A clinician's guide for conducting randomized trials in individual patients.

In determining optimal treatment for a patient conventional trials of therapy are susceptible to bias. Large-scale randomized trials can provide only a partial guide and have not been or cannot be carried out for most clinical disorders. However, randomized controlled trials (RCTs) in individual patients (N of 1 RCTs) may in some circumstances provide a solution to this dilemma. In an N of 1 RCT a patient undergoes pairs of treatment periods (one period of each pair with the active drug and one with matched placebo, assigned at random); both the patient and the clinician are blind to allocation, and treatment targets are monitored. N of 1 RCTs are useful for chronic, stable conditions for which the proposed treatment, which has a rapid onset of action and ceases to act soon after it is discontinued, has shown promise in an open trial of therapy. The monitoring of treatment targets usually includes quantitative measurement of the patient''s symptoms with the use of simple patient diaries or questionnaires. Pairs of treatment periods are continued until effectiveness is proved or refuted. The cooperation of a pharmacy is required for the preparation of matching placebos and conduct of the trial. Formal statistical analysis may be helpful for interpreting the results. The practical approach presented in this paper allows clinicians to conduct their own N of 1 RCTs.     

Current experiences with internet telepathology and possible evolution in the next generation of Internet services.

The last five years experience has definitely demonstrated the possible applications of the Internet for telepathology. They may be listed as follows: (a) teleconsultation via multimedia e-mail; (b) teleconsultation via web-based tools; (c) distant education by means of World Wide Web; (d) virtual microscope management through Web and Java interfaces; (e) real-time consultations through Internet-based videoconferencing. Such applications have led to the recognition of some important limits of the Internet, when dealing with telemedicine: (i) no guarantees on the quality of service (QoS); (ii) inadequate security and privacy; (iii) for some countries, low bandwidth and thus low responsiveness for real-time applications. Currently, there are several innovations in the world of the Internet. Different initiatives have been aimed at an amelioration of the Internet protocols, in order to have quality of service, multimedia support, security and other advanced services, together with greater bandwidth. The forthcoming Internet improvements, although induced by electronic commerce, video on demand, and other commercial needs, are of real interest also for telemedicine, because they solve the limits currently slowing down the use of Internet. When such new services will be available, telepathology applications may switch from research to daily practice in a fast way.     

Introducing the Internet.

The benefits to medical practitioners of using the Internet are growing rapidly as the Internet becomes easier to use and ever more biomedical resources become available on line. The Internet is the largest computer network in the world; it is also a virtual community, larger than many nation states, with its own rules of behaviour or "netiquette." There are several types of Internet connection and various ways of acquiring a connection. Once connected, you can obtain, free of charge, programs that allow easy use of the Internet''s resources and help on how to use these resources; you can access many of these resources through the hypertext references in the on line version of this series (go to http:@www.bmj.com/bmj/ to reach the electronic version). You can then explore the various methods for accessing, manipulating, or disseminating data on the Internet, such as electronic mail, telnet, file transfer protocol, and the world wide web. Results from a search of the world wide web for information on the rare condition of Recklinghausen''s neurofibromatosis illustrate the breadth of medical information available on the Internet.     

A clinician's personal view of assisted reproductive technology over 35 years

This invited presentation is intended to cover clinical developments in the evolution of assisted reproductive technology (ART), a process which was attempted during the 1940's and 50's and culminated in the first fruition in 1978. The first in vitro fertilisation (IVF) child ensued following the partnership by a scientist with a focussed ambition (Nobel laureate Robert Edwards) joining with the gynaecologist who introduced laparoscopy to Britain in the late 60's (Patrick Steptoe). My journey commenced in 1976 as a clinician who became immersed in the embryological and endocrinological science, whence most progress in ART emanates, and continued into a medical directorship position from which this personal view is documented. Several clinical advances have been important developments in the understanding and management of sub-fertile patients. However evolution of the various laboratory sciences has been the major key essential to meeting both the immediate as well as the long-term needs for human reproduction. The future requires a much better understanding and control over gametogenesis and a laboratory process which much more closely duplicates intrinsic reproductive physiology, avoiding gamete and embryo exposure to the atmosphere.This invited presentation is intended to cover clinical developments in the evolution of assisted reproductive technology (ART), a process which was attempted during the 1940's and 50's and culminated in the first fruition in 1978. The first in vitro fertilisation (IVF) child ensued following the partnership by a scientist with a focussed ambition (Nobel laureate Robert Edwards) joining with the gynaecologist who introduced laparoscopy to Britain in the late 60's (Patrick Steptoe). My journey commenced in 1976 as a clinician who became immersed in the embryological and endocrinological science, whence most progress in ART emanates, and continued into a medical directorship position from which this personal view is documented. Several clinical advances have been important developments in the understanding and management of sub-fertile patients. However evolution of the various laboratory sciences has been the major key essential to meeting both the immediate as well as the long-term needs for human reproduction. The future requires a much better understanding and control over gametogenesis and a laboratory process which much more closely duplicates intrinsic reproductive physiology, avoiding gamete and embryo exposure to the atmosphere.     

Debate: A subversive view of subsets - a dissident clinician's opinion

Clinical trialists and statisticians are very wary of subgroup analysis, for good reasons. Clinicians have to deal with situations in which subgroups of patients differ widely from one another in their prognosis and response to treatment. Few trials are large enough to demonstrate convincingly these differences in outcome, but often provide suggestive evidence. Should we ignore this and treat all patients as the same, or should we allow dubious statistical evidence to buttress biological plausibility in making clinical decisions?     

Characteristics of Internet Addiction/Pathological Internet Use in U.S. University Students: A Qualitative-Method Investigation

Studies have identified high rates and severe consequences of Internet Addiction/Pathological Internet Use (IA/PIU) in university students. However, most research concerning IA/PIU in U.S. university students has been conducted within a quantitative research paradigm, and frequently fails to contextualize the problem of IA/PIU. To address this gap, we conducted an exploratory qualitative study using the focus group approach and examined 27 U.S. university students who self-identified as intensive Internet users, spent more than 25 hours/week on the Internet for non-school or non-work-related activities and who reported Internet-associated health and/or psychosocial problems. Students completed two IA/PIU measures (Young’s Diagnostic Questionnaire and the Compulsive Internet Use Scale) and participated in focus groups exploring the natural history of their Internet use; preferred online activities; emotional, interpersonal, and situational triggers for intensive Internet use; and health and/or psychosocial consequences of their Internet overuse. Students’ self-reports of Internet overuse problems were consistent with results of standardized measures. Students first accessed the Internet at an average age of 9 (SD = 2.7), and first had a problem with Internet overuse at an average age of 16 (SD = 4.3). Sadness and depression, boredom, and stress were common triggers of intensive Internet use. Social media use was nearly universal and pervasive in participants’ lives. Sleep deprivation, academic under-achievement, failure to exercise and to engage in face-to-face social activities, negative affective states, and decreased ability to concentrate were frequently reported consequences of intensive Internet use/Internet overuse. IA/PIU may be an underappreciated problem among U.S. university students and warrants additional research.     

Role of severe psychopathology in sleep-related experiences: A pilot study.

The construct General Sleep-related Experiences (GSEs, such as elevated dream recall, vivid or bizarre dreams, flying dreams, hypnagogic hallucinations, nightmares, and recurrent dreams) has been previously linked to various forms of psychopathology in nonclinical populations. The aim of this pilot study was to explore this relationship in the context of severe psychopathology. Nineteen outpatients of a mental health clinic were compared to 26 controls on sleep experiences, psychopathology, sleep quality, life stress, and transliminality. Outpatients also reported illness intrusiveness levels. As expected, the outpatient group had elevated GSEs. Within the outpatient group, illness intrusiveness, stress, and transliminality were correlated with GSEs. These findings elucidate the association between GSEs and distress in the context of severe psychopathology. (PsycINFO Database Record (c) 2011 APA, all rights reserved)