values> 0.8 g / L. These levels are very dangerous for the life of those subjects. (Figure 9) Admissions for trauma. Of the 30 patients admitted for trauma, 24 were male (80%) and 6 women (20%). The median length of stay (one cannot have statistical average as the variables are asymmetrical) was 11 days, with a minimum of 3 and a maximum of 44 days. Overall, males have a median hospital stay which is double than that of females (12 days and 6 respectively). The average number of surgical operations, especially "Exploratory laparotomy, total Splenectomy and Surgical closure of lacerations of internal organs (liver and kidney), was 2 (Min: 0, Max: 4). Finally, the median value of the average weight of the DRG relative to interventions provided by the Hospital, is the same for both sexes and is equal to 46091 Euros, with a minimum of 17,349 euros and a maximum of 46091 Euro(Table 5). Conclusions: The normalization of the use of alcohol, in the light of cultural changes prompted by millions of Euros of investments in marketing, advertising and sponsorship of alcohol aimed at creating a value system for use of licit psychoactive substance and more available, which aims to encourage more However considerations and individual and collective well-being, pleasure, seduction, of leadership, has led and continues to lead the phenomena that go beyond the binge drinking and now come to decline it in various forms of hazardous and harmful alcohol consumption, boosted by 'use of technology and social media, as virtual stages, facilitate anyone in need to homologate and make an impact through risk taking and the violation of laws on the legal minimum, fitting in circles nomination and chains on which alcoholic there can be no control. It is a phenomenon which changes, culturally, more and more toward how their dependency on illegal substances, often integrating with other addictions. Virtual reality supplants, in other words, the concrete everyday: the popularity obtained the web is mirrored in the everyday, at school or in sports for many teens. This results in a spirit of idolatry if it is popular, a sense of marginalization and challenge to be "cool" if, on the contrary, you do not have an appropriate retinue in Social. And technology companies, well aware of the results of prorpi products on kids, continue to bring to market applications for smartphones, tablets and so on pushing more and more behaviors emulators on the web. The Klout Score, for example, is a tangible proof: it is a social networking service that offers customized statistical analysis on social media. In particular, it estimates the influence of the user through a score (from 0 to 100) obtained the degree of interaction in the user profiles of popular social networking sites, including Twitter, Facebook, Google+, LinkedIn and Foursquare. This influence is obtained from the amplitude of the network user, the generated content, and the feedback level obtained (https://klout.com/corp/score). The birth of NekNomination, Vodka Eyeballing, Butt Chugging and others is relatively recent. Initially concerned mainly beer but the need to dare and to be more popular soon brought teenagers from around the world to compete in these games with any alcoholic beverage they had available, also according to the culture of the country of alcohol: if in Italy and Western Europe consumes more wine, in the countries of Central alcoholic drink is beer cheaper in Eastern Europe you will also have easier access to hard liquor like vodka, which therefore give more effects serious in terms of health. Belts alcoholic Europe are European regions that are considered to be divided by consumption of beer, wine or liquor. Interestingly belts alcoholic beverages refer to traditional countries rather than in what is commonly drunk by the population; Today, in terms of beer consumption has become the most popular alcoholic beverage in the world. By anonymous questionnaires, it follows that 35% of respondents who habitually consume beer and 39% drink normally aperitifs and digestives (Aperol, Campari etc.). Aperitifs alcohol are consumed in 2012 from 31.5% of the population older than 11 years (M: 41.9%; F: 21.7%) The proportion of men aged over 11 years has remained stable compared the previous survey, but by focusing on older age group there was a significant increase in consumer amounting to 2.9 percentage points.The data collected through the study in question do reflect on the importance of dealing with behavior and health of young people who are tomorrow's adults. It is therefore necessary among adolescents to improve the living environment with an integrated approach and policies to prevent large-scale, combating tobacco consumption, obesity, physical inactivity, alcohol abuse and substance. The new games Alcohol encourage young people to consume large amounts of alcohol in a short period of time, putting them at risk of alcohol poisoning, which can potentially cause accidental injuries, unprotected sex, suicide, sexual violence and traffic accidents. This study showed that the frequency of these events is on the rise thanks to the widespread use and often indiscriminate "social media", and for this reason there may be an increase in the number of acute alcohol intoxication, severe trauma. Using the Internet it can be negatively associated with behavioral and social maladjustment among adolescents, and combining this with the fact that it can be a powerful source of pressure among peers with almost no direct link with the person concerned, may represent a potentially dangerous. It is, therefore, a need for greater awareness in order to prevent future incidents and also a deeper understanding of which population subgroups are most at risk, in order to establish a defensive and preventive education strategy. Emergency Physicians (as well as educators and in general all those who work in health care) that assist in these situations, have a responsibility to help identify and prevent the spread of these patterns of behavior, especially when there is a risk that they become hazardous to the health of an individual or of other persons. The alarming increase in the number of hospitalizations due to intoxication by alcohol unintentional adolescence, for neknomination, vodka eyeballing, butt chugging etc., And consequences of the absence of relevant interventions and adults, in all these cases, register exclusively on subjects defined as "disadvantaged" but more and more often in boys and girls around the world coming to characterize a social failure of education that swept reality increasingly heterogeneous and wide of too many young teens, as evidenced by the use of the services health care for the effects and consequences of drinking and alcohol-related mortality data they see alcohol as a leading cause of premature and avoidable death among young people. The questionnaires described in this work, while not constituting a survey of epidemiological, represented a pause for thought about the cescente impact of technology on adolescents. Future studies, conducted with epidemiological criteria and extended not only to the country but also the European, allow you to analyze and understand the true extent of the problem, developing prevention campaigns and education that is not only healthy regard to persons directly concerned but also the teaching staff and parents. The knowledge of the events described in quesa investigation would, in terms of medical and hospital, a better management of critically ill patients, with optimization of time and resources.

  • Remote monitoring of patients with heart failure: An overview of Systematic Reviews

    From: Journal of Medical Internet Research

    Date Submitted: Sep 8, 2016

    Open Peer Review Period: Sep 9, 2016 - Nov 4, 2016

    Background: Many systematic reviews exist on Remote Patient Monitoring (RPM) interventions to improve clinical outcomes and psychological wellbeing of patients with heart failure (HF). However, resear...

    Background: Many systematic reviews exist on Remote Patient Monitoring (RPM) interventions to improve clinical outcomes and psychological wellbeing of patients with heart failure (HF). However, research is broadly distributed from simple telephone based to highly technology based interventions. The scope and focus of such evidence also vary widely, creating challenges for clinicians who seek information on the effect of RPM interventions. Objective: The aim of this article is to investigate the effects of RPM interventions on the health outcomes of HF patients by synthesising review-level evidence. Methods: We searched CINAHL, PubMed, EMBASE and the Cochrane Electronic Library from 2005 to 2015.We screened reviews based on relevance to RPM interventions using criteria developed for this overview. Using the standardised forms, we extracted information from systematic reviews. Independent authors screened, selected and assessed reviews for methodological quality. We used standardised language to summarise results across reviews and provide final statements about intervention effectiveness. Results: 19 systematic reviews met our inclusion criteria. Reviews consisted of RPM with diverse interventions such as tele-monitoring, home telehealth, mobile phone based monitoring and video conferencing. All cause and HF mortality were the most frequently-reported outcomes, but others such as quality of life, rehospitalisation, emergency visits and length of stay were also reported. Self-care and knowledge were less commonly identified. Conclusions: Tele-monitoring and home telehealth appear generally effective to improve HF rehospitalisation and to reduce mortality. Other interventions including the use of mobile phone and videoconferencing require further investigation.

  • Opportunities and Challenges of Behavior Change Support Systems for Enhancing Habit Formation: Qualitative Study

    From: Journal of Medical Internet Research

    Date Submitted: Sep 9, 2016

    Open Peer Review Period: Sep 9, 2016 - Nov 4, 2016

    Background: Calls for action to break down the global burden of obesity have arisen, where already 5% weight loss can reduce the significantly prevalence of metabolic syndrome. Studies of health Behav...

    Background: Calls for action to break down the global burden of obesity have arisen, where already 5% weight loss can reduce the significantly prevalence of metabolic syndrome. Studies of health Behavior Change Support Systems (hBCSS) have been made, where individuals use the system to influence their own attitude or behavior to achieve their personal goals. However hardly any research have been made to study how users perceive habit formation with the help of eHealth intervention, not to mention how to design information systems aimed to particularly enhance habit formation. Habits are considered to play a fundamental role in behavior change, and the formation of healthy habits may be the key to aid maintenance beyond the intervention period. Objective: The objective of this article is to study hBCSS users’ experiences regarding habit formation of system use and healthier lifestyle. In addition this study aims to compare elements of PSD model with stages of habit formation suggested by Lally and Gardner. Methods: This study employs a web based hBCSS named Onnikka, a lifestyle intervention designed for prevention of metabolic syndrome for participants who are at risk of developing a metabolic syndrome or already suffering from it. A total of 43 Onnikka users were interviewed for this study during and after a 52-week eHealth-intervention period. The system was designed according to the principles of the Persuasive System Design (PSD) model and Behavior Change Support System framework. The research approach here is hermeneutics, which leans ontologically to social construction of reality, gained through language, consciousness, and shared meaning. Lally and Gardner’s research on stages of habit formation is used as a lens to explain data. In addition, the system’s login data and subjects’ weight measurements were utilized to build an interpretation of the results. Results: Habit formation stages provide possible explanation for why self-monitoring, reminders and tunneling were perceived as valuable features in this research case. The findings of this study suggest that IT habits appear to have a strong linkage with use adherence, whereas lifestyle habits did not seem to resonate with the 5% weight loss among subjects. Conclusions: Complete lifestyle change is highly complex activity where behavior change in one area might not be sufficient for sustainable weight management. Holistic eHealth interventions are needed to support weight loss, and stages of habit formation provide valuable guidance for hBCSS design. PSD model can offer practical design tools for developing a eHealth intervention system development that enhances also habit formation.

  • Filtering entities to optimize ADR identification from social media: how can the number of words between entities in the messages help?

    From: Journal of Medical Internet Research

    Date Submitted: Sep 1, 2016

    Open Peer Review Period: Sep 1, 2016 - Oct 27, 2016

    Background: With the increasing popularity of web 2.0 applications, social media has made it possible for individuals to post messages on adverse drug reactions. In such online conversations, patients...

    Background: With the increasing popularity of web 2.0 applications, social media has made it possible for individuals to post messages on adverse drug reactions. In such online conversations, patients discuss their symptoms, medical history, and diseases. These disorders may correspond to adverse drug reactions (ADRs) or any other medical condition. Therefore, methods must be developed to distinguish between false positives and true ADR declarations. Objective: We investigated a method for filtering out disorder terms that did not correspond to adverse events by using the distance between the drug term and the disorder/symptom term in the post. Methods: We analyzed a corpus of 648 messages corresponding to a total of 1 654 (drug, disorder) pairs from five French forums using Gaussian mixture models and an expectation-maximization (EM) algorithm. Results: The distribution of the distances between the drug term and the disorder term enabled the filtering of 50 % of the disorders that were not ADRs. Conclusions: This study suggests that such distance between terms can be used for identifying false positives, thereby improving ADR detection in social media.

  • Online Physician Rating Sites in Germany: Developments in the Frequency of Ratings and Evaluation Tendencies Compared with 2010 Baseline

    From: Journal of Medical Internet Research

    Date Submitted: Sep 1, 2016

    Open Peer Review Period: Sep 1, 2016 - Oct 27, 2016

    Background: At the beginning of 2010, the frequency of ratings and evaluation tendency on six German-language physician rating sites (PRSs) were investigated. This forms the basis for the present re-e...

    Background: At the beginning of 2010, the frequency of ratings and evaluation tendency on six German-language physician rating sites (PRSs) were investigated. This forms the basis for the present re-examination of PRSs, five years later. Objective: To examine the frequency of ratings and evaluation tendency of selected German-language PRSs and to compare these data with 2010 results. Methods: A total of 298 randomly selected physicians from the physician associations in Hamburg and Thuringia were searched for in 7 German-language PRSs regarding the quantity and quality of ratings. Results: Overall, between 64% and 95% of the physicians from the random sample could be identified on the selected PRSs. The average rating remains very positive and has improved even further towards “very good” since 2010. The average number of ratings per physician ranged from 1.2 to 8.9 across PRSs. While this represented an increase (range in 2010 was from 1.1 and 3.9), this increase reflects one more rating per physician per year. Conclusions: Further research is needed to identify barriers for patients to rate their physicians, to assist efforts to increase the number of ratings on PRSs, and therefore, improve the fairness and practical importance of PRSs. Clinical Trial: N/A

  • Developing a curriculum for ICT use in global health research and training: A qualitative study among Chinese health science graduate students

    From: Journal of Medical Internet Research

    Date Submitted: Aug 31, 2016

    Open Peer Review Period: Aug 31, 2016 - Oct 26, 2016

    Background: Rapid development of Information and communication technology (ICT) during the last decade have transformed biomedical and population based research and have become an essential part of ma...

    Background: Rapid development of Information and communication technology (ICT) during the last decade have transformed biomedical and population based research and have become an essential part of many types of research and educational programs. However, access to these ICT resources and the capacity to use them in global health research are often lacking in low and middle income country (LMIC) institutions. Objective: This study assesses the needs, barriers, and opportunities for developing an ICT training curriculum for use by researchers in China to build their capacity in using ICT for global health research and training. Methods: Nine Focus groups discussions (FGDs) were conducted during December 2015- March 2016, involving 74 graduate students studying in areas of health sciences from six medical universities in southern China. All FGDs were audio recorded and analyzed thematically. Results: Researchers had different views and arguments about the use of ICT which are summarized under five themes: 1) ICT use in routine research, 2) ICT related training and training experience; 3) 3) understanding about the pros and cons of online training, 4) suggestions about the design of ICT training curriculum, and 5) potential challenges to promoting ICT courses and related marketing strategies for ICT training curriculum. Many graduate students used ICT on a daily basis in their research, to stay up-to-date on current development in their area of research or study or practice. The participants were very willing to participate in ICT courses that were relevant to their academic majors and would count credits. They found the affordability and flexibility of on line training very important, and said it would also save them time. Suggestion for an ICT curriculum included: i) both organized training course or short lecture series, depending on the background and specialty of the students; ii) a mixture of lecture and on-line activities, and iii) inclusion of topics that are career focused. Conclusions: The findings of the current study suggest that a need exists for a specialized curriculum related to ICT use in health research for health sciences graduate students in China. The results have important implications for the design and implementation of ICT-related educational program in China or other developing countries.

  • Preventing depression in adults with subthreshold depression: health-economic evaluation alongside a pragmatic randomised controlled trial of a web-based intervention

    From: Journal of Medical Internet Research

    Date Submitted: Aug 31, 2016

    Open Peer Review Period: Aug 31, 2016 - Oct 26, 2016

    Background: Psychological interventions for the prevention of depression might be a cost-effective way to reduce the burden associated with depressive disorders. Objective: To evaluate the cost-effect...

    Background: Psychological interventions for the prevention of depression might be a cost-effective way to reduce the burden associated with depressive disorders. Objective: To evaluate the cost-effectiveness of a web-based guided self-help intervention to prevent major depressive disorder (MDD) in people with subthreshold depression. Methods: A pragmatic randomised controlled trial was conducted with follow-up at 12 months. Participants were recruited from the general population via a large statutory health insurance company and an open access website. Participants were randomised to a web-based guided self-help intervention (i.e. cognitive-behavioural therapy and problem-solving therapy assisted by supervised graduate students or health care professionals) in addition to usual care or to usual care supplemented with web-based psycho-education (enhanced usual care). Depression-free years (DFYs) were assessed by blinded diagnostic raters using the telephone-administered Structured Clinical Interview for DSM-IV Axis Disorders at 6- and 12-month follow-up, covering the period to the previous assessment. Costs were self-assessed through a questionnaire. Costs measured from a societal and health care perspective were related to DFYs and quality-adjusted life years (QALYs). Results: In total, 406 participants were enrolled in the trial. The mean treatment duration was 5.84 (SD 4.37) weeks. On average, participants completed 4.93 of 6 sessions. Significantly more DFYs were gained in the intervention group (0∙82 vs 0∙70). Likewise, QALY health gains were in favour of the intervention, but only statistically significant when measured with the more sensitive SF-6D. The incremental per-participant costs were €136 (£116). Taking the health care perspective and assuming a willingness-to-pay of €20,000 (£17,000), the intervention’s likelihood of being cost-effective was 99% for gaining a DFY, 64% or 99% for gaining an EQ-5D or a SF-6D QALY. Conclusions: Our study supports guidelines recommending web-based treatment for subthreshold depression and adds that this may not only restore health in people with subthreshold depression, but in addition reduces the risk of developing a MDD. Offering the intervention has an acceptable likelihood of being more cost-effective than enhanced usual care and could therefore reach community members on a wider scale. Clinical Trial: German Clinical Trials Register DRKS00004709, http://www.drks.de/DRKS00004709 (Archived at: http://www.webcitation.org/6kAZVUxy9)

  • Seeking Web-Based Information about Attention Deficit Hyperactive Disorder (ADHD): Where, What and When

    From: Journal of Medical Internet Research

    Date Submitted: Aug 30, 2016

    Open Peer Review Period: Aug 30, 2016 - Oct 25, 2016

    Background: Attention Deficit Hyperactive Disorder (ADHD) is a common neuro-developmental disorder, prevalent among 3-10% of the population. Objective: The objective of the current study was to descri...

    Background: Attention Deficit Hyperactive Disorder (ADHD) is a common neuro-developmental disorder, prevalent among 3-10% of the population. Objective: The objective of the current study was to describe where, what and when people search the web for topics related to ADHD. Methods: Data was collected from Microsoft’s Bing search engine and from the community question and answer site, Yahoo Answers. The questions were analyzed based on keywords and using further statistical methods. Results: Our results revealed that the internet indeed constitutes a source of information for people searching the topic of ADHD, and that they search for information mostly about ADHD symptoms. Furthermore, individuals personally affected by the disorder made 2.0 more questions about ADHD compared to others. Questions begin when children reach 2 years of age, with an average age of 5.1 years. Most of the websites searched were not specifically related to ADHD and the timing of searches as well as the query content were different among those pre-diagnosis compared to post-diagnosis. Conclusions: The study results shed light on the features of ADHD-related searches. Thus, they may help improve the web as a source of information, and promote improved awareness and knowledge of ADHD as well as quality of life for populations dealing with the complex phenomena of ADHD.

  • Planking: The “Lying Down Game” News In “Accidental Falls”

    From: JMIR Serious Games

    Date Submitted: Aug 28, 2016

    Open Peer Review Period: Aug 30, 2016 - Oct 25, 2016

    The monitoring and management of risks regarding children and young people admitted to Emergency as a result of dangerous behaviour “distributed via the internet”, should be based on clinical reas...

    The monitoring and management of risks regarding children and young people admitted to Emergency as a result of dangerous behaviour “distributed via the internet”, should be based on clinical reasoning. Some data now available describe a relatively new game: planking, also known as the "lying-down game". A key element of this research study is to report physicians’ misperceptions concerning planking and, with these cases, used for teaching purposes, to improve knowledge of the clinical and forensic aspects of this emerging problem. Adolescents often choose unusual and sometimes dangerous places to increase the number of their "likes" in social media, often with some new "game" like planking,. The poses of the people photographed while planking are unusual. Analysis of published data shows that traumatic lesions may occur as a result of planking, which has probably had little effect on the number of immediate fatalities, but these results can be projected to other trauma centres and processed to create injury surveillance data. Previous studies have shown how much trauma costs. Reporting these cases may potentially prevent future traumatic events occurring in similar circumstances: the scientific community cannot leave this problem unaddressed.

  • Lessons from recruitment to an internet based survey for Degenerative Cervical Myelopathy: merits of free and fee based methods

    From: Journal of Medical Internet Research

    Date Submitted: Aug 28, 2016

    Open Peer Review Period: Aug 30, 2016 - Oct 25, 2016

    Background: Degenerative Cervical Myelopathy [DCM] is a syndrome of subacute cervical spinal cord compression due to spinal degeneration. Although DCM is common, patient pathways are underdeveloped an...

    Background: Degenerative Cervical Myelopathy [DCM] is a syndrome of subacute cervical spinal cord compression due to spinal degeneration. Although DCM is common, patient pathways are underdeveloped and a unified treatment approach is lacking. Moreover, fundamental questions, such as the natural history of DCM remain to be answered. The internet has become an attractive tool for medical research, including internet health surveys, with its unrivalled, efficient reach. The most effective recruitment strategy is unknown. Objective: To compare the efficacy of fee based advertisement with alternative free recruitment strategies to a DCM internet health survey. Methods: An internet health survey (Survey Monkey ®), accessed by a new DCM internet platform (myelopathy.org) was created. Using multiple survey collectors and the website Google Analytics ®, the efficacy of fee based recruitment strategies (Google Adwords ®) and free alternatives (including Facebook ®, Twitter ® and Myelopathy.org) were compared. Results: Overall, 772 surveys (513, 66% fully complete) were completed, 305 (40%) from fee based strategies and 455 (59%) from free alternatives. Accounting for researcher time, fee based strategies were more expensive ($7.8/response vs $3.8/response) and identified a less motivated audience (Click-Through-Rate 5% vs 57%) but were more time efficient for the researcher (2mins/response vs 16mins/response). Facebook ® was the most effective free strategy, providing 239 (31%) responses; a single message to 4 existing communities yielded 133 (17%) responses within 7 days. Conclusions: The internet can efficiently reach large numbers of patients. Free and fee based recruitment strategies both have merits. Facebook communities are a rich resource for internet researchers. Clinical Trial: N/A

  • Remote Monitoring of Hypertension Diseases in Pregnancy

    From: JMIR mHealth and uHealth

    Date Submitted: Aug 26, 2016

    Open Peer Review Period: Aug 30, 2016 - Oct 25, 2016

    Background: Although remote monitoring has proven its added value in various healthcare domains, little is known about the remote follow-up of pregnant women diagnosed with a gestational hypertensive...

    Background: Although remote monitoring has proven its added value in various healthcare domains, little is known about the remote follow-up of pregnant women diagnosed with a gestational hypertensive disorder (GHD). Objective: To evaluate the added value of a remote follow-up program for pregnant women diagnosed with GHD. Methods: A one year retrospective study was performed in the outpatient clinic of a 2nd level prenatal center where pregnant women with GHD received remote monitoring (RM) or conventional care (CC). Study endpoints include number of prenatal visits and admissions to the prenatal observation ward, gestational outcome, mode of delivery, neonatal outcome and admission to neonatal intensive care (NIC). Differences in continuous and categorical variables were tested using Student’s two sampled t-test and the χ² test, respectively, at nominal level α = 0.05. Results: Of 166 patients diagnosed with GHD, 53 received RM and 113 CC. After excluding 9 patients in the RM group and 15 in de CC group because of missing data, 44 patients in RM group and 98 in CC group were taken into final analysis. Both groups had similar demographics. The RM group had more women diagnosed with gestational hypertension but less with pre-eclampsia when compared with CC (79.55% versus 42.86% and 15.91% versus 43.88%). The RM group had less hospital and NIC admissions together with less hospital stay until delivery when compared with CC (31.81% versus 74.47%; 11.36% versus 31.63% and 18.18% versus 64.24%). A spontaneous start of the birth process was more likely and less inductions occurred in RM than in CC (56.81% versus 31.63% and 27.27% versus 48.98%). Conclusions: A RM follow – up of women with GHD is a promising tool in the obstetrician care. It opens the perspectives to reverse the current evolution of antenatal interventions leading to more interventions and as such to ever increasing medicalized antenatal care.

  • Internet Use, eHealth Literacy and Attitudes Toward Computer/Internet Among People with Schizophrenia-Spectrum Disorders: A Cross-Sectional Study in Two Distant European Regions

    From: Journal of Medical Internet Research

    Date Submitted: Aug 26, 2016

    Open Peer Review Period: Aug 30, 2016 - Oct 25, 2016

    Background: Individuals with schizophrenia-spectrum disorders use the Internet for general and health-related purposes, such as searching for health information. However, their ability to find, unders...

    Background: Individuals with schizophrenia-spectrum disorders use the Internet for general and health-related purposes, such as searching for health information. However, their ability to find, understand, and apply the health information they acquire online in order to make appropriate health decisions – known as eHealth literacy – has never been investigated. The European agenda strives to limit health inequalities and enhance mental health literacy. Nevertheless, each European member state varies in levels of Internet use and online health information-seeking. Various studies have described Internet use of adults with mental illness; however, few have focused on their eHealth literacy and on their attitudes toward computer/Internet. Objective: To examine computer/Internet use for general and health-related purposes, eHealth literacy, and attitudes toward computer/Internet among adults with schizophrenia-spectrum disorders from two distant European regions. Methods: Data were collected from mental health services of psychiatric clinics in Finland (FI) and Greece (GR). A total of 229 patients (FI=128, GR=101) participated in the questionnaire survey. The data analysis included evaluation of frequencies and group comparisons with multiple linear and logistic regression models. Results: The majority of Finnish participants were current Internet users (FI=111, 87%, vs. GR=33, 33%, P<0.0001), while the majority of Greek participants had never used computers/Internet (GR=60, 59%, vs. FI=14, 11%, P<0.0001), mostly due to their perception that they do not need it. In both countries, more than half of Internet users used the Internet for health-related purposes (FI=61, 55%, vs. GR=20, 61%). The eHealth literacy of Internet users (previous and current Internet users) was found significantly higher in the Finnish group (FI: Mean=27.05, SD 5.36; GR: Mean=23.15, SD=7.23, P<0.0001) upon comparison with their Greek counterparts. Attitudes toward Computer/Internet of never Internet users was found to be higher in the Greek group (GR: Efficacy Mean=3.06, SD=.86, P=.58; Interest Mean=3.16, SD=.50) when compared to the Finnish group (FI: Efficacy Mean=2.93, SD=.81; Interest Mean=2.60, SD=.67, P<0.0001). For current Internet users, Internet use patterns were significantly different between country groups regarding: location and frequency of Internet access, ease of locating website, and reasons for Internet use. When adjusting for gender, age, education and disease duration, country was a significant predictor of frequency of Internet use, eHealth literacy and Interest (ATC/IQ component). The Finnish group of Internet users scored higher in eHealth literacy, while the Greek group of never Internet users had a higher Interest in computer/Internet. Conclusions: eHealth literacy is either moderate (Finnish group) or low (Greek group). Thus, exposure to ICT and eHealth skills training are needed for this population. Recommendations to improve the eHealth literacy and access to health information among these individuals are provided.

  • MONItoring and TELetransmission of medical data in Heart Failure. Rationale and design of the MONITEL-HF project

    From: Journal of Medical Internet Research

    Date Submitted: Aug 26, 2016

    Open Peer Review Period: Aug 28, 2016 - Oct 23, 2016

    Background: Frequent hospitalisation of patients with heart failure (HF) is a key clinical problem worldwide. Remote patient monitoring (RPM) has emerged as promising tool for early identification o...

    Background: Frequent hospitalisation of patients with heart failure (HF) is a key clinical problem worldwide. Remote patient monitoring (RPM) has emerged as promising tool for early identification of pending decompensation and prevention of further deterioration. The use of data from implanted ICD/CRT-D may be useful, but differences in RPM systems provided by different manufacturers impede standardized data analysis. Large proportion of patients with HF do not have indication for implantation; in such individuals RPM needs a non-invasive approach. The advent of miniaturized sensors enabling registration of numerous physiological parameters along with new teletransmission techniques open new era in multiparametric monitoring and intervention aimed at preservation of stability instead of treatment of established pathology. Objective: Our project run by Consortium MONITEL-HF consisting of 8 institutions has 3 objectives: - To design and develop biosensor device enabling non-invasive, individually customizable monitoring of patients with different HF phenotypes (EXTRABIOTEL-HF study), - To create an integrated information platform which will enable RPM either using any kind of implanted ICD/CRT-D, or by dint of individually customised non-invasive, biosensor network, provided to patients without implanted ICD/CRT-D, - To investigate whether teletransmission, telemonitoring and appropriate management of data collected from ICD/CRT-D of different manufacturers will reduce the number of hospitalisations, improve the quality of life and reduce treatment costs (RESULT study). Methods: The project contains three components, two developmental and one clinical. The first component is the development of information platform. This telematic infrastructure will give the technical base for recording, collection and standardized analysis of data from all kinds of implanted ICD/CRT-D, as well as from non-invasive device. This non-invasive device will be designed in second developmental component of the project. This study will start with survey of the market for miniaturised biosensors and its components suitable for integration with textile. The measurements of various biological signals provided by sensors will be tested against gold standard. In the next step, reproducibility of measurements in healthy persons and in HF population will be carried out. Finally, we will test the reliability of sensor`s network to transmit signals into the information platform. The clinical component of the project is the prospective, randomised, open-label study of 600 HF participants to show whether RPM from ICD/CRT-D delivered by different companies, recorded and analysed in a standardized fashion using information platform will reduce hospitalisations, improve quality of life and diminish costs of therapy in this population. Results: We expect that design and creation of proper information infrastructure for both invasive and non-invasive RPM and provision of proof to lower cost, will give rise to inclusion of procedures of RPM into the catalogue of treatment methods reimbursed by the State. This is in our opinion necessary step towards better and more economically efficient treatment of patients with HF in Poland. Conclusions: The project MONITEL-HF will give as a technological toll indispensable to initiate and expand RPM of heart failure in Poland. Clinical Trial: ClinicalTrials.gov - NCT02409225

  • Analyzing mHealth: Joint Models for Intensively Collected User Engagement Data

    From: JMIR mHealth and uHealth

    Date Submitted: Aug 19, 2016

    Open Peer Review Period: Aug 26, 2016 - Oct 21, 2016

    Background: Evaluating engagement with an intervention is a key component of understanding its efficacy. With an increasing interest in developing behavioral interventions in the mobile health (mHealt...

    Background: Evaluating engagement with an intervention is a key component of understanding its efficacy. With an increasing interest in developing behavioral interventions in the mobile health (mHealth) space, appropriate methods for evaluating engagement in the mHealth context is necessary. Data collected to evaluate mHealth interventions are often collected much more frequently than those for clinic-based interventions. Additionally, missing data on engagement is closely linked to level of engagement resulting in the potential for informative missingness. Thus, models that can accommodate intensively collected data and can account for informative missingness are required for unbiased inference when analyzing engagement with an mHealth intervention. Objective: The objective of this paper is to demonstrate the utility of a joint modeling approach to longitudinal engagement data in mHealth research. Methods: Engagement data from an evaluation of an mHealth intervention designed to support illness management among people with schizophrenia is analyzed. A joint model is applied to the longitudinal engagement outcome and time-to-dropout to allow unbiased inference on the engagement outcome. Results are compared to separate naïve models that do not account for the relationship between drop-out and engagement. Results: The joint model shows a strong relationship between engagement and reduced risk of dropout. Using the mHealth app one day more per week was associated with a 33% decreased risk of dropout (P<.001). The decline in engagement over time was steeper when the joint model was used in comparison with the naïve model. Conclusions: Naïve longitudinal models that do not account for informative missingness in mHealth data produce biased results. Joint models are appropriate for modeling intensively collected engagement outcomes in mHealth intervention research. Clinical Trial: Trial Registration: ClinicalTrials.gov NCT02364544.

  • An Online Group-based Self-tracking Program to Increase Fruit and Vegetable Consumption: The Effects of Demographic Similarity, Social Modeling and Performance Discrepancy

    From: Journal of Medical Internet Research

    Date Submitted: Aug 23, 2016

    Open Peer Review Period: Aug 24, 2016 - Oct 19, 2016

    Background: Self-tracking allows people to reflect on their health behaviors and make improvements accordingly to achieve a health goal. Web-based interventions with a self-tracking component have bee...

    Background: Self-tracking allows people to reflect on their health behaviors and make improvements accordingly to achieve a health goal. Web-based interventions with a self-tracking component have been found to be effective in promoting adults’ fruit and vegetable consumptions (FVC). However, these interventions primarily focus on individual- rather than group-based self-tracking. The rise of social media technologies enables sharing and comparing self-tracking records in a group context. Therefore, we develop an online group-based self-tracking program to promote FVC in early young adults, who are at an important stage of developing food patterns that will affect their future. Objective: This study aims to examine (1) the effectiveness of online group-based self-tracking on FVC, and (2) composition characteristics of online self-tracking groups that make the group more effective in promoting FVC in early young adults. Methods: During a 4-week web-based experiment, 113 college students self-tracked their FVC either individually (i.e., the control group) or in an online group characterized by a 2 (demographic similarity: demographically similar vs. demographically diverse) × 2 (social modeling: incremental-change vs. ideal-change) experimental design. Each online group consisted of one focal participant and three confederates as group members whose demographics and FVC were manipulated to create the four treatment groups. Self-reported FVC were assessed using the food frequency questionnaire at baseline and after the 4-week experiment, and were recorded using participants’ self-tracking messages during the 4-week experiment. Results: Participants who self-tracked their FVC collectively with other group members consumed more FV than participants who self-tracked their FVC individually, P = .02, η2 = .08, controlling for demographics, BMI, baseline FVC and meal plan enrollment. The results did not show significant main effects of demographic similarity (P = .47) or types of social modeling (P = .54) in making self-tracking groups more effective in promoting FVC. However, additional analyses revealed the main effect of performance discrepancy (i.e., difference in FVC between a focal participant and his/her group members during the 4-week experiment), such that participants who had a low performance discrepancy from other group members consumed greater FVC than participants who had a high performance discrepancy from other group members, P = .003, η2 = .16. A mediation test showed that low performance discrepancy led to greater downward contrast (b = -0.78, CI = [-2.44, -0.15]), which in turn, led to greater FVC. Conclusions: Online self-tracking groups with models consistently increasing their FVC were more effective than self-tracking alone in promoting FVC for early young adults. Low performance discrepancy from models would lead to downward contrast, which in turn, increased participants’ FVC over time. The study highlighted social comparison processes in online groups that allow for sharing personal health information.

  • Redirecting behavioural cues using technology: Is there a role for the use of social media in conjunction with activity trackers?

    From: Journal of Medical Internet Research

    Date Submitted: Aug 18, 2016

    Open Peer Review Period: Aug 23, 2016 - Oct 18, 2016

    Recent work by Cole-Lewis and colleagues explored the use of health promotion tools within social media to better understand complex network analyses. However, there is a lack of evidence on the use o...

    Recent work by Cole-Lewis and colleagues explored the use of health promotion tools within social media to better understand complex network analyses. However, there is a lack of evidence on the use of social media and activity trackers in conjunction to augment health behaviours. This is a novel strategy and we propose its use in combating the growing obesity epidemic.

  • A smarter pathway for delivering cue exposure therapy? The design and development of a smartphone application targeting alcohol use disorder.

    From: Journal of Medical Internet Research

    Date Submitted: Aug 19, 2016

    Open Peer Review Period: Aug 19, 2016 - Oct 14, 2016

    Background: While the number of alcohol-related treatments in app stores is proliferating, none of them are based on a psychological framework and supported by empirical evidence. Cue exposure treatme...

    Background: While the number of alcohol-related treatments in app stores is proliferating, none of them are based on a psychological framework and supported by empirical evidence. Cue exposure treatment (CET) with urge-specific coping skills (USCS) is often used in Danish treatment settings. It is an evidence-based psychological approach that focuses on promoting `confrontation with alcohol cues’ as a means of reducing urges and the likelihood of relapse. Objective: This paper describes the design and development of a CET-based smartphone application; an innovative delivery pathway for treating alcohol use disorder (AUD). Methods: The treatment is based on Monty and co-workers’ manual for CET with USCS (2002). It was created by a multidisciplinary team of psychiatrists, psychologists, engineers and graphic designers as well as patients with AUD. A database was developed for the purpose of registering and monitoring training activities. A final version of the CET app and database was developed after several user tests. Results: The final version of the CET app includes: an introduction, 4 sessions featuring USCS, 8 alcohol exposure videos promoting the use of one of the USCS, and a results component providing an overview of training activities and potential progress. Real-time urges are measured before, during and after exposure to alcohol cues and are registered in the app together with other training activity variables. Data packages are continuously sent in encrypted form to an external database, and will be merged with other data (in an internal database) in the future. Conclusions: The CET smartphone app is currently being tested in a large-scale, randomized controlled trial with the aim of clarifying whether it can be classified as an evidence-based treatment solution. The app has the potential to augment the reach of psychological treatment for AUD. Clinical Trial: ClinicalTrials.gov ID: NCT02298751 Registration date: 6 November 2014

  • Comparison of ecological momentary assessment versus direct measurement of e-cigarette use with a Bluetooth-enabled e-cigarette: a pilot study

    From: Journal of Medical Internet Research

    Date Submitted: Aug 15, 2016

    Open Peer Review Period: Aug 16, 2016 - Oct 11, 2016

    Background: Background: Assessing the frequency and intensity of e-cigarette use presents special challenges beyond those posed by cigarette use. Accurate measurement of puff counts, the duration of a...

    Background: Background: Assessing the frequency and intensity of e-cigarette use presents special challenges beyond those posed by cigarette use. Accurate measurement of puff counts, the duration of an e-cigarette puff, and the stability of these measures is the basis for estimating the behavioral and health effects of e-cigarette use. Objective: Objective: The purpose of this pilot study was to: 1) examine the feasibility of capturing e-cigarette puff behavior via ecological momentary assessment (EMA) by comparing daily EMA self-reported e-cigarette puff counts to objective puff data from a Bluetooth-enabled e-cigarette device; and, 2) to examine the feasibility and acceptability of using a second-generation e-cigarette among adult smokers. A secondary objective was to demonstrate the utility of e-cigarette EMA data for understanding the e-cigarette trial period, including examining the interaction between e-cigarette and cigarette consumption. Methods: Methods: Five adult smokers were enrolled in a 3-week longitudinal parent study assessing how e-cigarette use affects cigarette use among e-cigarette naïve smokers. Using a text message-based EMA system, participants reported cigarette smoking for one week, followed by cigarette smoking and e-cigarette puffs for two weeks. Participants were also given a Bluetooth-enabled e-cigarette (“Smokio”) that passively collected puff counts and puff duration. Comparisons between mean reports of Smokio (device report) and EMA (self-report) use were evaluated using paired t-tests. Correlation and agreement between device- and self-reports were evaluated using Pearson correlation and the concordance correlation coefficient (CCC), respectively. Results: Results: Five African American participants, 4 men and 1 woman, with a mean age of 38.8 years (SD=13.8) completed the study, resulting in 5,180 observations (device report) of e-cigarette use. At baseline, participants reported smoking for an average of 14.4 years (SD=8.5) and consumed a mean of 9 cigarettes per day (CPD; SD=3.5); 4 smoked within 30 minutes of waking. At the 30-day follow-up, CPD decreased to 1.8 (SD=2.3), 4 participants reported past 7-day e-cigarette use, and 1 participant reported no cigarette smoking in the past 7 days. Over 2 weeks of e-cigarette use, participants took an average of 1,074 e-cigarette puffs (SD=779.0) per person as captured by the device reports. Each participant took a mean of 75.0 puffs (SD=58.8) per day, with each puff lasting an average of 3.6 seconds (SD=2.4). Device reports captured an average of 33.3 more puffs per person per day (SD=47.8) than the self-reported e-cigarette puffs. In 87% of days, participants underestimated the number of puffs they had taken on the Smokio. There was significant moderate correlation (r = 0.47, p=0.0001) but poor agreement (pc=0.31, 95% CI: 0.15, 0.46) between the device- and self-reported data. Conclusions: Conclusions: EMA is a feasible method for collecting e-cigarette puff data; however, a Bluetooth-enabled device captured significantly more e-cigarette use and allowed for examination of puff duration in addition to puff counts.

  • What drives young Vietnamese to use M-health innovations? An insight into the patterns of smartphone usage and user preferences of mobile applications

    From: Journal of Medical Internet Research

    Date Submitted: Aug 12, 2016

    Open Peer Review Period: Aug 12, 2016 - Oct 7, 2016

    Background: Low and Middle - income countries, such as Vietnam, are becoming more connected to the Internet. In addition, aside to the increased penetration and proliferation of Internet services, th...

    Background: Low and Middle - income countries, such as Vietnam, are becoming more connected to the Internet. In addition, aside to the increased penetration and proliferation of Internet services, there has also been an eight times increment in the absolute number of mobile subscriptions in this period. There has been prior research looking at the attitudes of the general population towards smartphone and smartphone applications, as well as how smartphone have helped in terms of self-management of medical disorders Objective: With the increased penetration of Internet and smartphone devices in countries like Vietnam, it is the aim and objective of this current research article to look into the patterns of usage of smartphone applications as well as the preferences with regards to the functionalities of smartphone based applications. Methods: In order to achieve the study objectives, an online cross-sectional study was conducted from August 2015 to October 2015 in Vietnam. The Vietnam Authority of HIV/AIDS Control provided the ethical approval for the current research project. Response-driven sampling technique (RDS) was utilized in the recruitment of participants. The online questionnaire was programmed and implemented using Google Form. The web-based questionnaire that was conceptualized included the following parts: a) Baseline demographics; b) Smartphone usage pattern; c) Attitudes towards existing Smartphone applications and d) Preferences for a smartphone application. Chi-squared, t-test and ANOVA were used to explore the differences of satisfaction among characteristics. A p-value of less than 0.05 was set as the level of statistical significance. Results: A cumulative total of 380 individuals completed the web-based questionnaires, out of which 35.0% (n=133) were males. The vast majority of the participants were between the age groups of 18 to 22 years old, amounting to 77.6% of the entire sample. The vast majority of the participants (54.2%) rated themselves as being intermediate in terms of their proficiency with regards to their knowledge of utilization of a smartphone device. A similar percentage of the participants preferred to download applications for disease prevention (11.1%), as compared to applications for beauty counseling, nutrition counseling and disease treatment, with65.8% of the participants perceiving these applications to be very useful and 52.7% of the participants reported that they were very satisfied with the existing mobile health applications that were available. The vast majority of the participants would prefer applications that they could download and run directly from their smartphone. With regards to the contents of the applications, they would prefer there to be a balance between visuals as well as text-based information and participants also indicated that it is crucial for smartphone applications to have sharing functionalities, for them to share information onto their own personal social networks. Conclusions: An understanding of the attitudes and user preferences with regards to smartphone applications is essential in the conceptualization and development of appropriate smartphone interventions targeting youths and young adults.

  • E-Health Equity: Current Perspectives

    From: JMIR Medical Informatics

    Date Submitted: Aug 8, 2016

    Open Peer Review Period: Aug 11, 2016 - Oct 6, 2016

    Health justice is something that every country in the world needs. However, the existence of health disparities among different social groups and geographical regions in various countries of the world...

    Health justice is something that every country in the world needs. However, the existence of health disparities among different social groups and geographical regions in various countries of the world is inevitable. These health inequalities are a major obstacle in achieving health justice. There are a number of factors affecting health equity such as socio-economic status, education level, geographical position, racial and ethnical differences, gender minorities, environmental factors, accessibility level to health care services and resources, and also the quality of health care. Although e-health has the potential of eliminating health inequalities leading to the establishment of health justice, it is essential that governments and health policy makers provide some measures to diminish major barriers facing the society members specially the elderly, low-income people, low-educated people, and disabled people when implementing it. This can result in attaining the advantages of e-health for establishing health equity.

  • Opening the black box of eHealth: Collecting, analysing, and interpreting log data

    From: Journal of Medical Internet Research

    Date Submitted: Aug 5, 2016

    Open Peer Review Period: Aug 6, 2016 - Oct 1, 2016

    Background: In most eHealth research, limited insights have been obtained regarding why a particular outcome occurred or how the use of a technology has contributed to the users’ ability to have a h...

    Background: In most eHealth research, limited insights have been obtained regarding why a particular outcome occurred or how the use of a technology has contributed to the users’ ability to have a healthier life, improved wellbeing, or activate new attitudes in their daily tasks. As a result, eHealth is often perceived as a black box. One promising approach to explain why a statistical hypothesis was accepted or not and to identify the unexpected effects of a technology is the analysis of log data. Such analyses of anonymous records of real-time actions performed by each user can provide continuous and objective insights into the actual usage of the technology, and hence open the black box of eHealth. However, until now the possibilities of log data in eHealth research has not been exploited to its fullest extent. Objective: This article describes how log data can be of added value in eHealth research and how to fully exploit its possibilities. This paper serves as a starting point for using log data analysis in eHealth research. Outline: First, an overview of research questions to answer with log data is provided. Secondly, methods for data collection and data preparation are explained, as well as the requirements for the data. In the third part, some methods for data analysis are described. Finally, a conclusion is drawn regarding the importance of the results for both scientific and practical applications. Conclusion: The analysis of log data can be of great value for opening the black box of eHealth. A deliberate log data analysis can give new insights into the usage of the technology and help to improve the persuasiveness and effectiveness of the eHealth technology.

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