Association of Mentor-to-Program Contact and Applicant Rank Disclosure With Vitreoretinal Fellowship Applicant's Final Match Outcome in 2016 and 2017.

Importance: Communication between applicants, mentors, and training programs is common before the residency and fellowship match. Few studies have examined the association of prematch communication on final match outcomes. Objectives: To report various characteristics of the vitreoretinal surgery fellowship match and to examine the association of mentor-to-program communication and applicant disclosure of their number 1 ranking with the probability of matching number 1. Design, Setting, and Participants: In this cross-sectional study of the 2016 and 2017 vitreoretinal surgery fellowship matches, an online survey examined (1) number of applications submitted, (2) number of programs ranked, (3) rank order of final match, (4) total application and interview-related costs, (5) mentor-to-program contact, (6) applicant disclosure of number 1 ranking, and (7) mentor disclosure of number 1 ranking. A link to an anonymous online survey was sent to 198 matched fellows (105 fellows from the 2016 match and 93 from the 2017 match). Main Outcomes and Measures: Survey responses regarding the vitreoretinal surgery fellowship application process. Results: The survey was sent to 198 matched fellowship applicants, and 152 (77%) completed the survey. Of the 105 matched applicants in 2016, 21 (20%) were women. Of the 93 matched applicants in 2017, 24 (26%) were women. Matched applicants applied to a mean (SD) of 34 (17) programs (range, 1-85) and ranked a mean (SD) of 12 (4) programs (range, 1-27). Of 152 applicants, 66 (43%) matched at their number 1 ranked program, 23 (15%) matched number 2, and 21 (14%) matched number 3. The mean (SD) total cost was $5500 ($2776) (range, $500-$13 500). Two-sided χ2 testing found no association (odds ratio, 0.70; 95% CI, 0.34-1.4; P = .33) between mentor-to-program contact and the probability of applicants matching at their number 1 ranked program. Matched applicants who revealed their number 1 ranking either personally or via a mentor matched at a program ranked lower (more desirable) on their rank list (mean match ranking, 2.8) compared with those who did not reveal their number 1 ranking (mean match ranking, 4.2; 95% CI, 0.2-2.5; P = .01). Applicant disclosure of their intention to rank a program number 1, either personally or via a mentor, was associated with matching number 1 (odds ratio, 2.6; range, 1.1-6.0; P = .03). Conclusions and Relevance: Vitreoretinal fellowship applicants who disclosed their number 1 ranking, either personally or via a mentor, were associated with improved match outcomes compared with their cohorts who did not make such disclosures.

Lessons learned in the development and evaluation of RxCoach™, an mHealth app to increase tobacco cessation medication adherence.

OBJECTIVE: In this project we developed and evaluated a mobile health app to improve adherence to tobacco cessation medication. METHODS: The study was conducted in three phases: (1) Create app with input from our consultant, focus groups and user testing; (2) Test feasibility of the app; and (3) Develop and user-test the barcode scanner. RESULTS: Focus group feedback was instrumental in developing content and creating the user interface. User testing helped to identify problems and refine the app. The feasibility trial provided "real world" testing. We experienced challenges in recruitment due to the inclusion criteria. We had high attrition due to technical issues, medication side effects, enrollment procedures, and lack of personal contact. Among the five retained participants, use of the app was associated with good medication adherence and high consumer satisfaction. CONCLUSION: The small sample size limits the generalizability of the findings and the conclusions that can be drawn from the study. However, the feasibility trial enabled the team to identify ways to improve the conduct of this and other mHealth studies. PRACTICAL IMPLICATIONS: We should expand RxCoach to include all prescription and over-the-counter tobacco cessation medications, and re-test for feasibility using lessons learned to improve recruitment and retention.

Home medication support for childhood cancer: family-centered design and testing.

PURPOSE: Errors in the use of medications at home by children with cancer are common, and interventions to support correct use are needed. We sought to (1) engage stakeholders in the design and development of an intervention to prevent errors in home medication use, and (2) evaluate the acceptability and usefulness of the intervention. METHODS: We convened a multidisciplinary team of parents, clinicians, technology experts, and researchers to develop an intervention using a two-step user-centered design process. First, parents and oncologists provided input on the design. Second, a parent panel and two oncology nurses refined draft materials. In a feasibility study, we used questionnaires to assess usefulness and acceptability. Medication error rates were assessed via monthly telephone interviews with parents. RESULTS: We successfully partnered with parents, clinicians, and IT experts to develop Home Medication Support (HoMeS), a family-centered Web-based intervention. HoMeS includes a medication calendar with decision support, a communication tool, adverse effect information, a metric conversion chart, and other information. The 15 families in the feasibility study gave HoMeS high ratings for acceptability and usefulness. Half recorded information on the calendar to indicate to other caregivers that doses were given; 34% brought it to the clinic to communicate with their clinician about home medication use. There was no change in the rate of medication errors in this feasibility study. CONCLUSION: We created and tested a stakeholder-designed, Web-based intervention to support home chemotherapy use, which parents rated highly. This tool may prevent serious medication errors in a larger study.

Current options in the management of pellucid marginal degeneration.

PURPOSE: To review and evaluate current and future directions in the diagnosis and surgical management of pellucid marginal degeneration (PMD), including penetrating keratoplasty, full-thickness crescentic wedge resection (FTCWR), deep anterior lamellar keratoplasty (DALK), crescentic lamellar wedge resection (CLWR), crescentic lamellar keratoplasty, tuck-in lamellar keratoplasty (TILK), toric phakic intraocular lens (PIOL) implantation, intrastromal corneal ring segment implantation (ICRS), corneal collagen cross-linking (CXL), and combined therapies. This is the first review article looking at the literature specific to PMD. METHODS: Review of published studies. RESULTS: Reported data for each treatment is presented. Penetrating keratoplasty is the treatment of last resort in PMD and is effective, but with considerable complications. DALK provides visual outcomes similar to penetrating keratoplasty without the risk of immune-mediated graft rejection, but its complexity and relative novelty limit its acceptance. FTCWR has good visual outcomes, but with significant astigmatic drift. CLWR is effective, but lacks long-term results. Crescentic lamellar keratoplasty and TILK are effective, but technically difficult and without long-term results. Toric PIOL implantation is effective, but ectasia progression is a concern. ICRS implantation can delay penetrating keratoplasty and improve contact lens tolerance, but does not treat the underlying process. CXL demonstrates effectiveness without complications, although data are limited and long-term results are needed. Combining treatments such as ICRS, CXL, toric PIOL implantation, and refractive surgery is promising, but additional studies are needed to investigate their efficacy and safety. CONCLUSIONS: Although little is understood about the etiology, pathophysiology, epidemiology, and genetics of PMD, new treatments are improving visual outcomes and reducing complications. Corneal collagen cross-linking is especially exciting because it halts disease progression. Combined treatments and improved screening could eliminate the need for surgical management in most cases of PMD.

Change in keratometry after myopic laser in situ keratomileusis and photorefractive keratectomy.

PURPOSE: To compare the change in keratometry (K), spherical equivalent (SE), and visual acuity after myopic laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). SETTING: Academic tertiary care center. DESIGN: Retrospective review. METHODS: The postoperative K, SE, and uncorrected and corrected distance visual acuities were measured 6 months, 9 months, 1 year, 2 years, 3 years, 4 to 5 years, 6 to 7 years, and 8+ years postoperatively. A difference (Δ) for each variable was calculated from its 6-month postoperative baseline. The rates of change were grouped based on the magnitude of myopic correction (0.00 to 2.99 diopters [D]; 3.00 to 5.99 D; 6.00 to 8.99 D), type of surgery (LASIK versus PRK), and age (<34 years; 34 to 45 years; >45 years). RESULTS: Statistically significant differences were found in the rates of change between low and moderate corrections to high corrections for ΔKavg (P=.0472 and P=.0091, respectively) and ΔSE (both P<.0001). Statistically significant differences were found in the rate of change in ΔKavg between all 3 ages groups (P=.0330, P=.0051, and P<.0001) and in ΔSE between ages less than 34 years and 34 to 45 years to ages over 45 years (P=.0158 and P=.0015, respectively). There was no significant difference in the rate of change in ΔKavg and ΔSE between LASIK and PRK (P=.3599 and P=.9403, respectively). CONCLUSION: There was keratometric and refractive regression for myopic LASIK, with the rate of regression depending on treatment magnitude and age. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Long-term efficacy of click city(r): tobacco: a school-based tobacco prevention program.

INTRODUCTION: Click City (®) : Tobacco is an innovative, computer-based tobacco prevention program designed to be implemented in 5th-grade classrooms with a booster in 6th grade. The program targets etiological mechanisms predictive of future willingness and intentions to use tobacco and initiation of tobacco use. Each component was empirically evaluated to assure that it changed its targeted mechanism. This paper describes long-term outcomes for students who participated in a randomized controlled efficacy trial of the program. METHODS: A total of 26 middle schools were stratified and randomly assigned to the Click City (®) : Tobacco program or Usual Curriculum. The 47 elementary schools that fed into each middle school were assigned to the same condition as their respective middle school. In Click City (®) : Tobacco schools, 1,168 students from 24 elementary schools and 13 middle schools participated. In Usual Curriculum schools, 1,154 students from 23 elementary schools and 13 middle schools participated. All participating students completed baseline, post-6th grade program, and 7th grade assessments. RESULTS: As compared to students in schools that continued with their usual curriculum, intentions and willingness to smoke increased less from baseline to 6th grade and from baseline to 7th grade, among students in schools that used the Click City (®) : Tobacco curriculum. Changes in mechanisms were also in the expected direction. The program was particularly efficacious for at-risk students. CONCLUSIONS: Results provide evidence to support the long-term efficacy of Click City (®) : Tobacco. Program development, based on an empirical evaluation of each component, most likely played a role in the success of the program.

Vitreous and Aqueous Penetration of Orally Administered Trimethoprim-Sulfamethoxazole Combination in Humans.

PURPOSE: To determine the penetration of orally administered trimethoprim (TMP)-sulfamethoxazole (SMX) into the aqueous and vitreous cavity of noninflamed human eyes. METHODS: Nine adult patients undergoing cataract surgery and 10 adult patients undergoing pars plana vitrectomy were given 3 doses of oral TMP-SMX every 12 hours before the surgery. Aqueous and blood samples were collected from patients undergoing cataract surgery; vitreous and blood samples were collected from patients undergoing vitrectomy. The levels of TMP and SMX were analyzed using high-performance liquid chromatography and were compared with the mean minimum inhibitory concentrations (MIC) of potential ocular pathogens. RESULTS: TMP-SMX was present in all samples. Among eyes undergoing cataract surgery, the mean concentrations of TMP in aqueous and blood were 0.341 ± 0.141 µg/mL (mean ± SD) and 1.501 ± 0.433 µg/mL and of SMX were 5.259 ± 0.929 µg/mL and 11.835 ± 2.100 µg/mL, respectively. Among eyes undergoing vitrectomy, the mean concentrations of TMP in vitreous and blood were 1.864 ± 0.807 µg/mL and 4.591 ± 2.979 µg/mL and of SMX were 5.910 ± 2.705 µg/mL and 39.289 ± 15.469 µg/mL, respectively. MIC levels were achieved against many bacterial pathogens, including methicillin-resistant Staphylococcus aureus. CONCLUSIONS: TMP-SMX penetrates both the aqueous and vitreous cavities when given orally. The components reach therapeutic inhibitory concentrations in the ocular cavity against many potential pathogens.

Sources of medical error in refractive surgery.

PURPOSE: To evaluate the causes of laser programming errors in refractive surgery and outcomes in these cases. METHODS: In this multicenter, retrospective chart review, 22 eyes of 18 patients who had incorrect data entered into the refractive laser computer system at the time of treatment were evaluated. Cases were analyzed to uncover the etiology of these errors, patient follow-up treatments, and final outcomes. The results were used to identify potential methods to avoid similar errors in the future. RESULTS: Every patient experienced compromised uncorrected visual acuity requiring additional intervention, and 7 of 22 eyes (32%) lost corrected distance visual acuity (CDVA) of at least one line. Sixteen patients were suitable candidates for additional surgical correction to address these residual visual symptoms and six were not. Thirteen of 22 eyes (59%) received surgical follow-up treatment; nine eyes were treated with contact lenses. After follow-up treatment, six patients (27%) still had a loss of one line or more of CDVA. Three significant sources of error were identified: errors of cylinder conversion, data entry, and patient identification error. CONCLUSION: Twenty-seven percent of eyes with laser programming errors ultimately lost one or more lines of CDVA. Patients who underwent surgical revision had better outcomes than those who did not. Many of the mistakes identified were likely avoidable had preventive measures been taken, such as strict adherence to patient verification protocol or rigorous rechecking of treatment parameters.

A randomized clinical trial of a web-based tobacco cessation education program.

OBJECTIVES: We report the results of a randomized clinical trial of a 3-hour, web-based, tobacco cessation education program, the Web-Based Respiratory Education About Tobacco and Health (WeBREATHe) program, for practicing pediatric respiratory therapists (RTs), registered nurses (RNs), and nurse practitioners (NPs). METHODS: Two hundred fifteen RTs (n = 40), RNs (n = 163), and NPs (n = 12) employed at the Children's Hospital of Philadelphia and the Children's Hospital, University of Colorado at Denver, participated in this study. All study activities were completed online. After consenting, participants were randomly assigned to either the training (intervention) or delayed training (control) condition. The training condition consisted of a 3-hour continuing education unit course plus ongoing online resources. Participants were assessed at baseline, 1 week, and 3 months after enrollment. RESULTS: Participants in the training condition were more likely to increase their tobacco cessation intervention behaviors than their delayed training counterparts (F[1, 213] = 32.03, P < .001). Training participants showed significantly greater levels of advise (F[1, 213] = 7.22, P < .001); assess (F[1, 213] = 19.56, P < .001); and particularly assist/arrange (F[1213] = 35.52, P < .001). In addition, training condition participants rated the program highly on measures of consumer satisfaction. CONCLUSIONS: The WeBREATHe program is the first evidence-based education program in tobacco cessation designed specifically for pediatric RTs, RNs, and NPs. Engagement in WeBREATHe increased participants' tobacco cessation-related behaviors.

Laser in situ keratomileusis in patients with collagen vascular disease: a review of the literature.

PURPOSE: To evaluate the current United States Food and Drug Administration (FDA) recommendations regarding laser in situ keratomileusis (LASIK) surgery in patients with collagen vascular diseases (CVD) and assess whether these patients make appropriate candidates for laser vision correction, and offer treatment recommendations based on identified clinical data. METHODS: A literature search was conducted using PubMed, Medline, and Ovid to identify all existing studies of LASIK in patients with collagen vascular diseases. The search was conducted without date limitations. Keywords used for the search included MeSH terms: laser in situ keratomileusis, LASIK, refractive surgery, ocular surgery, and cataract surgery connected by "and" with the following MeSH and natural-language terms: collagen vascular disease, rheumatic disease, systemic disease, rheumatoid arthritis, systemic lupus erythematosus, Sjögren's syndrome, seronegative spondyloarthropathy, HLA B27, ankylosing spondylitis, reactive arthritis, psoriatic arthritis. The abstracts for all studies meeting initial search criteria were reviewed; relevant studies were included. No prospective studies were found; however, four retrospective case studies were identified that examined LASIK surgery in patients with CVD. Several case reports were also identified in similar fashion. RESULTS: The FDA considers CVD a relative contraindication to LASIK surgery, due largely to the ocular complications associated with disease in the CVD spectrum. However, recent studies of LASIK in patients with CVD indicate LASIK may be safe for patients with very well-controlled systemic disease, minimal ocular manifestations, and no clinical signs or history of dry-eye symptoms. CONCLUSION: LASIK surgery may be safe in patients with rheumatoid arthritis or systemic lupus erythematosus and the seronegative spondyloarthropathies if stringent preoperative criteria are met. Evidence suggests patients with Sjögren's syndrome are not suitable candidates for LASIK.

Comparison of the ratio of keratometric change to refractive change induced by myopic ablation.

PURPOSE: To compare the ratio of keratometric change (ΔK) to refractive change (ΔSE) induced by refractive laser ablation. METHODS: The charts of 3337 eyes that underwent LASIK or photorefractive keratectomy (PRK) from 2002 to 2011 were retrospectively reviewed, and the ratio ΔK/ΔSE measured at 3 months postoperatively was compared between eyes with low ΔSE (0.00 to 2.99 diopters [D]), moderate ΔSE (3.00 to 5.99 D), and high ΔSE (6.00 to 8.99 D). Eyes were further stratified by LASIK vs PRK; custom vs conventional treatments; microkeratome vs IntraLase (Abbott Medical Optics Inc) femtosecond laser-created flaps; and flat (38.00 to 41.99 D) vs moderate (42.00 to 45.99 D) vs steep (46.00 to 49.99 D) preoperative keratometry, and the ratio ΔK/ΔSE was similarly compared. RESULTS: Significant differences were found in the ratio ΔK/ΔSE among eyes with low ΔSE (1.00±0.50 D), moderate ΔSE (0.83±0.19 D), and steep ΔSE (0.80±0.15 D) (P<.001), and between eyes with moderate and high ΔSE in LASIK vs PRK, custom vs conventional treatments, and microkeratome vs IntraLase flaps. Significant differences in the ratio ΔK/ΔSE were also found in eyes with low, moderate, and high ΔSE regardless of preoperative keratometry. The ratio ΔK/ΔSE compared with ΔSE follows a nonlinear pattern and tended to be higher and more variable at lower amounts of correction. CONCLUSIONS: The change in simulated keratometry required to achieve 1.00 D of myopic refractive correction decreased as the amount of refractive change increased, was more variable with lower amounts of correction, and followed a nonlinear relationship. Many variables, such as LASIK vs PRK, custom vs conventional, and microkeratome vs IntraLase flaps, affected the ratio of ΔK/ΔSE for moderate and high myopic corrections.

Laser in-situ keratomileusis in patients with diabetes mellitus: a review of the literature.

PURPOSE: A growing number of diabetic patients request laser in situ keratomileusis (LASIK) for elective vision correction each year. While the United States Food and Drug Administration considers diabetes a relative contraindication to LASIK surgery, there are several reports in the literature of LASIK being performed safely in this patient population. The purpose of this review was to examine whether diabetes should still be considered a contraindication to LASIK surgery by reviewing the ocular and systemic complications of diabetes, and examining the existing data on the outcomes of LASIK in diabetic patients. METHODS: A literature review was conducted through PubMed, Medline, and Ovid to identify any study on LASIK surgery in patients with diabetes mellitus. This search was conducted without date restrictions. The search used the Medical Subject Headings (MeSH(®)) term LASIK linked by the word "and" to the following MeSH and natural language terms: diabetes, diabetes mellitus, systemic disease, and contraindications. Abstracts for all studies meeting initial search criteria were reviewed for relevance. There were no prospective clinical studies identified. Three retrospective studies were identified. Key sources from these papers were identified, reviewed, and included as appropriate. An additional literature search was conducted to identify any study of ocular surgery on patients with diabetes using the MeSH terms refractive surgery, photorefractive keratectomy, radial keratotomy, cataract surgery, vitrectomy, and iridectomy linked by the word "and" to the following MeSH terms: diabetes, diabetes mellitus, and systemic disease. This search was conducted without date restrictions. Abstracts of studies meeting the initial search criteria were reviewed and articles deemed relevant to the subject were included in this review. CONCLUSION: LASIK may be safe in diabetic patients with tight glycemic control and no ocular or systemic complications.

Use of loteprednol for routine prophylaxis after photorefractive keratectomy.

BACKGROUND: The purpose of this work is to report our experience using loteprednol 0.5% for routine prophylaxis after photorefractive keratectomy in an academic refractive surgery center. MATERIALS AND METHODS: Photorefractive keratectomy was performed on 579 eyes from 316 patients in this retrospective chart review of patients treated postoperatively with either fluorometholone 0.1% (273 eyes) or loteprednol 0.5% (306 eyes). Primary outcome measures at 6 months included uncorrected distance visual acuity, corrected distance visual acuity, and manifest refraction spherical equivalent. Secondary outcome measures were incidence of corneal haze and increased intraocular pressure. RESULTS: There were no statistically significant differences in preoperative characteristics between the two groups when comparing age, sex, best-corrected visual acuity, spherical equivalent, or keratometry. Both groups achieved excellent visual outcomes, with a mean uncorrected distance visual acuity (logMAR) of 0.004 ± 1.4 in the fluorometholone group and -0.028 ± 1.1 in the loteprednol group (P = 0.013) at 6 months. Postoperative corneal haze and increased intraocular pressure were uncommon and not statistically different between the groups. CONCLUSION: Loteprednol 0.5% performed similarly to fluorometholone 0.1% when used for prophylaxis following photorefractive keratectomy. The incidence of haze and increased intraocular pressure were similar between the two groups.

The effect of preoperative keratometry on visual outcomes after moderate myopic LASIK.

PURPOSE: To evaluate visual outcomes in moderately myopic eyes with flat and steep corneas (preoperatively) that have been treated with laser-assisted in situ keratomileusis (LASIK). PATIENTS AND METHODS: Records of ninety-six eyes with average preoperative keratometry (K) values between 39.9 and 42.0 diopters (D) (flat) were matched with 103 eyes with preoperative K values between 46.0 and 47.2 D (steep) that underwent LASIK between March 2007 and March 2010 for moderate myopia, and were retrospectively reviewed. The primary outcome measures used to determine the effect of preoperative keratometry on visual prognosis were refraction, visual acuity, change in keratometry (ΔK), and change in spherical equivalent (ΔSE), measured at 1, 3, 6, and 12 months postoperatively. RESULTS: Significant differences were found at 6 months postoperatively between the flat group and steep group in SE (P = 0.029), sphere (P = 0.018), ΔK (P = 0.002), percentage of eyes achieving SE of -0.25 to + 0.25 D (P = 0.0125), -0.26 to -0.50 D (P = 0.003), -0.51 to -1.00 D (P = 0.044), and the percentage of eyes achieving uncorrected distance visual acuity of 20/15 or better (P = 0.0006). CONCLUSION: Moderately myopic eyes with flatter corneas preoperatively have better visual prognosis following LASIK compared with moderately myopic eyes with steeper corneas.

Computerized portion-size estimation compared to multiple 24-hour dietary recalls for measurement of fat, fruit, and vegetable intake in overweight adults.

Validated self-report methods of dietary assessment exist and might be improved in terms of both accuracy and cost-efficiency with computer technology. The objectives of this preliminary study were to develop an initial version of an interactive CD-ROM program to estimate fruit, vegetable, and fat intake, and to compare it to multiple 24-hour dietary recalls (averaged over 3 days). In 2009, overweight male and female adults (n=205) from Lane County, OR, completed computerized and paper versions of fruit, vegetable, and fat screening instruments, and multiple 24-hour dietary recalls. Summary scores from the 10-item National Cancer Institute Fruit and Vegetable Scan and the 18-item Block Fat Screener were compared to multiple 24-hour dietary recall-derived fruit/vegetable and fat intake estimates (criterion measures). Measurement models were used to derive deattenuated correlations with multiple 24-hour dietary recalls of paper and CD-ROM administrations of Fruit and Vegetable Scan fruit intake, vegetable intake, and fruit and vegetable intake, and Block Fat Screener fat intake. The computerized assessment and paper surveys were related to multiple 24-hour dietary recall-derived fruit/vegetable and fat intake. Deattenuated correlation coefficients ranged from 0.50 to 0.73 (all P≤0.0001). The CD-ROM-derived estimate of fruit intake was more closely associated with 24-hour dietary recall (r=0.73) than the paper-derived estimate (r=0.54; P<0.05), but the other comparisons did not differ significantly. Findings from this preliminary study with overweight adults indicate the need for additional enhancements to the CD-ROM assessment and more extensive validation studies.

Engagement in a diabetes self-management website: usage patterns and generalizability of program use.

BACKGROUND: Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors. A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change. OBJECTIVE: This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement. The multimedia website involved goal setting, action planning, and self-monitoring as well as offering features such as "Ask an Expert" to enhance healthy eating, physical activity, and medication adherence. We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes. METHODS: We report on participants in a randomized controlled trial (RCT) who were randomized to receive (1) the website alone (n = 137) or (2) the website plus human support (n = 133) that included additional phone calls and group meetings. The website was available in English and Spanish and included features to enhance engagement and user experience. A number of engagement variables were calculated for each participant including number of log-ins, number of website components visited at least twice, number of days entering self-monitoring data, number of visits to the "Action Plan" section, and time on the website. Key outcomes included exercise, healthy eating, and medication adherence as well as body mass index (BMI) and biological variables related to cardiovascular disease risk. RESULTS: Of the 270 intervention participants, the average age was 60, the average BMI was 34.9 kg/m², 130 (48%) were female, and 62 (23%) self-reported Latino ethnicity. The number of participant visits to the website over 4 months ranged from 1 to 119 (mean 28 visits, median 18). Usage decreased from 70% of participants visiting at least weekly during the first 6 weeks to 47% during weeks 7 to 16. There were no significant differences between website only and website plus support conditions on most of the engagement variables. In total, 75% of participants entered self-monitoring data at least once per week. Exercise action plan pages were visited more often than medication taking and healthy eating pages (mean of 4.3 visits vs 2.8 and 2.0 respectively, P < .001). Spearman nonparametric correlations indicated few significant associations between patient characteristics and summary website engagement variables, and key factors such as ethnicity, baseline computer use, age, health literacy, and education were not related to use. Partial correlations indicated that engagement, especially in self-monitoring, was most consistently related to improvement in healthy eating (r = .20, P = .04) and reduction of dietary fat (r = -.31, P = .001). There was also a significant correlation between self-monitoring and improvement in exercise (r = .20, P = .033) but not with medication taking. CONCLUSIONS: Participants visited the website fairly often and used all of the theoretically important sections, but engagement decreased over 4 months. Usage rates and patterns were similar for a wide range of participants, which has encouraging implications for the potential reach of online interventions. TRIAL REGISTRATION: NCT00987285; http://clinicaltrials.gov/show/NCT00987285 (Archived by WebCite at http://www.webcitation.org/5vpe4RHTV).

Short-term efficacy of Click City®: Tobacco: changing etiological mechanisms related to the onset of tobacco use.

This paper described the short-term results from an ongoing randomized controlled efficacy study of Click City®: Tobacco, a tobacco prevention program designed for 5th graders, with a booster in sixth grade. Click City®: Tobacco is an innovative school-based prevention program delivered via an intranet, a series of linked computers with a single server. The components of the program target theoretically based and empirically supported etiological mechanisms predictive of future willingness and intentions to use tobacco and initiation of tobacco use. Each component was designed to change one or more etiological mechanisms and was empirically evaluated in the laboratory prior to inclusion in the program. Short-term results from 47 elementary schools (24 schools who used Click City®: Tobacco, and 23 who continued with their usual curriculum) showed change in intentions and willingness to use tobacco from baseline to 1-week following the completion of the 5th grade sessions. The results demonstrate the short-term efficacy of this program and suggest that experimentally evaluating components prior to including them in the program contributed to the efficacy of the program. The program was most efficacious for students who were most at risk.