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Background: Insomnia is a common diagnosis among patients in psychiatric health care and effective treatments are highly demanded. Previous research suggests that internet-delivered cognitive behavioural therapy for insomnia (ICBT-i) is helpful for a variety of patients and may be effective for psychiatric health care patients. Little is known about implementation of ICBT-i in psychiatric health care. The aim of this study was to explore experiences among therapists and managers who participated in a pilot implementation of ICBT-i in outpatient psychiatric health care, and to identify determinants for the implementation., Methods: Semi-structured interviews were conducted with 7 therapists and 5 managers working in outpatient psychiatric health care and directly involved with the pilot implementation. Data were analysed using qualitative content analysis guided by the NASSS framework, combining inductive and deductive approaches., Results: The analysis revealed 32 facilitators, 21 barriers, and 2 determinants that were both a barrier and a facilitator, organised in 1-5 themes under each of the 7 NASSS domains. Key facilitators included: meeting a demand for treatment options with the ICBT-i programme, the experienced benefits of ICBT-i as a treatment option for insomnia, training and support, engagement and support from managers and the wider system, and a long-term organisation for maintenance of the technology. Key barriers included: low interest in ICBT-i among therapists, difficulty in recruiting patients, perceived low ability in therapists to deliver treatment online, technical problems, and therapists' competing demands leading to low priority of ICBT-i. Complexity analysis assessed two NASSS domains as simple, four as complicated, and one as complex., Conclusions: The study contributes new knowledge and insights into the implementation process of ICBT-i in psychiatric health care. Our findings highlight the importance of providing training, support, and guidance in online treatment for therapists when implementing a technological innovation. Technical problems should be minimised and the maintenance and demand-side value for the technology must be clear. Support from managers at all levels is crucial, particularly support to therapists in everyday prioritisation among competing demands. Besides taking the identified determinants into account, managing complexity is important for successful scale-up implementation.

Objective: This study aims to improve the management quality of chronic obstructive pulmonary disease (COPD) in rural areas., Methods: Two hundred forty discharged COPD patients were divided into an intervention group and a control group. In the intervention group, 120 patients established contact with doctors through the network consulting room, i.e., the doctor's mobile platform, and were managed through video, voice, and text by the doctors, kept close contact with the doctors after discharge (education, consultation), and received electronic prescriptions, and drugs were sent to the patients' door by online retailers. The patients in the control group were managed in the traditional manner. One year later, the predicted forced expiratory volume in 1 s (FEV1)%, FEV1/forced vital capacity (FVC), and CAT scores and the number of rehospitalized patients were compared between these 2 groups., Results: After 1 year of follow-up, the predicted FEV1% and the FEV1/FVC ratio were significantly higher in the intervention group than in the control group (p < 0.05). CAT scores were lower for patients in the intervention group than for those in the control group after 1 year of follow-up (p < 0.05). After 1 year of follow-up, 22 (18.33%) patients were rehospitalized in the intervention group and 58 (48.33%) patients were rehospitalized in the control group (p < 0.05)., Conclusion: Doctors can improve the quality of life of patients with COPD and reduce the number of rehospitalizations through use of the network consulting room., (© 2018 The Author(s) Published by S. Karger AG, Basel.)

Aim: Computers, video games and technological devices are part of young people's everyday lives. However, their use in first-episode psychosis (FEP) treatment is rare. The purpose of this study was to better understand the access and use of technology among individuals with FEP, including gaming activities, to inform future development of technology-enabled therapeutic applications., Methods: Self-administered survey on use of technological tools in 71 FEP individuals., Results: PCs/laptops were used by all participants; cellphones/smartphones by 92%, consoles by 83% (mainly male and younger participants). Women texted and used social networks more frequently; men played games (mainly action) more often. The younger individuals reported playing games frequently (32% daily) with less use of the Web and social networks (favourite: Facebook)., Conclusions: These data will be useful for developing Web-based psychoeducation tools and cognitive remediation video games for youth with FEP., (© 2015 Wiley Publishing Asia Pty Ltd.)

Background: The aim of this study was to examine the efficacy of a collaborative care intervention in reducing depression, pain, and fatigue and improve quality of life., Methods: A total of 261 patients with advanced cancer and 179 family caregivers were randomized to a web-based collaborative care intervention or enhanced usual care. The intervention included the following: 1) a web site with written and audiovisual self-management strategies, a bulletin board, and other resources; 2) visits with a care coordinator during a physician's appointment every 2 months; and 3) telephone follow-up every 2 weeks. Primary patient outcomes included measures of depression, pain, fatigue, and health-related quality of life. Secondary outcomes included Interleukin (IL)-1α, IL-1β, IL-6, and IL-8 levels, Natural Killer (NK) cell numbers, and caregiver stress and depression., Results: At the baseline, 51% of the patients reported 1 or more symptoms in the clinical range. For patients who presented with clinical levels of symptoms and were randomized to the intervention, reductions in depression (Cohen's d = 0.71), pain (Cohen's d = 0.62), and fatigue (Cohen's d = 0.26) and improvements in quality of life (Cohen's d = 0.99) were observed when compared to those in the enhanced usual car arm at 6 months. Reductions in IL-6 (φ = 0.18), IL-1β (φ = 0.35), IL-1α (φ = 0.19), and IL-8 (φ = 0.15) and increases in NK cell numbers (φ = 0.23) were observed in comparison with enhanced usual care arm at 6 months. Reductions in caregiver stress (Cohen's d = 0.75) and depression (Cohen's d = 0.37) were observed at 6 months for caregivers whose loved ones were randomized to the intervention arm., Conclusions: The integration of screening and symptom management into cancer care is recommended., (© 2016 American Cancer Society.)

Background: In-ambulance telemedicine is a recently developed and a promising approach to improve emergency care. We implemented the first ever 24/7 in-ambulance telemedicine service for acute stroke. We report on our experiences with the development and pilot testing of the Prehospital Stroke Study at the Universitair Ziekenhuis Brussel (PreSSUB) to facilitate a wider spread of the knowledge regarding this technique., Methods: Successful execution of the project involved the development and validation of a novel stroke scale, design and creation of specific hardware and software solutions, execution of field tests for mobile internet connectivity, design of new care processes and information flows, recurrent training of all professional caregivers involved in acute stroke management, extensive testing on healthy volunteers, organisation of a 24/7 teleconsultation service by trained stroke experts and 24/7 technical support, and resolution of several legal issues., Results: In all, it took 41 months of research and development to confirm the safety, technical feasibility, reliability, and user acceptance of the PreSSUB approach. Stroke-specific key information can be collected safely and reliably before and during ambulance transportation and can adequately be communicated with the inhospital team awaiting the patient., Conclusion: This paper portrays the key steps required and the lessons learned for successful implementation of a 24/7 expert telemedicine service supporting patients with acute stroke during ambulance transportation to the hospital., (© 2016 S. Karger AG, Basel.)

Among the most important innovations within the psychotherapeutic care system are the new opportunities in the field of e-mental health. During the past decade, Internet-based and other e-mental health approaches for the treatment of post-traumatic stress disorder and related stress-associated symptoms have been developed in great variety. Solely Internet-based self-help programs are the lowest-threshold approaches in a stepped-care system. By contrast, individualized online psychotherapy and virtual reality programs are at the opposite pole of the spectrum. Approaches in the field of m(obile)-mental health complement these new developments in psychotherapy. The existing evidence supports the clinical efficacy of all the described approaches, although not all have been tested rigorously analog to phase III studies in psychopharmacology. Nonetheless, e-mental health approaches will shape our field more and more in the future.

Background: This study evaluates the use of in-person focus groups and online engagement within the context of a large public engagement initiative conducted in rural Newfoundland., Methods: Participants were surveyed about their engagement experience and demographic information. Pre and post key informant interviews were also conducted with organizers of the initiative., Results: Of the 111 participants in the focus groups, 97 (87%) completed evaluation surveys; as did 23 (88%) out of 26 online engagement participants. Overall, focus group participants were positive about their involvement, with 87.4% reporting that they would participate in a similar initiative. Online participation was below expectations and these participants viewed their experience less positively than in-person participants. Organizers viewed the engagement initiative and the combined use of online and in-person engagement positively., Conclusions: This study presents a real-world example of the use of two methods of engagement. It also highlights the importance of the successful execution of whatever engagement mechanism is selected., (Copyright © 2015 Longwoods Publishing.)

Background: The relationship between physical activity and cardiovascular disease (CVD) protection is well documented. Numerous factors (e.g. patient motivation, lack of facilities, physician time constraints) can contribute to poor PA adherence. Web-based computer-tailored interventions offer an innovative way to provide tailored feedback and to empower adults to engage in regular moderate- to vigorous-intensity PA. To describe the rationale, design and content of a web-based computer-tailored PA intervention for Canadian adults enrolled in a randomized controlled trial (RCT)., Methods/design: 244 men and women aged between 35 and 70 years, without CVD or physical disability, not participating in regular moderate- to vigorous-intensity PA, and familiar with and having access to a computer at home, were recruited from the Quebec City Prospective Urban and Rural Epidemiological (PURE) study centre. Participants were randomized into two study arms: 1) an experimental group receiving the intervention and 2) a waiting list control group. The fully automated web-based computer-tailored PA intervention consists of seven 10- to 15-min sessions over an 8-week period. The theoretical underpinning of the intervention is based on the I-Change Model. The aim of the intervention was to reach a total of 150 min per week of moderate- to vigorous-intensity aerobic PA., Discussion: This study will provide useful information before engaging in a large RCT to assess the long-term participation and maintenance of PA, the potential impact of regular PA on CVD risk factors and the cost-effectiveness of a web-based computer-tailored intervention., Trial Registration: ISRCTN36353353 registered on 24/07/2014.

Objective: The purpose of this project was to develop a user-centered web-portal for empowerment in mental disorders., Methods: The development of the portal included mixed-methods techniques for needs assessment to identify user-relevant content. Exposure and use of the portal was investigated as part of a process evaluation., Results: psychenet.de informs about mental disorders and treatment option. Results of the process evaluation showed a highly accessed website, the portal was assessed as "good" or "very good" by 73 % of the respondents., Discussion: Using psychenet.de attempts to raise awareness, to inform about mental disorders, and to engage patients in the course of their treatment., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The Lidcombe Program is an operant treatment for early stuttering shown with meta-analysis to have a favorable odds ratio. However, many clients are unable to access the treatment because of distance and lifestyle factors. In this Phase I trial, we explored the potential efficacy, practicality, and viability of an Internet webcam Lidcombe Program service delivery model., Method: Participants were 3 preschool children who stuttered and their parents, all of whom received assessment and treatment using webcam in their homes with no clinic attendance., Results: At 6 months post-Stage 1 completion, all children were stuttering below 1.0% syllables stuttered. The webcam intervention was acceptable to the parents and appeared to be practical and viable, with only occasional audiovisual problems. At present, there is no reason to doubt that a webcam-delivered Lidcombe Program will be shown with clinical trials to have comparable efficacy with the clinic version., Conclusion: Webcam-delivered Lidcombe Program intervention is potentially efficacious, is practical and viable, and requires further exploration with comparative clinical trials and a qualitative study of parent and caregiver experiences.

Objective: The primary goal of this study was to examine which characteristics differentiated patients who highly engaged with a computerized recovery support program after alcohol/drug treatment from those who did not engage with the program., Materials and Methods: The program delivered individually tailored clinical content in a multimedia format over 18 months following residential treatment. A key component of the program was access to a recovery coach, a licensed drug and alcohol counselor. Posttreatment logins to the program, the amount of clinical content accessed, and the number of recovery coach contacts were measured., Results: Several factors were found to predict program engagement, including several demographic variables, the number of recovery coach contacts, motivation to be in recovery, and attendance at 12-step groups., Conclusions: These findings, combined with others in the literature, suggest that low engagement with computerized health programs is a widespread problem. Because many of these programs show therapeutic promise, future studies should continue to increase understanding of factors associated with high engagement so that efforts to increase engagement may be applied more effectively.

Rheumatic patients are at risk of social isolation and physical inactivity which can have a significant impact on physical and mental health. Only every seventh patient is organized in a self-help group (SHG), most of them in the German League Against Rheumatism (GLAR). Members of a SHG are socially and physically more active and take part in exercise therapy (ET) more often. Depending on the study, the utilization of ET ranges from 25 % to 71 %. The functional training as the most attended offer of the GLAR showed positive effects at the physical and psychological levels. To motivate difficult to reach patients to engage in self-help and regular exercise, further development of exercise programs with individually tailored intensive strength and endurance elements as well as the increased use of new media seems promising. The Internet provides various opportunities for networking and social participation especially for severely impaired and temporally less flexible patients.

Background: Disordered eating behavior and body dissatisfaction affect a large proportion of the Dutch population and account for severe psychological, physical and social morbidity. Yet, the threshold for seeking professional care is still high. In the Netherlands, only 7.5% of patients with bulimia nervosa and 33% of patients with anorexia nervosa are treated within the mental health care system. Easily accessible and low-threshold interventions, therefore, are needed urgently. The internet has great potential to offer such interventions. The aim of this study is to determine whether a web-based treatment program for patients with eating disorders can improve eating disorder psychopathology among female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified., Methods/design: This randomized controlled trial will compare the outcomes of an experimental treatment group to a waiting list control group. In the web-based treatment program, participants will communicate personally and asynchronously with their therapists exclusively via the internet. The first part of the program will focus on analyzing eating attitudes and behaviors. In the second part of the program participants will learn how to change their attitudes and behaviors. Participants assigned to the waiting list control group will receive no-reply email messages once every two weeks during the waiting period of 15 weeks, after which they can start the program. The primary outcome measure is an improvement in eating disorder psychopathology as determined by the Eating Disorder Examination Questionnaire. Secondary outcomes include improvements in body image, physical and mental health, body weight, self-esteem, quality of life, and social contacts. In addition, the participants' motivation for treatment and their acceptability of the program and the therapeutic alliance will be measured. The study will follow the recommendations in the CONSORT statement relating to designing and reporting on RCTs., Discussion: This study protocol presents the design of a RCT for evaluating the effectiveness of a web-based treatment program using intensive therapeutic support for female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified., Trial Registration: The protocol for this study is registered with the Netherlands Trial Registry NTR2415.

Clinical pathways are among the main tools used to manage the quality in health-care concerning the standardization of care processes. This paper deals with a recommendation service to support adaptive clinical pathways. The proposed approach can guide physicians in clinical pathways by providing recommendations on possible next steps based on the measurement of the target patient status and medical knowledge from completed clinical cases. The efficiency and usability of the proposed method is validated by experiments referring to a real data set extracted from Electronic Patient Records. The experimental results indicate that the recommendation service can provide its users with advice rationales that remain consistent even when patient status has changed. This makes adaptive clinical pathways possible.

Background: Two key elements to improve the quality of care for people with long-term conditions in primary care are improved clinical information systems to support delivery of evidence-based care, and enhanced self-management support. Although both elements are viewed as necessary, their interaction is not well understood., Aim: To explore the use of computer-based 'disease management' templates and their relevance to self-management dialogue within clinical encounters., Design and Setting: Qualitative study of general practices located in three primary care trusts in the north of England., Method: A qualitative mixed methods study was conducted that included comparative analysis of (1) observations of general practice consultations (n = 86); and (2) interviews with health professionals in general practice (n = 17)., Results: The analysis suggested that use of the computer templates reinforced a checklist approach to consultations, which included professionals working through several self-management topics framed as discrete behaviours. As a consequence, conversation tended to become focused on the maintenance of the professional-patient relationship at the expense of expansion in self-management dialogue. The computer templates also shaped how patient-initiated self-management dialogue was managed when it arose, with a shift towards discussion around medical agendas., Conclusion: In order to enhance the management of long-term conditions in primary care, the design and implementation of clinical information systems to improve evidence-based care need to take into account their potential impact on supporting self-management.

Pressure ulcers and depression are common preventable conditions secondary to a spinal cord dysfunction. However, few successful, low-cost preventive approaches have been identified. We have developed a dynamic automated telephone calling system, termed Care Call, to empower and motivate people with spinal cord dysfunction to improve their skin care, seek treatment for depression, and appropriately use the healthcare system. Herein, we describe the design and development of Care Call, its novel features, and promising preliminary results of our pilot testing. Voice quality testing showed that Care Call was able to understand all voice characteristics except very soft-spoken speech. Importantly, pilot study subjects felt Care Call could be particularly useful for people who are depressed, those with acute injury, and those without access to quality care. The results of a randomized controlled trial currently underway to evaluate Care Call will be available in 2011.

Background: As the popularity of e-therapies grows, so too has the body of literature supporting their effectiveness. However, these interventions are often plagued by high attrition rates and varying levels of user adherence. Understanding the role of adherence may be crucial to understanding how program usage influences the effectiveness of e-therapy interventions., Objective: The aim of this study was to systematically review the e-therapy literature to (1) describe the methods used to assess adherence and (2) evaluate the association of adherence with outcome of these interventions., Methods: A systematic review of e-therapy interventions was conducted across disease states and behavioral targets. Data were collected on adherence measures, outcomes, and analyses exploring the relationship between adherence measures and outcomes., Results: Of 69 studies that reported an adherence measure, only 33 (48%) examined the relationship between adherence and outcomes. The number of logins was the most commonly reported measure of adherence, followed by the number of modules completed. The heterogeneity of adherence and outcome measures limited analysis. However, logins appeared to be the measure of adherence most consistently related to outcomes in physical health interventions, while module completion was found to be most related to outcomes in psychological health interventions., Conclusions: There is large variation in the reporting of adherence and the association of adherence with outcomes. A lack of agreement about how best to measure adherence is likely to contribute to the variation in findings. Physical and psychological outcomes seem influenced by different types of adherence. A composite measure encompassing time online, activity completion, and active engagements with the intervention may be the best measure of adherence. Further research is required to establish a consensus for measuring adherence and to understand the role of adherence in influencing outcomes.

Background and Aims: The efficacy and effectiveness of a computerized cognitive behavioural therapy (CCBT) package, Beating the Blues, has been demonstrated in a large randomized controlled trial and several pragmatic studies in the National Health Service (NHS). The current study tests the generalizability of this finding to the implementation of CCBT in a service user-led, third sector Self Help Clinic., Method: 510 referrals for the Beating the Blues program were received over a 16 month period in routine care. The Patient Health Questionnaire Depression (PHQ-9) and Anxiety (GAD-7) Scales were administered pre-treatment and during each treatment session. The 10-item Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), Work and Social Adjustment Scale and Patient Experience Questionnaire were also administered pre-treatment and immediately on completing treatment., Results: More than two-thirds of referrals were suitable for treatment and completed a baseline assessment; 84% of these started the Beating the Blues program. Two-hundred and twenty-six people meeting caseness criteria at baseline completed at least two sessions of CCBT. Of these, 50% met recovery criteria at their final point of measurement. Completer and intention-to-treat analysis also demonstrated statistically and clinically significant improvements on key outcome measures., Conclusion: CCBT can be effectively implemented in a service user-led, third sector Self Help Clinic, increasing access to psychological therapies to meet local needs for tier two interventions for depression and anxiety.

Background: As the prevalence of heart failure (HF) rises sharply, the costs related to the care of these patients increases in parallel. Considering the already limited resources and manpower, in the future the demand for care may exceed the supply. Therefore, health care systems are encouraged to develop innovative strategies to deal with the burden of HF to improve the quality of care in order to medical outcomes and patients' quality of life. For that reason new management systems - such as telemonitoring - have to be explored., Objectives: This paper outlines the study protocol of a tailor-made telemonitoring program in ambulant patients with HF., Design and Methods: A prospective randomised controlled trial is carried out at 3 hospitals in the South-Limburg area in the Netherlands. Primary outcome measures are hospital admissions and cost-effectiveness. Secondary outcomes are effects on therapy compliance, level of disease specific knowledge and quality of life. Also determinants are studied of most and less benefited patients in the intervention group. POWER CALCULATION: It is estimated that 390 patients have to be included in the study, with 185 in each arm., Results: Inclusion started in September 2007 with a follow-up time of 12 months. First results are expected at the end of 2010., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Security considerations are an often overlooked and underfunded aspect of the development, delivery, and evaluation of e-mental health interventions although they are crucial to the overall success of any eHealth project. The credibility and reliability of eHealth scientific research and the service delivery of eHealth interventions rely on a high standard of data security. This paper describes some of the key methodological, technical, and procedural issues that need to be considered to ensure that eHealth research and intervention delivery meet adequate security standards. The paper concludes by summarizing broad strategies for addressing the major security risks associated with eHealth interventions. These include involving information technology (IT) developers in all stages of the intervention process including its development, evaluation, and ongoing delivery; establishing a wide-ranging discourse about relevant security issues; and familiarizing researchers and providers with the security measures that must be instituted in order to protect the integrity of eHealth interventions.

Objectives: Family psychoeducation has been found to reduce relapse in schizophrenia but penetration rates are low. In this study, we evaluate the feasibility of an online multifamily group program for relatives of persons with schizophrenia that can be accessed from participants' homes., Methods: We explored participation rates and evaluations of a 12-month multimodal website intervention. Using a quasi-experimental design, we compared illness outcomes (factors on the Brief Psychiatric Rating Scale, hospitalizations) of persons with diagnosed schizophrenia, and relative distress outcomes (somatic concerns and anxiety/depression subscales on the Brief Symptom Inventory) from relatives participating in the intervention (n = 26) to archival data we had from comparable dyads who received customary care (n = 16)., Results: The majority of participants in the program attended more than half the core online support sessions, expressed high levels of satisfaction, and found the technology easy to access. There appeared to be little impact of online participation on clinical status of persons with schizophrenia or relatives' distress, although there was a trend for fewer hospitalizations in the online group. Small sample size is a factor in interpreting results., Conclusions: Online interventions for relatives of persons with schizophrenia, while feasible, present unique challenges. These include 1) assuring access to the intervention in populations who do not own a computer; 2) addressing privacy concerns; 3) overcoming the special challenges of conducting groups in real time; 4) managing emergent situations adequately; and 5) questions about efficacy.

Goals are presented in the chronic illness literature as effective strategies to help people adopt self-management behaviors; however, not much is known about the types and characteristics of individuals' goals. The purpose of this study was to examine goal setting among people with epilepsy who participated in the WebEase program. WebEase is an Internet-based, theory-driven, self-management program with modules on medication adherence, stress management, and sleep habits. Participants had the opportunity to create and evaluate goals over the course of 6 weeks, with 2 weeks for each module. The goals were analyzed using three dimensions: content, specificity, and proximity. Most participants in the sample wrote goals for each week of the program. Several main content areas emerged within the modules. Goal quality, measured by specificity and proximity, did not differ according to readiness for behavior change. Readiness to change did not differ between those who wrote a goal and those who did not. The diversity of goal content and quality indicates that individuals should be supported in goal development and encouraged to set their own self-management goals, regardless of their readiness for behavior change.

Objective: To test a computer-delivered program for preventing substance use among adolescent girls., Methods: Randomly, 916 girls aged 12.76+/-1.0 years and their mothers were assigned to an intervention arm or to a test-only control arm. Intervention-arm dyads engaged in exercises to improve the mother-daughter relationship, build girls' substance use prevention skills, and reduce associated risk factors. Study outcomes were girls' and mothers' substance use and mediator variables related to girls' substance use risk and protective factors. The study was conducted between September 2006 and February 2009 with participants from greater New York City, including southern Connecticut and eastern New Jersey., Results: At 2-year follow-up and relative to control-arm girls, intervention-arm girls reported lower relevant risk factors and higher protective factors as well as less past 30-day use of alcohol (p<0.006), marijuana (p<0.016), illicit prescription drugs (p<0.03), and inhalants (p<0.024). Intervention-arm mothers showed more positive 2-year outcomes than control-arm mothers on variables linked with reduced risks of substance use among their daughters, and mothers reported lower rates of weekly alcohol consumption (p<0.0001)., Conclusions: A computer-delivered prevention program for adolescent girls and their mothers was effective in changing girls' risk and protective factors and girls' and mothers' substance use behavior.

The purpose of this study was to compare differences in emotional self-disclosure between young adult Internet users who prefer face-to-face therapy to those who prefer Internet therapy. A convenience sample of 328 was recruited from Facebook to complete an online survey. A total of 263 preferred face-to-face therapy (F2FT) while 65 preferred Internet therapy (IT). Significant differences were found with the F2FT group willing to disclose emotions of depression, jealously, anxiety, and fear to a therapist more frequently than the IT group. The majority reported a preference for F2FT over IT. Recommendations for future professional practice and research are included.

Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.

Background: Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care., Methods: In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578., Findings: 113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2.39, 95% CI 1.23-4.67; p=0.011), and 46 (42%) versus 26 (26%) at 8 months (2.07, 1.11-3.87; p=0.023)., Interpretation: CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT., Funding: BUPA Foundation.

A randomized controlled trial was conducted to evaluate the impact of an automated telephone intervention on glycemic control in patients with type 2 diabetes. One hundred twenty participants were randomly assigned to a treatment group that received a daily, automated telephone message regarding diabetes or to a control group that received usual care. The treatment group demonstrated a significant improvement in the frequency of self-monitoring of blood glucose levels compared with the control group (P < .001). A favorable trend in positive attitudes toward diabetes and a reduction in perceived monitoring and exercise barriers were seen in the intervention group compared with the control group.

Current care guidelines recommend glucose control (GC) in critically ill patients. To achieve GC, many ICUs have implemented a (nurse-based) protocol on paper. However, such protocols are often complex, time-consuming, and can cause iatrogenic hypoglycemia. Computerized glucose regulation protocols may improve patient safety, efficiency, and nurse compliance. Such computerized clinical decision support systems (Cuss) use more complex logic to provide an insulin infusion rate based on previous blood glucose levels and other parameters. A computerized CDSS for glucose control has the potential to reduce overall workload, reduce the chance of human cognitive failure, and improve glucose control. Several computer-assisted glucose regulation programs have been published recently. In order of increasing complexity, the three main types of algorithms used are computerized flowcharts, Proportional-Integral-Derivative (PID), and Model Predictive Control (MPC). PID is essentially a closed-loop feedback system, whereas MPC models the behavior of glucose and insulin in ICU patients. Although the best approach has not yet been determined, it should be noted that PID controllers are generally thought to be more robust than MPC systems. The computerized Cuss that are most likely to emerge are those that are fully a part of the routine workflow, use patient-specific characteristics and apply variable sampling intervals.

Obesity in adolescents is continuing to rise at an alarming rate and is becoming an important public health problem in Taiwan. Therefore, the aims of this study were (1) to evaluate the effectiveness of a Weight-loss E-learning Program (WEP) on obese Chinese adolescents and (2) to gauge this group's satisfaction with the WEP. The design was quasi-experimental, using purposive samples from two junior high schools in Taipei, Taiwan. Obese adolescents between 12 and 14 years of age with body mass indexes (BMI) over 25 kg/m2 were recruited. A 14-week WEP was developed to expedite weight loss for the selected adolescents. Data such as BMI, waist-to-hip ratio, waist circumference, hip circumference, mid-arm circumference, triceps skinfold, blood pressure, and physical fitness were collected through standardized instruments and methods before and after the WEP. The satisfaction of the subjects and four psychosocial variables were evaluated and taken into account by authoritative scales and questionnaires. In total, 37 adolescents participated in this study. After the WEP, we found significant decreases in BMI (p < 0.05), waist circumference (p < 0.05), and triceps skinfold (p < 0.001) in the sample population. Improvements were found in three of four tests of physical fitness (p < 0.001, p < 0.05, and p < 0.01, respectively). All psychosocial variables showed significant favorable changes (p < 0.01 for self-esteem scores, p < 0.001 for the other three variables) and satisfaction levels for the WEP ranged from 56.6% to 83.8% in four different criteria. The WEP was effective in helping obese Chinese adolescents lose weight. However, there is still room for improvement.

Background: Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood., Objectives: Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS., Search Strategy: Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages., Selection Criteria: Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS., Data Collection and Analysis: Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis., Main Results: Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed., Authors' Conclusions: Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

The purpose of this article is to describe the results of a clinical trial in which telephonic case management was evaluated as a supplement to substance abuse treatment. An interactive voice response system (IVR) was developed by the research team for use in the case management of randomly assigned participants in a clinical trial research project. The features of the software program facilitated a double caseload for the case manager as well as real-time data capture. At intake, no significant differences were found between participants in the telecommunication condition and the general project. Thus, the effectiveness of random assignment was supported. An IVR was useful for case management services, was less costly, and showed acceptability to clients. A reduction in time expenditure by using telecommunication occurred within three activity areas. Telecommunication facilitated client interaction and the use of case management, and it reduced provider time expenditure. As an alternative strategy, telecommunication case management can enhance cost effectiveness improvements.

Objective: To test the feasibility and safety of a computer-based application designed to facilitate the healthy coping of children and their families who must contend with significant congenital heart disease (CHD). The application, called the Experience Journal (EJ), is a psychoeducational intervention based on a narrative model involving the sharing of personal stories about an illness., Method: Testing was conducted in 2 phases. In phase 1, 9 parents of children with CHD and 1 adult with CHD were asked to use the EJ. After utilization, semistructured interviews assessed EJ usability and safety. In phase 2, 40 mothers of children with CHD used the EJ during a hospitalization. Assessment of feasibility and safety was measured through the use of semistructured interviews prior to EJ utilization and 2 to 4 weeks after hospital discharge., Results: Results revealed that the EJ was safe and useful for decreasing social isolation, increasing understanding of familial feelings about cardiac illness, and fostering positive reactions in mothers., Conclusions: Computer-based interventions that present psychoeducational and medical information closely connected to "one's own story" may open up new possibilities for families facing pediatric illnesses.

The Decision Systems Group is pursuing a vision in which every available medical resource can be brought together at the point of need. The DSG focuses on the components and tools in specific areas as well as on the models, approaches, and infrastructure that make this type of integration possible. Its academic mission is to train individuals with dual expertise: those who understand and appreciate the issues involved in developing and validating a method or technique, plus the issues of deployment, operation, and interaction in practical environments. Ultimately, the application of this vision can only serve to enhance the current level of healthcare.

Today's spinal-cord-injured (SCI) person is discharged from the inpatient clinical setting very early in his or her recovery process. Faced with the tremendous challenges of relearning the skills of daily living and psychologically adjusting to a catastrophic injury, the newly injured person is thrust into an overwhelming environment. As early as 1994, when inpatient stays were longer, concern was expressed about the impact of early discharge on the health and well-being of persons with SCI (Ditunno & Formal, 1994). For over 10 years, the Medical Illness Counseling Center (MICC) has offered a community-based, nurse-directed program of Computerized Functional Electrical Stimulation (CFES) for persons with SCI. The program is founded on the belief that when multi-system deterioration associated with paralysis is avoided and a behavioral approach is used, the person with SCI will have a renewed sense of well-being that enables him or her to overcome the challenges of daily living. Over time, the need for expansion of the program became apparent; it evolved into a comprehensive package of medical, nursing, and psychological care. This article describes the essential elements that comprised a successful program design, the benefits of participation in CFES, and the significance of this technology in a nurse-managed setting.

Objective: To study the implementation of electronic guidelines designed for general practitioners (GPs)., Design: A descriptive 3-year follow-up study., Subjects: All new subscribers to Physician's Desk Reference and Database (PDRD) in 1992., Setting: Locations of computers, where PDRD software was installed for the first time in 1992., Main Outcome Measures: Expectations of the program and changes in attitudes towards it, getting started with the system, frequency and continuity of use and estimated usefulness of the program., Results: The guidelines were expected to enhance diagnostic accuracy (60% of subscribers), save time (45%), and reduce costs (11%). After 1 year's use, the opinions of the users on these topics had become slightly more positive. Technical problems delayed starting to use the program in 27%. After 1 year 72% were using the program at least weekly. Using frequency was associated with having the computer in the office. The subscribers who renewed their subscription after one year often became regular users., Conclusions: The study provides insight into the implementation phase of computer-based guidelines in a population of early adopters. Technical support was essential to overcome the barriers associated with computer technology. The perceived need for information was independent of the age and experience of the physicians.

We all know that "bicarbonate dialysate" became the world wide used fluid for use in haemodialysis and related techniques. To prepare bicarbonate dialysate we actually have to use two separate concentrates: one containing sodium bicarbonate, solely or in combination with other electrolytes other than calcium, and a second concentrate containing mostly all the other electrolytes (sodium, magnesium, potassium, chloride and/or some acetate).