JMIR Publications

Interactive Journal of Medical Research

A new general medical journal for the 21st centrury, focusing on innovation in health and medical research


Journal Description

i-JMR is a general medical journal with a focus on innovation in health, health care, and medicine - through new medical techniques and innovative ideas and/or research, including - but not limited to - technology, clinical informatics, sociotechnical and organizational health care innovations, or groundbreaking research.

Published by JMIR Publications, publisher of JMIR, the leading eHealth/mHealth journal (Impact Factor 2016: 5.175), i-JMR is a JMIR "sister journal" with a projected impact factor of about 2.03 (2016). which features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs.

i-JMR is indexed in PubMed and archived in PubMed Central.

i-JMR is also indexed in Clarivate Analytics (formerly the IP and Science Division of Thomson Reuters) new Emerging Sources Citation Index (ESCI).


Recent Articles:

  • Help-Diabetes home page (montage). Source: e-Health Unit, UCL /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Promoting Engagement With a Digital Health Intervention (HeLP-Diabetes) Using Email and Text Message Prompts: Mixed-Methods Study


    Background: Engagement with digital health interventions (DHIs) may be regarded as a prerequisite for the intervention to achieve positive health or behavior change outcomes. One method employed to promote engagement is the use of prompts such as emails and text messages. However, little is known about the characteristics of prompts that promote engagement. This study explored the association between the content and delivery mode of prompts and the users’ engagement with HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a DHI that aimed to promote self-management in adults with type 2 diabetes. Objective: The objective of this study was to identify the characteristics of prompts, specifically the content and delivery mode, which were associated with increased engagement. Methods: This was a mixed-methods study. Email and text message prompts were sent to the registered users of HeLP-Diabetes. Use of the intervention was recorded and examined to identify which email and text message prompts were associated with subsequent visits to the DHI. Characteristics of prompts that were identified as particularly effective or ineffective were explored through think-aloud interviews with the participants. Results: Of a total of 39 email prompts, 49% (19/39) prompts showed a significant association with subsequent visits to the DHI. However, none of the text message prompts were associated with subsequent visits to the DHI. Furthermore, think-aloud interviews were carried out with 6 experienced participants with type 2 diabetes. The findings suggest that these participants preferred email prompts that were clear, relatively short, and empowering; used nondirective advice; included health professional references; were visually appealing; and contained news and updates. Conclusions: The findings of this study contribute to the existing evidence supporting the role of email prompts in promoting and maintaining engagement with DHIs. This study described the content of prompts that may be engaging. However, the results should be interpreted with caution, as prompts may be context-specific interventions and the results may not be generalizable across other DHIs or other types of interventions targeting self-management of type 2 diabetes.

  • Source: Image created by the authors; Copyright: Mitch J Duncan; URL:; License: Creative Commons Attribution (CC-BY).

    Activity Trackers Implement Different Behavior Change Techniques for Activity, Sleep, and Sedentary Behaviors


    Background: Several studies have examined how the implementation of behavior change techniques (BCTs) varies between different activity trackers. However, activity trackers frequently allow tracking of activity, sleep, and sedentary behaviors; yet, it is unknown how the implementation of BCTs differs between these behaviors. Objective: The aim of this study was to assess the number and type of BCTs that are implemented by wearable activity trackers (self-monitoring systems) in relation to activity, sleep, and sedentary behaviors and to determine whether the number and type of BCTs differ between behaviors. Methods: Three self-monitoring systems (Fitbit [Charge HR], Garmin [Vivosmart], and Jawbone [UP3]) were each used for a 1-week period in August 2015. Each self-monitoring system was used by two of the authors (MJD and BM) concurrently. The Coventry, Aberdeen, and London-Refined (CALO-RE) taxonomy was used to assess the implementation of 40 BCTs in relation to activity, sleep, and sedentary behaviors. Discrepancies in ratings were resolved by discussion, and interrater agreement in the number of BCTs implemented was assessed using kappa statistics. Results: Interrater agreement ranged from 0.64 to 1.00. From a possible range of 40 BCTs, the number of BCTs present for activity ranged from 19 (Garmin) to 33 (Jawbone), from 4 (Garmin) to 29 (Jawbone) for sleep, and 0 (Fitbit) to 10 (Garmin) for sedentary behavior. The average number of BCTs implemented was greatest for activity (n=26) and smaller for sleep (n=14) and sedentary behavior (n=6). Conclusions: The number and type of BCTs implemented varied between each of the systems and between activity, sleep, and sedentary behaviors. This provides an indication of the potential of these systems to change these behaviors, but the long-term effectiveness of these systems to change activity, sleep, and sedentary behaviors remains unknown.

  • iStart Smart for Teens. Source: Image created by the authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Short-Term Efficacy of an Innovative Mobile Phone Technology-Based Intervention for Weight Management for Overweight and Obese Adolescents: Pilot Study


    Background: In the United States, approximately one-third of adolescents are now overweight or obese, and one in six is obese. This financial cost and the larger nonfinancial costs of obesity make obesity prevention and management for adolescents imperative for the health of the nation. However, primary care visits are typically brief, and primary care providers may lack adequate resources to help overweight or obese adolescents to manage weight issues. To augment the efficacy of primary care visits for adolescent weight management, mobile phone technology can be used as an adjunct treatment that provides additional opportunities for encouraging improvement in lifestyle, attainment, and maintenance of healthy weight. Objective: The purposes of this study were to (1) measure effects of an innovative mobile phone technology-based intervention for overweight and obese adolescents and to (2) examine the intervention’s feasibility for use in primary care clinics. Methods: The mobile phone-based intervention had three components: use of the Fitbit Flex, participation in an online educational program, and receipt of biweekly text messages during the maintenance phase. A randomized controlled study design was utilized. Data regarding anthropometrics (body mass index [BMI] and waist-to-hip ratio), blood pressure, levels of physical and sedentary activity, diet, and self-efficacy regarding physical activity and diet were collected at baseline and at 3 and 6 months after the baseline assessment. Results: A total of 40 adolescents participated in the study. At the 6-month follow-up visit, compared to participants in the control group, the mobile phone-based intervention participants had significant improvement in BMI (z=–4.37, P=.001), diastolic blood pressure (z=–3.23, P=.001), physical activity days per week (z=2.58, P=.01), TV and computer time (z=–3.34, P=.001), servings of fruits and vegetables per day (z=2.74, P=.006), servings of soda and sweetened drinks (z=–3.19, P=.001), physical activity self-efficacy (z=2.75, P=.006), and dietary self-efficacy (z=5.05, P=.001). Medium to large effect sizes were found in these outcome variables. Conclusions: The use of mobile technologies may offer a practical, reliable adjunct to weight management for overweight and obese adolescents in busy primary care clinics serving adolescents. Trial Registration: NCT 01693250; term=Adolescent+ obesity+AND+mhealth&rank=5 (Archived by WebCite at)

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

    WhatsApp Messenger as an Adjunctive Tool for Telemedicine: An Overview


    Background: The advent of telemedicine has allowed physicians to deliver medical treatment to patients from a distance. Mobile apps such as WhatsApp Messenger, an instant messaging service, came as a novel concept in all fields of social life, including medicine. The use of instant messaging services has been shown to improve communication within medical teams by providing means for quick teleconsultation, information sharing, and starting treatment as soon as possible. Objective: The aim of this study was to perform a comprehensive systematic review of present literature on the use of the WhatsApp Messenger app as an adjunctive health care tool for medical doctors. Methods: Searches were performed in PubMed, EMBASE, and the Cochrane Library using the term “whatsapp*” in articles published before January 2016. A bibliography of all relevant original articles that used the WhatsApp Messenger app was created. The level of evidence of each study was determined according to the Oxford Levels of Evidence ranking system produced by the Oxford Centre for Evidence-Based Medicine. The impact and the indications of WhatsApp Messenger are discussed in order to understand the extent to which this app currently functions as an adjunctive tool for telemedicine. Results: The database search identified a total of 30 studies in which the term “whatsapp*” was used. Each article’s list of references was evaluated item-by-item. After literature reviews, letters to the editor, and low-quality studies were excluded, a total of 10 studies were found to be eligible for inclusion. Of these studies, 9 had been published in the English language and 1 had been published in Spanish. Five were published by medical doctors. Conclusions: The pooled data presents compelling evidence that the WhatsApp Messenger app is a promising system, whether used as a communication tool between health care professionals, as a means of communication between health care professionals and the general public, or as a learning tool for providing health care information to professionals or to the general population. However, high-quality and properly evaluated research is needed, as are improvements in descriptions of the methodology and the study processes. These improvements will allow WhatsApp Messenger to be categorically defined as an effective telemedicine tool in many different fields of health care.

  • Life activities icons shaping MS (Multiple Sclerosis). Source: Image created by authors; Copyright: Simone & Chiara Eboli; License: Creative Commons Attribution (CC-BY).

    Health-Related Coping and Social Interaction in People with Multiple Sclerosis Supported by a Social Network: Pilot Study With a New Methodological Approach


    Background: Social media are a vital link for people with health concerns who find in Web communities a valid and comforting source for information exchange, debate, and knowledge enrichment. This aspect is important for people affected by chronic diseases like multiple sclerosis (MS), who are very well informed about the disease but are vulnerable to hopes of being cured or saved by therapies whose efficacy is not always scientifically proven. To improve health-related coping and social interaction for people with MS, we created an MS social network ( with a medical team constantly online to intervene promptly when false or inappropriate medical information are shared. Objective: The goal of this study was to assess the impact of on the health-related coping and social interaction of people with MS by analyzing areas of interest through a Web-based survey. Methods: Referring to previous marketing studies analyzing the online platform’s role in targeted health care, we conducted a 39-item Web-based survey. We then performed a construct validation procedure using a factorial analysis, gathering together like items of the survey related to different areas of interest such as utility, proximity, sharing, interaction, solving uncertainty, suggestion attitude, and exploration. Results: We collected 130 Web-based surveys. The areas of interest analysis demonstrated that the users positively evaluated to obtain information, approach and solve problems, and to make decisions (utility: median 4.2); improve feeling of closeness (proximity: median 5); catalyze relationships and text general personal opinions (sharing: median 5.6); get in touch with other users to receive innovative, effective, and practical solutions (interaction, solving uncertainty, and suggestion attitude medians were respectively: 4.1, 3, and 3); and share information about innovative therapeutic approaches and treatment options (suggestion attitude: median: 3.3). Conclusions: was perceived by users to be a useful tool to support health-related coping and social interaction, and may suggest a new kind of therapeutic alliance between physicians and people with MS.

  • Sneezing boy. Source: Flickr; Copyright: Sherif Salama; URL:; License: Creative Commons Attribution (CC-BY).

    Toward a New Kind of Vaccine: A Logical Extension of the Symmetrical Immune Network Theory


    Background: The symmetrical immune network theory, developed in 1975, is based on the existence of specific T cell factors and hypothesizes that normal IgG immune responses comprise the production of 2 kinds of antibodies, namely antigen-specific antibodies and anti-idiotypic antibodies. Objective: The aim of this study was to confirm the existence of specific T cells factors and to show that immunization of C3H mice with BL/6 skin or using nominal antigen for immunization (Tetanus Toxoid) induced production of antigen-specific (anti-BL/6 or antitetanus) antibodies plus anti-idiotypic antibodies (C3H anti-anti-C3H). Subsequently, we investigated the role of combinations of antigen-specific and anti-idiotype antibodies in a variety of animal models of clinical diseases. Methods: Antigen-specific antibodies were produced by conventional immunization of mice (eg, with tetanus toxoid or by skin allografting). Subsequent anti-idiotypic antibodies were derived by exhaustive absorption of antigen-specific antibody, with confirmation of anti-idiotypic specificity by binding to relevant target antigen-specific antibodies in an enzyme-linked immunosorbent assay (ELISA). Antigen-specific plus anti-idiotypic antibodies were then used to modulate skin allograft survival, dextran sulfate sodium (DSS)-induced colitis, ovalbumin (OVA)-induced IgE production, and breast cancer growth in mice. Results: Infusions of anti-BL/6 antibodies together with BL/6 anti-anti-BL/6 antibodies specifically suppressed (>85%) an immune response to BL/6 lymphocytes in C3H mice. The two kinds of antibodies with complementary specificity are hypothesized to stimulate 2 populations of T lymphocytes. Coselection of these 2 populations leads to a new stable steady state of the system with diminished reactivity to BL/6 tissue. A combination of anti-C3H and C3H anti‑anti-C3H IgG antibodies down-regulated inflammation in a mouse model of inflammatory bowel disease (>75%) and attenuated anti-IgE production and sensitization to produce IL4 cytokines (>70%) in an OVA-allergy model. Combination of C3H anti‑BL/6 and BL/6 anti-anti-BL/6 antibodies decreased tumor growth and metastases (>705) in an EMT6 transplantable breast cancer model. Conclusions: Use of a combination of antigen-specific and anti-idiotypic antibodies has potential as a new class of vaccines.

  • Dupuytren's disease. Source: Flickr; Copyright: Martin Sharman; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Dupuytren Disease: Is There Enough Comprehensive Patient Information on the Internet?


    Background: Dupuytren disease is a chronic nonmalign fibroproliferative disorder that causes finger contractures via proliferation of new tissue under the glabrous skin of the hand, resulting in multiple functional limitations for the patient. As many surgical therapy options exist, patients suffering from this condition actively search for information in their environment before consulting a health professional. Objective: As little is known about the quality of Web-based patient information, the aim of this study was to conduct its systematic evaluation using a validated tool. Methods: A total of 118 websites were included, and qualitative and quantitative assessment was performed using the modified Ensuring Quality Information for Patients (EQIP) tool. This standardized and reproducible tool consists of 36 items to assess available information in three categories: contents, identification, and structure data. Scientific data with restricted access, duplicates, and irrelevant websites were not included. Results: Only 32 websites addressed more than 19 items, and the scores did not significantly differ among the website developers. The median number of items from the EQIP tool was 16, with the top websites addressing 28 out of 36 items. The quality of the newly developed websites did not increase with passing time. Conclusions: This study revealed several shortcomings in the quality of Web-based information available for patients suffering from Dupuytren disease. In the world of continuously growing and instantly available Web-based information, it is the health providers’ negligence of the last two decades that there are very few good quality, informative, and educative websites that could be recommended to patients.

  • Google search for "thoracoscopy" (montage). Source: Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Thoracic Surgery Information on the Internet: A Multilingual Quality Assessment


    Background: Previous data suggest that quality of Internet information regarding surgical conditions and their treatments is variable. However, no comprehensive analysis of website quality exists for thoracic surgery. Objective: The aim of this study was to quantify website quality in a multilingual setting using an international standard for assessment. Methods: Health On the Net (HON) principles may be applied to websites using an automated toolbar function. We used the English, French, Spanish, and German Google search engines to identify 12,000 websites using keywords related to thoracic conditions and procedures. The first 150 websites returned by each keyword in each language were examined. We compared website quality to assess for tertile (is the quality better in first, second, or third 50 websites returned) and language differences. A further analysis of the English site types was undertaken performing a comparative analysis of website provider types. Results: Overall, there are a considerable number of websites devoted to thoracic surgery: “lung cancer” returned over 150 million websites. About 7.85% (940/11,967) of websites are HON-accredited with differences by search term (P<.001) and tertiles (P<.001) of the first 150 websites, but not between languages. Oncological keywords regarding conditions and procedures were found to return a higher percentage of HON-accreditation. The percentage of HON-accredited sites was similar across all four languages (P=.77). In general, the first tertile contained a higher percentage of HON-accredited sites for every keyword. Conclusions: Clinicians should appreciate the lack of validation of the majority of thoracic websites, with discrepancies in quality and number of websites across conditions and procedures. These differences appear similar regardless of language. An opportunity exists for clinicians to participate in the development of informative, ethical, and reliable health websites on the Internet and direct patients to them.

  • Cardiac stress testing. Source: Wikimedia Commons; Copyright: Blue0ctane; URL:; License: Public Domain (CC0).

    Quality of Social Media and Web-Based Information Regarding Inappropriate Nuclear Cardiac Stress Testing and the Choosing Wisely Campaign: A Cross-Sectional...


    Background: The World Wide Web and social media provide the public with access to medical information unlike any other time in human history. However, the quality of content related to cardiac stress testing is not well understood. Objective: The aim of our study was to evaluate the quality of content on the Internet relating to the use of cardiac nuclear stress testing and the Choosing Wisely campaign. Methods: We searched the World Wide Web, Google Video (including YouTube), and Twitter for information relating to these two topics. Searches were performed using English language terms from a computer in the United States not logged into any personal user accounts. Search results were reviewed for discussion of specific topics including radiation risk, accuracy of testing, alternative testing options, and discouragement of inappropriate test use. Results: We evaluated a total of 348 items of content from our searches. Relevant search results for Choosing Wisely were fewer than for other search terms (45 vs 303). We did not find any content which encouraged inappropriate testing (ie, screening in low risk individuals or testing prior to low risk operations). Content related to Choosing Wisely was more likely to discourage inappropriate testing than search results for other terms (29/45, 64% vs 12/303, 4.0%, odds ratio 43.95, 95% CI 17.6-112.2, P<.001). Conclusions: The Internet content on nuclear stress tests consistently discouraged inappropriate testing. The Choosing Wisely content was more likely to discourage inappropriate testing, less relevant content was available. Generating authoritative content on the Internet relating to judicious use of medical interventions may be an important role for the Choosing Wisely campaign.

  • Planking. Source: Pinterest; URL:; License: Fair use/fair dealings.

    Planking or the “Lying-Down Game:” Two Case Reports


    Background: The monitoring and management of risks regarding children and young people admitted to the emergency department as a result of dangerous behaviors distributed via the Internet should be based on clinical reasoning and knowledge about these social media–related phenomena. Here we examine 2 cases of teenagers who reported severe injuries while performing the “planking” craze, a challenge that consists in lying face-down stiffly like a board on any kind of surface. Objective: Our objective is to examine and describe the Internet craze called planking, also known as the “lying-down game,“ through 2 case reports from our experience, enriching this study with information gained through discussions with secondary school teenagers. Methods: Details of the 2 case reports were taken from electronic medical records giving information on care support processes, care management, and the costs of traumatic episodes. Demographic data, hemoglobin and serum lactate values, and Injury Severity Scores were evaluated. The study took place in secondary schools of our city from 2013 to 2014 during medical education courses, with the aim of analyzing the influence of social media on teenagers' activities and behaviors. Results: Both patients suffered multiple trauma injuries and needed high-level health assistance. The first patient underwent a splenectomy and the second one a nephrectomy; both of them required a long hospital stay (14 and 20 days, respectively), and the costs for their management have been estimated at US $27,000 and US $37,000, respectively. Their decision to perform the planking in dangerous locations was due to their ambition to gain peers' acclaim through shared videos and pictures. Conclusions: Reporting and understanding these cases may potentially help prevent future events occurring in similar circumstances: the scientific community cannot leave this problem unaddressed. There is also a role of education resources for health care professionals; for this, we must identify and follow up strange or misleading information found on websites. A key element of this research study was to report physicians’ misperceptions concerning planking and, with these cases used for teaching purposes, improve knowledge of the clinical and forensic aspects of this emerging problem.

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

    Using eHealth Technologies: Interests, Preferences, and Concerns of Older Adults


    Background: The Internet and eHealth technologies represent new opportunities for managing health. Age, sex, socioeconomic status, and current technology use are some of the known factors that influence individuals’ uptake of eHealth; however, relatively little is known about facilitators and barriers to eHealth uptake specific to older adults, particularly as they relate to their experiences in accessing health care. Objective: The aim of our study was to explore the interests, preferences, and concerns of older adults in using the Internet and eHealth technologies for managing their health in relation to their experiences with the current health care system. Methods: Two focus groups (n=15) were conducted with adults aged 50+ years. Pragmatic thematic analysis using an inductive approach was conducted to identify the interests, preferences, and concerns of using the Internet and eHealth technologies. Results: Five themes emerged that include (1) Difficulty in identifying credible and relevant sources of information on the Web; (2) Ownership, access, and responsibility for medical information; (3) Peer communication and support; (4) Opportunities to enhance health care interactions; and (5) Privacy concerns. These findings support the potential value older adults perceive in eHealth technologies, particularly in their ability to provide access to personal health information and facilitate communication between providers and peers living with similar conditions. However, in order to foster acceptance, these technologies will need to provide personal and general health information that is secure, readily accessible, and easily understood. Conclusions: Older adults have diverse needs and preferences that, in part, are driven by their experiences and frustrations with the health care system. Results can help inform the design and implementation of technologies to address gaps in care and access to health information for older adults with chronic conditions who may benefit the most from this approach.

  • Image source: iStock. License purchased by the author.

    Assessing the Performance of a Modified LACE Index (LACE-rt) to Predict Unplanned Readmission After Discharge in a Community Teaching Hospital


    Background: The LACE index was designed to predict early death or unplanned readmission after discharge from hospital to the community. However, implementing the LACE tool in real time in a teaching hospital required practical unavoidable modifications. Objective: The purpose of this study was to validate the implementation of a modified LACE index (LACE-rt) and test its ability to predict readmission risk using data in a hospital setting. Methods: Data from the Canadian Institute for Health Information’s Discharge Abstract Database (DAD), the National Ambulatory Care Reporting System (NACRS), and the hospital electronic medical record for one large community hospital in Toronto, Canada, were used in this study. A total of 3855 admissions from September 2013 to July 2014 were analyzed (N=3855) using descriptive statistics, regression analysis, and receiver operating characteristic analysis. Prospectively collected data from DAD and NACRS were linked to inpatient data. Results: The LACE-rt index was a fair test to predict readmission risk (C statistic=.632). A LACE-rt score of 10 is a good threshold to differentiate between patients with low and high readmission risk; the high-risk patients are 2.648 times more likely to be readmitted than those at low risk. The introduction of LACE-rt had no significant impact on readmission reduction. Conclusions: The LACE-rt is a fair tool for identifying those at risk of readmission. A collaborative cross-sectoral effort that includes those in charge of providing community-based care is needed to reduce readmission rates. An eHealth solution could play a major role in streamlining this collaboration.

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)