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Journal of Medical Internet Research

The leading peer-reviewed journal for digital medicine, and health & healthcare in the Internet age

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

Recent Articles:

  • Source: Wikimedia Commons; Copyright: Sigismund von Dobschütz; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Telemedicine in Primary Care for Patients With Chronic Conditions: The ValCrònic Quasi-Experimental Study


    Background: The increase of chronic diseases prevalence has created the need to adapt care models and to provide greater home supervision. Objective: The objective of our study was to evaluate the impact of telemonitoring on patients with long-term conditions at high risk for rehospitalization or an emergency department visit, in terms of target disease control (diabetes, hypertension, heart failure, and chronic obstructive pulmonary disease). Methods: We conducted a quasi-experimental study with a before-and-after analysis to assess the effectiveness of the ValCrònic program after 1 year of primary care monitoring. The study included high-risk patients with 1 or more of the following conditions: diabetes, high blood pressure, heart failure, and chronic obstructive pulmonary disease. We assessed risk according to the Community Assessment Risk Screen. Participants used an electronic device (tablet) to self-report relevant health information, which was then automatically entered into their eHealth record for consultation. Results: The total sample size was 521 patients. Compared with the preintervention year, there were significant reductions in weight (82.3 kg before vs 80.1 kg after; P=.001) and in the proportion of people with high systolic (≥140 mmHg; 190, 36.5% vs 170, 32.6%; P=.001) and diastolic (≥90 mmHg; 72, 13.8% vs 40, 7.7%; P=.01) blood pressures, and hemoglobin A1c ≥8% (186, 35.7% vs 104, 20.0%; P=.001). There was also a decrease in the proportion of participants who used emergency services in primary care (68, 13.1% vs 33, 6.3%; P<.001) and in hospital (98, 18.8% vs 67, 12.8%; P<.001). Likewise, fewer participants required hospital admission due to an emergency (105, 20.2% vs 71, 13.6%; P<.001) or disease exacerbation (55, 10.5% vs 42, 8.1%; P<.001). Conclusions: The ValCrònic telemonitoring program in patients at high risk for rehospitalization or an emergency department visit appears to be useful to improve target disease control and to reduce the use of resources.

  • Cover of e-book (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Development and Usability Evaluation of an Art and Narrative-Based Knowledge Translation Tool for Parents With a Child With Pediatric Chronic Pain:...


    Background: Chronic pain in childhood is increasingly being recognized as a significant clinical problem for children and their families. Previous research has identified that families want information about the causes of their child’s chronic pain, treatment options, and effective strategies to help their child cope with the pain. Unfortunately, parents have reported that finding this information can be challenging. Objective: The aim of this study was to actively work together with children attending a pediatric chronic pain clinic and their parents to develop, refine, and evaluate the usability of an art and narrative-based electronic book (e-book) for pediatric chronic pain. Methods: A multiphase, multi-method research design employing patient engagement techniques was used to develop, refine, and evaluate the usability of an art and narrative based e-book for pediatric chronic pain management to facilitate knowledge translation for parents with a child with chronic pain. The multiple phases included the following: (1) qualitative interviews to compile parents’ narratives using qualitative interviews; (2) qualitative data analysis; (3) development of an e-book prototype; (4) expert clinician feedback; (5) parent usability evaluation, knowledge change, and confidence in knowledge responses using an electronic survey; (6) e-book refinement; and (7) dissemination of the e-book. Results: A 48-page e-book was developed to characterize the experiences of a family living with a child with chronic pain. The e-book was a composite narrative of the parent interviews and encompassed descriptions of the effects the condition has on each member of the family. This was merged with the best available research evidence on the day-to-day management of pediatric chronic pain. The e-book was vetted for clinical accuracy by expert pediatric pain clinicians. All parents that participated in the usability evaluation (N=14) agreed or strongly agreed the content of the e-book was easy to understand and stated that they would recommend the e-book to other families who have children with chronic pain. Our research identified up to a 21.4% increase in knowledge after using the e-book, and paired t tests demonstrated a statistically significant difference in confidence in answering two of the five knowledge questions (chronic pain is a disease involving changes in the nervous system; the use of ibuprofen is usually effective at controlling chronic pain); t13=0.165, P=.001 and t13=0.336, P=.002, respectively, after being exposed to the e-book. Conclusions: Our results demonstrate that parents positively rated an e-book developed for parents with a child with chronic pain. Our results also identify that overall, parents’ knowledge increased after using the e-book, and confidence in their knowledge about chronic pain and its management increased in two aspects after e-book exposure. These results suggest that art and narrative-based knowledge translation interventions may be useful in transferring complex health information to parents.

  • Source: Wikimedia Commons; Copyright: Jean-Pierre Dalbéra; URL:; License: Creative Commons Attribution (CC-BY).

    Individual Differences in the Relationship Between Attachment and Nomophobia Among College Students: The Mediating Role of Mindfulness


    Background: There is a growing interest in nomophobia, which is defined as the fear of being out of cellular phone contact, or "feelings of discomfort or anxiety experienced by individuals when they are unable to use their mobile phones or utilize the affordances these devices provide”. However, only limited research can be found in terms of its determinants at present. Contemporary literature suggests that the relationships among attachment styles, mindfulness, and nomophobia have not been investigated. Objective: This study aims to investigate the mediating effect of mindfulness on the relationship between attachment and nomophobia. In addition, the study also focuses on gender differences in attachment, mindfulness, and nomophobia. A theory-based structural model was tested to understand the essentials of the associations between the constructs. Methods: The Experiences in Close Relationships Scale, Nomophobia Questionnaire, and Mindful Attention Awareness Scale were used to collect data from undergraduate students (N=450; 70.9% women [319/450]; mean age=21.94 years [SD 3.61]). Two measurement models (ie, attachment and mindfulness) and a structural model were specified, estimated, and evaluated. Results: The structural equation model shows that the positive direct effects of avoidant (.13, P=.03) and anxious attachment (.48, P<.001) on nomophobia were significant. The negative direct effects of avoidant (−.18, P=.01) and anxious attachment (−.33, P<.001) on mindfulness were also significant. Moreover, mindfulness has a significant negative effect on nomophobia for women only (−.13, P=.03). Finally, the Sobel test showed that the indirect effects of avoidant and anxious attachment on nomophobia via mindfulness were significant (P<.001). The direct and indirect effects of anxious attachment, avoidant attachment, and mindfulness altogether accounted for 33% of the total variance in nomophobia. Gender comparison results show that there is a significant difference in attachment based on gender (F2,447=6.97, P=.01, Wilk λ=.97, partial η2=.03). Women (mean 68.46 [SD 16.96]) scored significantly higher than men (mean 63.59 [SD 15.97]) in anxious attachment (F1=7.93, P=.01, partial η2=.02). Gender differences in mindfulness were not significant (F4,448=3.45, P=.69). On the other hand, results do show significant gender differences in nomophobia (F4,445=2.71, P=.03, Wilk λ=.98, partial η2=.02) where women scored significantly higher than men. Conclusions: In general, individuals who are emotionally more dependent and crave more closeness and attention in the relationship tend to display higher levels of fear or discomfort when they have no access to their mobile phones. However, gender has a differential impact on the relationship between avoidant attachment and nomophobia. This study establishes the impact of mindfulness on nomophobia for women; therefore, future studies should test the effectiveness of mindfulness-based therapy approaches and confirm whether they are effective and efficient. On the basis of significant gender difference in nomophobia and attachment, we conclude that gender should be taken into account in mindfulness-based treatments dealing with nomophobia.

  • SARAH hand exercise. Source: Image created by authors of the SARAH clinical trial ISRCTN89936343; Copyright: Universities of Warwick and Oxford 2014 (S Lamb, M Williams, E Williamson and P Heine); URL:; License: Licensed by the authors.

    A Web-Based Training Resource for Therapists to Deliver an Evidence-Based Exercise Program for Rheumatoid Arthritis of the Hand (iSARAH): Design,...


    Background: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) is a tailored, progressive exercise program for people having difficulties with wrist and hand function due to rheumatoid arthritis (RA). The program was evaluated in a large-scale clinical trial and was found to improve hand function, was safe to deliver, and was cost-effective. These findings led to the SARAH program being recommended in the UK National Institute for Health and Care Excellence guidelines for the management of adults with RA. To facilitate the uptake of this evidence-based program by clinicians, we proposed a Web-based training program for SARAH (iSARAH) to educate and train physiotherapists and occupational therapists on delivering the SARAH program in their practice. The overall iSARAH implementation project was guided by the 5 phases of the analysis, design, development, implementation, and evaluation (ADDIE) system design model. Objective: The objective of our study was to conduct the first 3 phases of the model in the development of the iSARAH project. Methods: Following publication of the trial, the SARAH program materials were made available to therapists to download from the trial website for use in clinical practice. A total of 35 therapists who downloaded these materials completed an online survey to provide feedback on practice trends in prescribing hand exercises for people with RA, perceived barriers and facilitators to using the SARAH program in clinical practice, and their preferences for the content and Web features of iSARAH. The development and design of iSARAH were further guided by a team of multidisciplinary health professionals (n=17) who took part in a half-day development meeting. We developed the preliminary version of iSARAH and tested it among therapists (n=10) to identify and rectify usability issues and to produce the final version. Results: The major recommendations made by therapists and the multidisciplinary team were having a simple Web design and layout, clear exercise pictures and videos, and compatibility of iSARAH on various browsers and devices. We rectified all usability issues in the preliminary version to develop the final version of iSARAH, which included 4 short modules and additional sections on self-assessment, frequently asked questions, and a resource library. Conclusions: The use of the ADDIE design model and engagement of end users in the development and evaluation phases have rendered iSARAH a convenient, easy-to-use, and effective Web-based learning resource for therapists on how to deliver the SARAH program. There is also huge potential for adapting iSARAH across different cultures and languages, thus opening more opportunities for wider uptake and application of the SARAH program into practice.

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Evaluating the Dental Caries-Related Information on Brazilian Websites: Qualitative Study


    Background: Dental caries is the most common chronic oral disease, affecting 2.4 billion people worldwide who on average have 2.11 decayed, missing, or filled teeth. It impacts the quality of life of patients, socially and economically. However, the comprehension of dental caries may be difficult for most people, as it involves a multifactorial etiology with the interplay between the tooth surface, the dental biofilm, dietary fermentable carbohydrates, and genetic and behavioral factors. Therefore, the production of effective materials addressed to the education and counseling of patients for the prevention of dental caries requires a high level of specialization. In this regard, the dental caries-related contents produced by laypersons and their availability on the Internet may be low-quality information. Objective: The aim of this study was to assess the readability and the quality of dental caries-related information on Brazilian websites. Methods: A total of 75 websites were selected through Google, Bing, Yahoo!, and Baidu. The websites were organized in rankings according to their order of appearance in each one of the 4 search engines. Furthermore, 2 independent examiners evaluated the quality of websites using the DISCERN questionnaire and the Journal of American Medical Association (JAMA) benchmark criteria. The readability of the websites was assessed by the Flesch Reading Ease adapted to Brazilian Portuguese (FRE-BP). In addition, the information presented on the websites was categorized as etiology, prevention, and treatment of dental caries. The statistical analysis was performed using Spearman rank correlation coefficient, Mann-Whitney U test, hierarchical clustering analysis by Ward minimum variance method, Kruskal-Wallis test, and post hoc Dunn test. P<.05 was considered significant. Results: The Web contents were considered to be of poor quality by DISCERN (mean 33.48, standard deviation, SD 9.06) and JAMA (mean 1.12, SD 0.97) scores, presenting easy reading levels (FRE-BP: mean 62.93, SD 10.15). The rankings of the websites presented by Google (ρ=−.22, P=.08), Baidu (ρ=−.19, P=.53), Yahoo! (ρ=.22, P=.39), and Bing (ρ=−.36, P=.23) were not correlated with DISCERN scores. Moreover, the quality of websites with health- and nonhealth-related authors was similar (P=.27 for DISCERN and P=.47 for JAMA); however, the pages with a greater variety of dental caries information showed significantly higher quality scores than those with limited contents (P=.009). Conclusions: On the basis of this sample, dental caries-related contents available on Brazilian websites were considered simple, accessible, and of poor quality, independent of their authorship. These findings indicate the need for the development of specific policies focused on the stimulus for the production and publication of Web health information, encouraging dentists to guide their patients in searching for recommended oral health websites.

  • Source: JMIR Publications/; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Using Social Media Data to Understand the Impact of Promotional Information on Laypeople’s Discussions: A Case Study of Lynch Syndrome


    Background: Social media is being used by various stakeholders among pharmaceutical companies, government agencies, health care organizations, professionals, and news media as a way of engaging audiences to raise disease awareness and ultimately to improve public health. Nevertheless, it is unclear what effects this health information has on laypeople. Objective: This study aimed to provide a detailed examination of how promotional health information related to Lynch syndrome impacts laypeople’s discussions on a social media platform (Twitter) in terms of topic awareness and attitudes. Methods: We used topic modeling and sentiment analysis techniques on Lynch syndrome–related tweets to answer the following research questions (RQs): (1) what are the most discussed topics in Lynch syndrome–related tweets?; (2) how promotional Lynch syndrome–related information on Twitter affects laypeople’s discussions?; and (3) what impact do the Lynch syndrome awareness activities in the Colon Cancer Awareness Month and Lynch Syndrome Awareness Day have on laypeople’s discussions and their attitudes? In particular, we used a set of keywords to collect Lynch syndrome–related tweets from October 26, 2016 to August 11, 2017 (289 days) through the Twitter public search application programming interface (API). We experimented with two different classification methods to categorize tweets into the following three classes: (1) irrelevant, (2) promotional health information, and (3) laypeople’s discussions. We applied a topic modeling method to discover the themes in these Lynch syndrome–related tweets and conducted sentiment analysis on each layperson’s tweet to gauge the writer’s attitude (ie, positive, negative, and neutral) toward Lynch syndrome. The topic modeling and sentiment analysis results were elaborated to answer the three RQs. Results: Of all tweets (N=16,667), 87.38% (14,564/16,667) were related to Lynch syndrome. Of the Lynch syndrome–related tweets, 81.43% (11,860/14,564) were classified as promotional and 18.57% (2704/14,564) were classified as laypeople’s discussions. The most discussed themes were treatment (n=4080) and genetic testing (n=3073). We found that the topic distributions in laypeople’s discussions were similar to the distributions in promotional Lynch syndrome–related information. Furthermore, most people had a positive attitude when discussing Lynch syndrome. The proportion of negative tweets was 3.51%. Within each topic, treatment (16.67%) and genetic testing (5.60%) had more negative tweets compared with other topics. When comparing monthly trends, laypeople’s discussions had a strong correlation with promotional Lynch syndrome–related information on awareness (r=.98, P<.001), while there were moderate correlations on screening (r=.602, P=.05), genetic testing (r=.624, P=.04), treatment (r=.69, P=.02), and risk (r=.66, P=.03). We also discovered that the Colon Cancer Awareness Month (March 2017) and the Lynch Syndrome Awareness Day (March 22, 2017) had significant positive impacts on laypeople’s discussions and their attitudes. Conclusions: There is evidence that participative social media platforms, namely Twitter, offer unique opportunities to inform cancer communication surveillance and to explore the mechanisms by which these new communication media affect individual health behavior and population health.

  • fNIRS recording during a virtual reality dental task. Source: Suzanne Perry; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Getting to the Root of Fine Motor Skill Performance in Dentistry: Brain Activity During Dental Tasks in a Virtual Reality Haptic Simulation


    Background: There is little evidence considering the relationship between movement-specific reinvestment (a dimension of personality which refers to the propensity for individuals to consciously monitor and control their movements) and working memory during motor skill performance. Functional near-infrared spectroscopy (fNIRS) measuring oxyhemoglobin demands in the frontal cortex during performance of virtual reality (VR) psychomotor tasks can be used to examine this research gap. Objective: The aim of this study was to determine the potential relationship between the propensity to reinvest and blood flow to the dorsolateral prefrontal cortices of the brain. A secondary aim was to determine the propensity to reinvest and performance during 2 dental tasks carried out using haptic VR simulators. Methods: We used fNIRS to assess oxygen demands in 24 undergraduate dental students during 2 dental tasks (clinical, nonclinical) on a VR haptic simulator. We used the Movement-Specific Reinvestment Scale questionnaire to assess the students’ propensity to reinvest. Results: Students with a high propensity for movement-specific reinvestment displayed significantly greater oxyhemoglobin demands in an area associated with working memory during the nonclinical task (Spearman correlation, rs=.49, P=.03). Conclusions: This small-scale study suggests that neurophysiological differences are evident between high and low reinvesters during a dental VR task in terms of oxyhemoglobin demands in an area associated with working memory.

  • Using a direct microblog message to engage a suicide ideation population. Source: Tingshao Zhu, Wenyan Liu, Yameng Wang, Ziying Tan; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Designing Microblog Direct Messages to Engage Social Media Users With Suicide Ideation: Interview and Survey Study on Weibo


    Background: While Web-based interventions can be efficacious, engaging a target population’s attention remains challenging. We argue that strategies to draw such a population’s attention should be tailored to meet its needs. Increasing user engagement in online suicide intervention development requires feedback from this group to prevent people who have suicide ideation from seeking treatment. Objective: The goal of this study was to solicit feedback on the acceptability of the content of messaging from social media users with suicide ideation. To overcome the common concern of lack of engagement in online interventions and to ensure effective learning from the message, this research employs a customized design of both content and length of the message. Methods: In study 1, 17 participants suffering from suicide ideation were recruited. The first (n=8) group conversed with a professional suicide intervention doctor about its attitudes and suggestions for a direct message intervention. To ensure the reliability and consistency of the result, an identical interview was conducted for the second group (n=9). Based on the collected data, questionnaires about this intervention were formed. Study 2 recruited 4222 microblog users with suicide ideation via the Internet. Results: The results of the group interviews in study 1 yielded little difference regarding the interview results; this difference may relate to the 2 groups’ varied perceptions of direct message design. However, most participants reported that they would be most drawn to an intervention where they knew that the account was reliable. Out of 4222 microblog users, we received responses from 725 with completed questionnaires; 78.62% (570/725) participants were not opposed to online suicide intervention and they valued the link for extra suicide intervention information as long as the account appeared to be trustworthy. Their attitudes toward the intervention and the account were similar to those from study 1, and 3 important elements were found pertaining to the direct message: reliability of account name, brevity of the message, and details of the phone numbers of psychological intervention centers and psychological assessment. Conclusions: This paper proposed strategies for engaging target populations in online suicide interventions.

  • mHealth supports young people's chronic NCD self-management. Source: Image created by Authors; Copyright: Helen Slater; URL:; License: Creative Commons Attribution (CC-BY).

    End User and Implementer Experiences of mHealth Technologies for Noncommunicable Chronic Disease Management in Young Adults: Systematic Review


    Background: Chronic noncommunicable diseases (NCDs) such as asthma, diabetes, cancer, and persistent musculoskeletal pain impose an escalating and unsustainable burden on young people, their families, and society. Exploring how mobile health (mHealth) technologies can support management for young people with NCDs is imperative. Objective: The aim of this study was to identify, appraise, and synthesize available qualitative evidence on users’ experiences of mHealth technologies for NCD management in young people. We explored the perspectives of both end users (young people) and implementers (health policy makers, clinicians, and researchers). Methods: A systematic review and meta-synthesis of qualitative studies. Eligibility criteria included full reports published in peer-reviewed journals from January 2007 to December 2016, searched across databases including EMBASE, MEDLINE (PubMed), Scopus, and PsycINFO. All qualitative studies that evaluated the use of mHealth technologies to support young people (in the age range of 15-24 years) in managing their chronic NCDs were considered. Two independent reviewers identified eligible reports and conducted critical appraisal (based on the Joanna Briggs Institute Qualitative Assessment and Review Instrument: JBI-QARI). Three reviewers independently, then collaboratively, synthesized and interpreted data through an inductive and iterative process to derive emergent themes across the included data. External validity checking was undertaken by an expert clinical researcher and for relevant content, a health policy expert. Themes were subsequently subjected to a meta-synthesis, with findings compared and contrasted between user groups and policy and practice recommendations derived. Results: Twelve studies met our inclusion criteria. Among studies of end users (N=7), mHealth technologies supported the management of young people with diabetes, cancer, and asthma. Implementer studies (N=5) covered the management of cognitive and communicative disabilities, asthma, chronic self-harm, and attention deficit hyperactivity disorder. Quality ratings were higher for implementer compared with end user studies. Both complementary and unique user themes emerged. Themes derived for end users of mHealth included (1) Experiences of functionality that supported self-management, (2) Acceptance (technical usability and feasibility), (3) Importance of codesign, and (4) Perceptions of benefit (self-efficacy and empowerment). For implementers, derived themes included (1) Characteristics that supported self-management (functional, technical, and behavior change); (2) Implementation challenges (systems level, service delivery level, and clinical level); (3) Adoption considerations for specific populations (training end users; specific design requirements); and (4) Codesign and tailoring to facilitate uptake and person-centered care. Conclusions: Synthesizing available data revealed both complementary and unique user perspectives on enablers and barriers to designing, developing, and implementing mHealth technologies to support young people’s management of their chronic NCDs. Trial Registration: PROSPERO CRD42017056317; 42017056317 (Archived by WebCite at

  • Source: The Authors; Copyright: Bond University; URL:; License: Licensed by the authors.

    Reporting of Telehealth-Delivered Dietary Intervention Trials in Chronic Disease: Systematic Review


    Background: Telehealth-delivered dietary interventions are effective for chronic disease management and are an emerging area of clinical practice. However, to apply interventions from the research setting in clinical practice, health professionals need details of each intervention component. Objective: The aim of this study was to evaluate the completeness of intervention reporting in published dietary chronic disease management trials that used telehealth delivery methods. Methods: Eligible randomized controlled trial publications were identified through a systematic review. The completeness of reporting of experimental and comparison interventions was assessed by two independent assessors using the Template for Intervention Description and Replication (TIDieR) checklist that consists of 12 items including intervention rationale, materials used, procedures, providers, delivery mode, location, when and how much intervention delivered, intervention tailoring, intervention modifications, and fidelity. Where reporting was incomplete, further information was sought from additional published material and through email correspondence with trial authors. Results: Within the 37 eligible trials, there were 49 experimental interventions and 37 comparison interventions. One trial reported every TIDieR item for their experimental intervention. No publications reported every item for the comparison intervention. For the experimental interventions, the most commonly reported items were location (96%), mode of delivery (98%), and rationale for the essential intervention elements (96%). Least reported items for experimental interventions were modifications (2%) and intervention material descriptions (39%) and where to access them (20%). Of the 37 authors, 14 responded with further information, and 8 could not be contacted. Conclusions: Many details of the experimental and comparison interventions in telehealth-delivered dietary chronic disease management trials are incompletely reported. This prevents accurate interpretation of trial results and implementation of effective interventions in clinical practice.

  • Source: Shutterstock; Copyright: Boryana Manzurova; URL:; License: Licensed by the authors.

    Media Consumption and Creation in Attitudes Toward and Knowledge of Inflammatory Bowel Disease: Web-Based Survey


    Background: Inflammatory bowel disease (IBD) is a chronic gastrointestinal condition affecting over 5 million people globally and 1.6 million in the United States but currently lacks a precisely determined cause or cure. The range of symptoms IBD patients experience are often debilitating, and the societal stigmas associated with some such symptoms can further degrade their quality of life. Better understanding the nature of this public reproach then is a critical component for improving awareness campaigns and, ultimately, the experiences of IBD patients. Objective: The objective of this study was to explore and assess the public’s awareness and knowledge of IBD, as well as what relationship, if any, exists between the social stigma surrounding IBD, knowledge of the disease, and various media usage, including social media. Methods: Utilizing a Web-based opt-in platform, we surveyed a nationally representative sample (n=1200) with demographics mirroring those of the US Census figures across baseline parameters. Using constructed indices based on factor analysis, we were able to build reliable measures of personal characteristics, media behaviors, and perceptions and knowledge of IBD. Results: Among the American public, IBD is the most stigmatized of seven diseases, including genital herpes and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Additionally, IBD knowledge is generally low with 11.08% (133/1200) of the sample indicating no familiarity with the disease and 85.50% (1026/1200) of participants inaccurately answering two-thirds of the IBD index questions with which their knowledge was assessed. Increased knowledge of IBD is associated with lower levels of stigma. However, social media use is currently related to lower levels of IBD knowledge (P<.05). Furthermore, findings indicate that participants who most frequently engaged in producing social media content are less knowledgeable about IBD (P<.10), highlighting the potential for a dangerous cycle should they be contributing to a Web-based IBD dialogue. Conclusions: Greater efforts must be taken to stymie IBD misinformation across all media, but especially in social media channels, to increase IBD knowledge and reduce stigma surrounding IBD. These findings pave the way for further research qualitatively examining the pervasiveness of specific IBD messages found in today’s social media landscape and their impact on enacted stigmas so as to better equip providers and patient advocacy organizations with impactful communication solutions.

  • MyHealthKeeper system implementation with mobile phone application and EHR-integrated PHR module interface (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Licensed by the authors.

    Impact of an Electronic Health Record-Integrated Personal Health Record on Patient Participation in Health Care: Development and Randomized Controlled Trial...


    Background: Personal health record (PHR)–based health care management systems can improve patient engagement and data-driven medical diagnosis in a clinical setting. Objective: The purpose of this study was (1) to demonstrate the development of an electronic health record (EHR)–tethered PHR app named MyHealthKeeper, which can retrieve data from a wearable device and deliver these data to a hospital EHR system, and (2) to study the effectiveness of a PHR data-driven clinical intervention with clinical trial results. Methods: To improve the conventional EHR-tethered PHR, we ascertained clinicians’ unmet needs regarding PHR functionality and the data frequently used in the field through a cocreation workshop. We incorporated the requirements into the system design and architecture of the MyHealthKeeper PHR module. We constructed the app and validated the effectiveness of the PHR module by conducting a 4-week clinical trial. We used a commercially available activity tracker (Misfit) to collect individual physical activity data, and developed the MyHealthKeeper mobile phone app to record participants’ patterns of daily food intake and activity logs. We randomly assigned 80 participants to either the PHR-based intervention group (n=51) or the control group (n=29). All of the study participants completed a paper-based survey, a laboratory test, a physical examination, and an opinion interview. During the 4-week study period, we collected health-related mobile data, and study participants visited the outpatient clinic twice and received PHR-based clinical diagnosis and recommendations. Results: A total of 68 participants (44 in the intervention group and 24 in the control group) completed the study. The PHR intervention group showed significantly higher weight loss than the control group (mean 1.4 kg, 95% CI 0.9-1.9; P<.001) at the final week (week 4). In addition, triglyceride levels were significantly lower by the end of the study period (mean 2.59 mmol/L, 95% CI 17.6-75.8; P=.002). Conclusions: We developed an innovative EHR-tethered PHR system that allowed clinicians and patients to share lifelog data. This study shows the effectiveness of a patient-managed and clinician-guided health tracker system and its potential to improve patient clinical profiles. Trial Registration: NCT03200119; (Archived by WebCite at

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  • Improvements in pain, mobility, and surgery risk through a 12-week digital care program for chronic knee pain: a randomized controlled trial.

    Date Submitted: Dec 15, 2017

    Open Peer Review Period: Dec 15, 2017 - Dec 27, 2017

    Background: Chronic knee pain (CKP), most commonly caused by knee osteoarthritis, is a prevalent condition which in most cases can be effectively treated through conservative, non-surgical care involv...

    Background: Chronic knee pain (CKP), most commonly caused by knee osteoarthritis, is a prevalent condition which in most cases can be effectively treated through conservative, non-surgical care involving exercise therapy, education, psychosocial support, and weight loss. However, most people living with CKP do not receive adequate care, leading to unnecessary use of opiates and surgical procedures. Objective: Assess the efficacy of a remotely delivered digital care program (DCP) for CKP. Methods: We enrolled 162 participants into a randomized controlled trial between January and March 2017. Participants were recruited from participating employers using questionnaires for self-assessment of their knee pain, and randomized into treatment (n = 101) and control (n = 61) groups. Participants in the treatment group were enrolled in the Hinge Health DCP for CKP. This is a remotely delivered, home-based 12-week intervention that includes sensor-guided exercise therapy, education, cognitive behavioral therapy, weight loss, and psychosocial support through a personal coach and team-based interactions. The control group received three education pieces regarding self-care for chronic knee pain. Both groups had access to treatment-as-usual. The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain subscale and KOOS physical function short form (KOOS-PS). Secondary outcomes were visual analog scales (VAS) for pain and stiffness respectively, surgery intent, and self-reported understanding of the condition and treatment options. Outcome measures were analyzed by intention to treat (excluding 7 control participants who received the DCP due to administrative error) and per protocol. Results: In an intent-to-treat analysis the DCP group had a significantly greater reduction in KOOS Pain compared to the control group at the end of the program (greater reduction of 7.7 [3.0, 12.3], p = .002), as well as a significantly greater improvement in physical function (7.2 [3.0, 11.5], p = .001). This was also reflected in the secondary outcomes VAS pain (12.3 [5.4, 19.1], p < .001) and VAS stiffness (13.4 [5.6, 21.1], p = .001). Participants’ self-reported likelihood (from 0 to 100%) of having surgery also reduced more strongly in the DCP group compared to the control group over the next 1 year (-9.4 percentage points (pp) [-16.6, -2.2], p = .01), 2 years (-11.3 pp [-20.1, -2.5], p = .01), and 5 years (-14.6 pp [-23.6, -5.5], p = 0.002). Interest in surgery (from 0 to 10) also reduced more so in the DCP compared to control group (-1.0 [-1.7, -0.2], p = .01). Participants’ understanding of the condition and treatment options (on a scale from 0 to 4) increased more substantially for participants in the DCP than those in the control group (0.9 [0.6, 1.3], p < .001). In an analysis on participants that completed the intervention (per protocol analysis) all primary and secondary outcomes remained significant at greater effect magnitudes compared to intention to treat, with those completing the program showing a 61% [48, 74] reduction in VAS pain compared to 21% [5, 38] in the control group (p < .001). Accounting for the cost of administering the program, we estimate net cost savings on surgery alone of $4340 over 1 year and $7900 over 5 years for those participants completing the DCP compared to those in the control group receiving treatment-as-usual. In an exploratory subgroup analysis including only participants exhibiting clinical symptoms for osteoarthritis the program proved equally effective. Conclusions: This trial provides strong evidence that a comprehensive 12-week digital care program for chronic knee pain, including osteoarthritis, yields significantly improved outcomes for pain, physical function, stiffness, surgery risk, and understanding of the condition, compared to a control group. Clinical Trial: ISRCTN13307390,

  • Digital characteristics and dissemination indicators to optimize delivery of internet-supported mindfulness-based interventions for people with a chronic condition: a systematic review

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 15, 2017 - Feb 9, 2018

    Background: Internet-supported mindfulness-based interventions (MBIs) are increasingly being used to support people managing a chronic condition. Characteristics of MBIs vary greatly in their mode of...

    Background: Internet-supported mindfulness-based interventions (MBIs) are increasingly being used to support people managing a chronic condition. Characteristics of MBIs vary greatly in their mode of delivery, communication patterns, level of facilitator involvement, intervention period and resource intensity, making it difficult to compare how individual digital features may optimize intervention adherence and outcomes. Objective: The aims of this review were to (1) provide a description of digital characteristics of internet-supported MBIs, and examine how these relate to evidence for efficacy and adherence to the intervention; and (2) gain insights into the type of information available to inform translation of internet-supported MBIs to applied settings. Methods: Medline Complete, PsycInfo and CINAHL databases were searched for studies assessing a MBI delivered or accessed via the internet, and engaging participants in daily mindfulness-based activities such as mindfulness meditations and/or informal mindfulness practices. Only studies using a comparison group of alternative interventions (active compactor), usual care, or wait-list were included. Given the broad definition of chronic conditions, specific conditions were not included in the original search to maximize results. The search resulted in 958 articles, from which 11 articles describing 10 interventions met the inclusion criteria. Results: Internet-supported MBIs were more effective than usual care or wait-list groups, and self-guided interventions were as effective as facilitator guided interventions. Findings were mainly informed by female participants. Adherence to interventions was inconsistently defined, and prevented robust comparison between studies. Reporting of factors associated with intervention dissemination, such as population representativeness, program adoption and maintenance, and costs was rare. Conclusions: More comprehensive descriptions of digital characteristics need to be reported to further our understanding of features that may influence engagement and behavior change, and to improve the reproducibility of MBIs. Gender differences in determinants and patterns of health behavior should be taken into account at the intervention design stage to accommodate for male and female preferences. Future research could compare MBIs with established evidence-based therapies to identify the population groups that would benefit most from internet-supported programs. Clinical Trial: PROSPERO - CRD42017078665

  • PIVET: A Scaled Phenotype Evidence Generation Framework using Online Medical Literature

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Researchers are developing methods to automatically extract clinically relevant and useful patient characteristics from raw healthcare datasets. These characteristics, often capturing esse...

    Background: Researchers are developing methods to automatically extract clinically relevant and useful patient characteristics from raw healthcare datasets. These characteristics, often capturing essential properties of patients with common medical conditions, are called computational phenotypes. Being generated by (semi)-automated, data-driven methods, such potential phenotypes need to be validated as clinically meaningful (or not) before they are acceptable for use in decision making. Objective: We present Phenotype Instance Verification and Evaluation Tool (PIVET), a framework that uses co-occurrence analysis on an online corpus of publically available medical journal articles to build clinical relevance evidence sets for user-supplied phenotypes. PIVET adopts a conceptual framework similar to the pioneering prototype tool, PheKnow-Cloud, which was developed for the phenotype validation task. PIVET completely re-factors each part of the PheKnow-Cloud pipeline to deliver vast improvements in speed without sacrificing the quality of the insights PheKnow-Cloud achieved. Methods: PIVET leverages indexing in NoSQL databases to efficiently generate evidence sets. Specifically, PIVET uses a succinct representation of the phenotypes that corresponds to the index on the corpus database and an optimized co-occurrence algorithm inspired by the Aho-Corasick algorithm. We compare PIVET’s phenotype representation to PheKnow-Cloud’s by using PheKnow-Cloud’s experimental set-up. We also introduce a statistical model trained on domain-expert verified phenotypes to automatically classify phenotypes as clinically relevant or not. Additionally, we show how the classification model can be used to examine user-supplied phenotypes in an online, rather than batch, manner. Results: PIVET maintains the discriminative power of PheKnow-Cloud in terms of identifying clinically relevant phenotypes for the same corpus with which PheKnow-Cloud was originally developed, but PIVET’s analysis is an order of magnitude faster than that of PheKnow-Cloud. Not only is PIVET much faster, it can be scaled to a larger corpus and still retain speed. We evaluated multiple classification models on top of the PIVET framework and found ridge regression to perform best, realizing an average F1 score of 0.91 when predicting clinically relevant phenotypes. Conclusions: We show PIVET improves on the most notable existing computational tool for phenotype validation in terms of speed and automation, and is comparable in terms of accuracy.

  • Parent-based, Indicated Prevention for Anorexia Nervosa: Results of a Randomized Controlled Efficacy Trial

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Web-based preventive interventions reduce risk and incidence of bulimic and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia...

    Background: Web-based preventive interventions reduce risk and incidence of bulimic and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak. Objective: The primary objective of this trial was to evaluate the efficacy of an indicated, parent-based, online preventive program “E@T” in reducing risk factors and symptoms of AN. Methods: Girls, age 11-17 years, were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre-, post-intervention (six weeks later), 6-, and 12-month follow-up. Results: 12,377 screens were handed out in 86 German schools and 3,941 including consent returned. 477 (12.1%) girls were identified as at-risk for AN. 66 families were randomized to the E@T or control condition, 43 participated in post-assessments, 27 in 12-month FUs. Due to low participation rates of parents, recruitment was terminated prematurely. At 12-month-FU, girls` % expected body weight (EBW) was significantly greater for intervention participants compared with control participants (XX; P = .007) No other significant effects were found on risk factors and attitudes of disturbed eating. Conclusions: Despite a significant increase in girls` %EBW, parental participation and adherence to the intervention was low. Parent-based prevention for children at risk for AN does not seem very promising but may have a place for higher motivated parents. Clinical Trial: ISRCTN18614564

  • Agile Development to Improve Recruitment and Enrollment for mHealth Research: Lessons from the Dot™ Contraceptive Efficacy Study

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Smartphone applications (apps) that provide women with information about their daily fertility status during their menstrual cycles have the potential to become an important addition to th...

    Background: Smartphone applications (apps) that provide women with information about their daily fertility status during their menstrual cycles have the potential to become an important addition to the contraceptive method mix. However, if these apps claim to help a user prevent pregnancy, they must undergo similar rigorous research required for other contraceptive methods. Georgetown University’s Institute for Reproductive Health (IRH) is conducting a prospective longitudinal efficacy trial on Dot, an algorithm-based fertility app designed to help women prevent pregnancy. Objective: Recruiting research participants who meet the criteria required of a contraceptive efficacy study and enrolling an adequate number to statistically assess the effectiveness of Dot is critical. Recruiting and enrolling participants for the Dot study involved making decisions based on research and analytic data, constant process modification, and close monitoring and evaluation of the effect of these modifications. The aim of this paper is to highlight decision points during the recruitment-enrollment process and the effect of modifications on enrollment numbers and demographics. Methods: Originally, the only option for women to enroll in the study was to do so over the phone with a study representative. Upon noticing low enrollment numbers, we examined the seven steps from the time a woman received the recruitment message until she completed enrollment, and made modifications accordingly. In Modification 1, we added call-back and voicemail procedures to increase the number of completed calls. Modification 2 involved employing a chat/instant message (IM) feature to facilitate study enrollment. In Modification 3, the process was fully automated to allow participants to enroll in the study without the aid of study representatives. Results: After these modifications were implemented, 719 women were enrolled in the study over a 6 month period. The majority of participants (68.7%) were enrolled during Modification 3, in which they had the option to enroll via phone, chat, or the fully automated process. Overall, 27.5% were enrolled via a phone call, 19.9% a chat/IM, and 50.9% directly through the fully automated process. With respect to the demographic profile of our study sample, we found a significant statistical difference in education level across all modifications (p<0.05) but not in age or race/ethnicity (p>0.05). Conclusions: Our findings show that agile and consistent modifications to the recruitment and enrollment process were necessary to yield an appropriate sample size. An automated process resulted in significantly higher enrollment rates than one that required phone interaction with study representatives. While there were some differences in demographic characteristics of enrollees as the process was modified, in general our study population is diverse and reflects the overall United States population in terms of race/ethnicity, age, and education. Additional research is proposed to identify how differences in mode of enrollment and demographic characteristics may affect participants’ performance in the study. Clinical Trial: NCT02833922; (Archived be WebCite at

  • Drug Repositioning for Parkinson’s Disease Based on Adverse Drug Reactions Detected from Social Media

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Due to the high cost and low success rate in new drug development, systematical drug repositioning methods are exploited to find new indications from existing drugs. Objective: We sought t...

    Background: Due to the high cost and low success rate in new drug development, systematical drug repositioning methods are exploited to find new indications from existing drugs. Objective: We sought to propose a new computational drug repositioning method to identify repositioning drugs for Parkinson’s disease (PD). Methods: We developed a novel heterogeneous network mining repositioning method that constructed a three-layer network of disease, drug, and adverse drug reaction (ADR), and involved user-generated data from online health communities, to identify potential candidate drugs for PD. Results: We identified 44 non-Parkinson drugs by using the proposed approach, with data collected from both pharmaceutical databases and online health communities. Based on the further literature analysis, we found literature evidence for 28 drugs. Conclusions: In summary, the proposed heterogeneous network mining repositioning approach is promising for identifying repositioning candidates for PD. It shows that adverse drug reactions (ADRs) are potential intermediaries to reveal relationships between disease and drug.