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Importance: In most countries, young people with obsessive-compulsive disorder have limited access to specialist cognitive behavioral therapy (CBT), a first-line treatment.Objective: To investigate whether internet-delivered CBT implemented in a stepped-care model is noninferior to in-person CBT for pediatric obsessive-compulsive disorder.Design, Setting and Participants: A randomized clinical noninferiority trial conducted at 2 specialist child and adolescent mental health clinics in Sweden. Participants included 152 individuals aged 8 to 17 years with obsessive-compulsive disorder. Enrollment began in October 2017 and ended in May 2019. Follow-up ended in April 2020.Interventions: Participants randomized to the stepped-care group (n = 74) received internet-delivered CBT for 16 weeks. Nonresponders at the 3-month follow-up were then offered a course of traditional face-to-face treatment. Participants randomized to the control group (n = 78) immediately received in-person CBT for 16 weeks. Nonresponders at the 3-month follow-up received additional face-to-face treatment.Main Outcomes and Measures: The primary outcome was the masked assessor-rated Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score at the 6-month follow-up. The scale includes 10 items rated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range of 0 to 40, with higher scores indicating greater severity. Assessors were masked to treatment allocation at pretreatment, posttreatment, 3-month follow-up, and 6-month follow-up assessments. The predefined noninferiority margin was 4 points on the CY-BOCS.Results: Among the 152 randomized participants (mean age, 13.4 years; 94 [62%] females), 151 (99%) completed the trial. At the 3-month follow-up, 34 participants (46%) in the stepped-care group and 23 (30%) in the in-person CBT group were nonresponders. At the 6-month follow-up, the CY-BOCS score was 11.57 points in the stepped-care group vs 10.57 points in the face-to-face treatment group, corresponding to an estimated mean difference of 0.91 points ([1-sided 97.5% CI, -∞ to 3.28]; P for noninferiority = .02). Increased anxiety (30%-36%) and depressive symptoms (20%-28%) were the most frequently reported adverse events in both groups. There were 2 unrelated serious adverse events (1 in each group).Conclusions and Relevance: Among children and adolescents with obsessive-compulsive disorder, treatment with an internet-delivered CBT program followed by in-person CBT if necessary compared with in-person CBT alone resulted in a noninferior difference in symptoms at the 6-month follow-up. Further research is needed to understand the durability and generalizability of these findings.Trial Registration: ClinicalTrials.gov Identifier: NCT03263546. [ABSTRACT FROM AUTHOR]

The article compares the effect sizes associated with biomarkers reported in highly cited individual studies and in subsequent meta-analyses (MA) as determinants of disease risk, prognosis or response to treatment. The authors searched and analyzed 35 articles that have been cited more than 400 citations in the academic citation indexing and search service, ISI Web of Science, and also MA in the MEDLINE database on the same associations. They found that highly cited studies commonly report larger effect estimates for postulated associations than are announced in subsequent MA.

The article reports on the results of research which was conducted in an effort to define quantitative relationships between cardiorespiratory fitness (CRF) and coronary heart disease (CHD) events, cardiovascular disease (CVD) events, or all-cause mortality in healthy men and women. Researchers performed a systematic literature search was conducted for observational cohort studies using the MEDLINE and EMBASE databases. They found that better CRF was associated with lower risk of all-cause mortality and both coronary heart disease and cardiovascular disease.

The article discusses researcher seeking to determine if a care model combining Internet service blood pressure (BP) monitoring and pharmacist-assisted care improves BP regulation in patients with hypertension. The design and setting of the study which involved 778 patients with uncontrolled essential hypertension and web site training are detailed. The outcomes measured include percentage of patients with controlled BP and changes in systolic and diastolic BP over 1-year. Researchers conclude that patients assigned BP monitoring and web service with pharmacist care management had significant improvements in BP control.

The article focuses on research which was done to determine the accuracy of historical features, physical examination, and laboratory testing which is done on diabetic patients who have symptoms of osteomyelitis of the lower extremity. Researchers examined English language articles published between 1966 and 2007 which were related to osteomyelitis in patients with diabetes and were found on MEDLINE. They found that the best diagnostic tool is bone biopsy and that an ulcer area of a certain size, a positive probe to bone test result, an erythrocyte sedimentation rate of more than 70 mm/h, and an abnormal plain radiograph result are helpful in diagnosing osteomyelitis.

The article presents a clinical review examining diagnostic lumbar puncture (LP) techniques that may lower the risk of negative events and the test accuracy of cerebrospinal fluid analysis in patients with possible bacterial meningitis. For the systematic review the authors searched the Cochrane Library, EMBASE, and MEDLINE. According to the article, small-gauge atraumatic needles may lower the risk of a headache after a diagnostic LP. The article also states that reinsertion of the stylet before removal of the needle should occur and patients do not need be rest after LP.

Inconsistent data suggest that endogenous sex hormones may have a role in sex-dependent etiologies of type 2 diabetes, such that hyperandrogenism may increase risk in women while decreasing risk in men. Objective To systematically assess studies evaluating the association of plasma levels of testosterone, sex hormone-binding globulin (SHBG), and estradiol with risk of type 2 diabetes. Data Sources Systematic search of EMBASE and MEDLINE (1966-June 2005) for English-language articles using the keywords diabetes, testosterone, sex-hormone-binding-globulin, and estradiol; references of retrieved articles; and direct author contact. Study Selection From 80 retrieved articles, 43 prospective and cross-sectional studies were identified, comprising 6974 women and 6427 men and presenting relative risks (RRs) or hormone levels for cases and controls. Data Extraction Information on study design, participant characteristics, hormone levels, and risk estimates were independently extracted by 2 investigators using a standardized protocol. Data Synthesis Results were pooled using random effects and meta-regressions. Cross-sectional studies indicated that testosterone level was significantly lower in men with type 2 diabetes (mean difference, -76.6 ng/dL; 95% confidence interval [CI], -99.4 to -53.6) and higher in women with type 2 diabetes compared with controls (mean difference, 6.1 ng/dL; 95% CI, 2.3 to 10.1) (P< .001 for sex difference). Similarly, prospective studies showed that men with higher testosterone levels (range, 449.6-605.2 ng/dL) had a 42% lower risk of type 2 diabetes (RR, 0.58; 95% CI, 0.39 to 0.87), while there was suggestion that testosterone increased risk in women (P = .06 for sex difference). Cross-sectional and prospective studies both found that SHBG was more protective in women than in men (P .01 for sex difference for both), with prospective studies indicating that women with higher SHBG levels (7gt;60 vs 60 nmol/L) had an 80% lower risk of type 2 diabetes (RR, 0.20; 95% CI, 0.12 to 0.30), while men with higher SHBG levels (> 28.3 vs 28.3 nmol/L) had a 52% lower risk (RR, 0.48; 95% CI, 0.33 to 0.69). Estradiol levels were elevated among men and postmenopausal women with diabetes compared with controls (P = .007). Conclusions This systematic review indicates that endogenous sex hormones may differentially modulate glycemic status and risk of type 2 diabetes in men and women. High testosterone levels are associated with higher risk of type 2 diabetes in women but with lower risk in men; the inverse association of SHBG with risk was stronger in women than in men. [ABSTRACT FROM AUTHOR]

Context: Although factorial trials have become common, standards for the analysis and reporting of such trials have not been established and, despite concerns about the possibility of unrecognized interactions between therapies in factorial trials, the magnitude of this potential problem is unknown. Objective: To examine the rationale, methods, and analysis of randomized factorial trials. Data Sources and Study Selection: We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Register using the terms factorial, interaction, 2 × 2, 2 by 2, and incremental to identify factorial randomized trials published from January 2000 to July 2002. To identify trials missed by the electronic search, we performed a hand search of English-language trials in a defined topic area (using the term myocardial ischemia [exp]) listed in MEDLINE (1966-2002), EMBASE (1980-2002), and the Cochrane Controlled Trials Register, as well as all trials in any topic area published in December 2000, excluding trials reporting only continuous surrogate end points. The final set of 33 eligible publications described 29 unique trials. Data Extraction: Two investigators independently identified factorial trials, generated a list of items affecting validity of results, and abstracted these items from each trial. Data Synthesis: The sensitivity of electronic searching for identifying factorial trials was 76%. Our 3-pronged search strategy identified 44 factorial trials with clinically important binary outcomes: 36 (82%) were done for reasons of efficiency (testing 2 interventions in the same patient population), and 8 (18%) were done to assess the incremental benefits of combining the 2 treatments. All but 1 of the trials reported treatment effects by comparing all patients who received treatment A (ie, those receiving either A alone or both A and B) vs all those not receiving treatment A (ie, those receiving either B alone or neither A nor B). Twenty-nine of the 44 trials (66%) reported... [ABSTRACT FROM AUTHOR]

Context: Of the several factors implicated in causing QT interval prolongation and torsades de pointes, errors in the use of medications that may prolong this interval deserve special attention. Objective: To systematically summarize the available clinical data on the QT interval and to offer improved recommendations for the use of QT-prolonging medications. Data Sources: We searched MEDLINE from 1966 through 2002 for all English-language articles related to the QT interval. Additional data sources included bibliographies of articles identified on MEDLINE, a survey of experts, and data presented at a meeting of experts on long QT syndrome. Study Selection: We selected for review registries and case series examining clinical outcomes of patients with prolonged QT interval and the effect of different methods of measurement of the QT interval on patient outcomes. Ten studies were identified, of which 6 were included in the analysis. Data Extraction: Data quality was determined by publication in the peer-reviewed literature. Data Synthesis: Optimal measurement of the QT interval is problematic because of lack of standardization and lack of data regarding the best way to adjust for heart rate. Reliable information on the proper use of QT-prolonging medications is scarce. Although a QT interval of at least 500 milliseconds generally has been shown to correlate with a higher risk of torsades de pointes, there is no established threshold below which prolongation of the QT interval is considered free of proarrhythmic risk. The risk of torsades de pointes should be assessed in patients who are about to begin taking a QT-prolonging medication. Although inadequate clinical studies preclude prediction of absolute risk for individual patients, particularly high-risk situations can be defined based on clinical variables. We propose recommendations on proper monitoring of the QT interval in patients receiving QT-prolonging medications. Conclusion: Although the use of... [ABSTRACT FROM AUTHOR]

Reports on a study which evaluated the health information on beast cancer, depression, obesity, and childhood asthma available through English- and Spanish-language search engines and Web sites on the Internet. Design; Setting; Main outcome measures; Results; Conclusion that information is poor and inconsistent but accurate and requires a high reading level.

This study reports 2-year survival outcomes among patients with advanced nonprogressive stage IIA to IV lung cancer randomized to symptom monitoring during chemotherapy via web-based patient-reported outcomes vs standard scheduled imaging after treatment to detect symptomatic recurrence. [ABSTRACT FROM AUTHOR]

The authors offer commentary concerning how the Internet has changed patients' expectations of physicians. Issues involving patients who demand a non-medical relationship and press for information about their caregiver are discussed. The amount of personal information about physicians that is easily assessable to patients via the Internet is examined. Differing views regarding the management of personal information on the Internet by older and younger generations of doctors are weighted.

The article focuses on the follow-up virtual physician visits being conducted at Massachusetts General Hospital in Boston. It describes how a virtual physician visit is being done, including the use of a web-based portal and a condition-specific questionnaire. The advantages of follow-up virtual physician visits are also discussed.

The authors discuss the potential of web health surveillance in the field of behavioral medicine. Topics addressed include barriers to health surveys that can be overcome with the use of web data in behavioral medicine, the ease of observing behavior or the manifestation of mental health problems via the Internet, and capturing social context online. Also mentioned are web data's provision of real-time insights into behavioral medicine and identifying new hypotheses in behavioral medicine.

A letter to the editor in response to the article "Social Media and Physicians' Online Identity Crisis," by M. DeCamp, T. W. Koenig, and M. S. Chisolm in the August 14, 2013 issue is presented.

A reply from the authors of the article "Social Media and Physicians' Online Identity Crisis" in the August 14, 2013 issue is presented.

The author reflects on the convenient care options for the treatment of low-acuity conditions like bronchitis and urinary tract infections. According to him, low-acuity patients can receive care via several options including the Internet, store kiosks, and a nurse home visit. He mentions that the convenient care options provide specialization for the problems related to basic primary care. He opines that the future of convenient care options depends on their range beyond low-acuity care.

A letter to the editor is presented in response to the article "Internet-based Learning in the Health Professions: A Meta-analysis," by D.A. Cook, A.J. Levinson, S. Garside, D.M. Dupras, P.J. Erwin, and V.M. Montori.

The author replies to letters written in response to the article "Internet-based Learning in the Health Professions: A Meta-analysis."

The article reports on the Internet's role in clinical research. University of California researchers, led by Bradly P. Jacobs, conducted a randomized, placebo-controlled, double-blind clinical trial over the Internet. Jacobs comments on their finding that kava and valerian extracts were no more effective than placebo in the self-management of anxiety and insomnia. Vance Berger, a National Cancer Institute mathematical statistician, comments on Internet-only clinical trials. The advantages and disadvantages of Internet-only clinical trials are mentioned.

Presents a list of books related to medicine, public health, and other topics. "Alternative Medicine and Miracles: A Grand Unified Theory," by Reginald O. Crosley; "Critical Care Medicine: Reviews and Self-Assessment," by Joseph E. Parrillo; "Joslin's Diabetes Mellitus," edited by C. Ronald Kahn, Gordon C. Weir, George L. King, Alan M. Jacobson, Alan C. Moses, and Robert J. Smith; "Fever of War: The Influenza Epidemic in the U.S. Army During World War I," by Carol R. Byerly; "Medicine in the Days of Pharaohs," by Bruno Halioua and Bernard Ziskind, translated by M.B. DeBevoise; "Catalog of Teratogenic Agents," by Thomas H. Shepard and Ronald J. Lemire; "Internet Discourse and Health Debates," by Kay Richardson; "The Benefits of Herbs and Spices in Food," by Sandra F. El Hage and Thankam Matthew; "A Physician's Guide to Return to Work," edited by James B. Talmage and J. Mark Melhorn; "Clinical Practice in Small Incision Cataract Surgery," edited by Ashok Garg, Luther L. Fry, Geoffrey Tabin, Suresh K. Pandey, and Francisco J. Gutiérrez-Carmona.

Discusses the challenge facing researchers trying to develop ways to treat and prevent smallpox. How smallpox was eradicated and no new cases cited; Project to post information on the Internet concerning smallpox; Reasons for sequencing the rabbitpox virus; Need for information on smallpox, in case it is created by bioterrorists or scientists.

Reports on a conference of the Radiological Society of North America in November, 2000. Technology which allows radiologist to digitally create three-dimensional images of body areas; Proposal that medical images can be sent via the Internet in a reliable and inexpensive fashion; Outcome of a study which indicated that family members of men being treated for prostate cancer with brachytherapy are exposed to safe levels of radiation from the men.

This section offers news briefs related to health agencies in the U.S. as of July 2014. There was an increase in the number of patients brought to the emergency department due to misuse of the sedative alprazolam. Due to an increase in the number of doctors ordering exome or genome testing for patients, a primer to help clinicians implement these technologies has been published. Guidance for marketing through social media was released by the U.S. Food and Drug Administration (FDA) in June.

A letter to the editor is presented in response to the article "Internet-based Learning in the Health Professions: A Meta-analysis," by D.A. Cook, A.J. Levinson, S. Garside, D.M. Dupras, P.J. Erwin, and V.M. Montori.

Announces the online availability of articles from the 'Journal of the American Medical Association.'

Discusses the use of the Internet to gather health and medical information. How information may be overly simplified, incomplete, or inaccurate; Suggestion to consult a doctor before using medical advice from the Internet; Signs of a quality medical web site.

Focuses on the impact of the Internet on medical education. Advantages of Internet use, including convenience and facilitation of communication; Multimedia nature of the learning experience; Challenges in the development and integration of Web-based learning.

Focuses on the importance of physician proficiency in using the Internet to communicate with patients and access information. Use of the Internet by patients to obtain medical information; Possibilities for telecommunication in medicine; Responsibility of medical schools to provide technological training.

Focuses on the legal and ethical issues associated with the fundamental re-engineering of the medical information delivery system brought about by the Internet. Tension between providing broad access to information and maintaining quality control; Impact on the patient-physician relationship; Positive potential of e-health systems.

Focuses on MEDLINE and MEDLINEplus, the Web sites of the United States National Library of Medicine. Availability of medical information for patients on the Internet; History of the MEDLINE database; Additional online resources.

Examines the way in which the Internet has transformed the definition of community for patients with rare diseases. How the author used the Internet to disseminate information about Takayasu arteritis; Benefits of communication between patients with rare diseases.

Focuses on the impact of the Internet on the field of medicine. Distribution of medical information over the Internet; Effects on the patient-physician relationship; Potential dangers.

Reports that the World Health Organization has joined with a number of public and private partners to improve access to high-quality scientific information for research centers in Africa, Central Asia, and Eastern Europe. Opinion that much valuable research is carried out in developing countries; Plans to use the Internet as a means of connecting researchers worldwide.