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Many effective new agents for relapsed childhood acute lymphoblastic leukemia (ALL) are now becoming available, and international standard chemotherapy should be developed to optimize use of these agents. Randomized controlled trials (RCTs) are needed to establish a standard treatment, but few have been conducted for relapsed childhood ALL in Japan due to the small patient population. Participation in international RCTs is necessary to access sufficient patients for informative study results, but differences in approved drugs and healthcare systems between countries make this challenging. In 2014, the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) participated in an international study on standard-risk relapsed childhood ALL (IntReALL SR 2010) involving two RCTs and multiple drugs not approved in Japan, which was addressed by replacing the unapproved drugs with alternative approved drugs with the same or similar efficacy. This article discusses the historical background of treatment development for relapsed childhood ALL, our experience in participating in the IntReALL SR 2010 trial, and prospects for treating relapsed childhood ALL.

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BACKGROUND: Pancreatoduodenectomy (PD) is a major surgical procedure associated with significant risks, particularly postoperative pancreatic fistula (POPF). Studies have highlighted the importance of certain risk factors for POPF, which are crucial for surgical decision-making and the management of high-risk patients undergoing PD. This study aimed to assess the surgical outcomes of patients undergoing PD who met the International Study Group of Pancreatic Surgery - Class D (ISGPS-D) criteria. METHODS: This study analyzed American College of Surgeons National Surgical Quality Improvement Program data (2014-2021) for patients undergoing ISGPS-D PD, classified as having a soft pancreatic texture and a pancreatic duct of ≤3 mm. This study focused on mortality rates and the correlation between several factors and POPF (ISGPS grade B/C). RESULTS: From 5964 patients who underwent PD and met the ISGPS-D criteria, the 30-day mortality rate was 1.98%. Males had a higher incidence of POPF than females (57.42% vs 47.35%, respectively; P < .001). Patients with POPF experienced significantly higher rates of major postoperative complications (Clavien-Dindo grade ≥ IIIa), including thrombosis, pneumonia, sepsis, delayed gastric emptying, wound disruption, infections, and acute renal failure. There was a marked increase in the 30-day readmission and mortality rates in patients with POPF (30.0% vs 17.6% and 3.2% vs 1.4%, respectively; all P < .001). Multivariate analysis highlighted female sex as a protective factor against mortality (odds ratio [OR], 0.47; P < .001) and extended hospital stay (>10 days) as a predictor of increased mortality risk (OR, 2.37; P < .001). CONCLUSION: This study underscored the significant association between POPF and increased postoperative morbidity and mortality rates. Future efforts should concentrate on refining surgical techniques and improving preoperative assessments to mitigate the risks associated with POPF in patients undergoing PD.

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Introduction: Otitis media eith effusion (OME) is an inflammatory condition of the middle ear that involves accumulation of sterile fluid or effusion in the tympanic cavity with the tympanic membrane intact. The pathophysiology of OME is undoubtedly multifactorial. Aim: To assess the co-occurrence of OME, allergic rhinitis, and asthma. Material and methods: The study involved a group of 18,617 subjects aged 6-7 years, 13-14 years, or 20-44 years. ECRHS and ISAAC questionnaires, validated and adopted for Polish conditions, were used in the study. Results: OME increases the risk of developing allergic rhinitis by nearly two-fold (OR = 2.07, 95% CI: 1.738-2.479 in 6-7-year-olds; OR = 1.61, 95% CI: 1.299-1.995 in 13-14-year-olds, and OR = 1.55, 95% CI: 1.262-1.83 in 20-44-year-olds). Protective factors against otitis media with effusion include the number of siblings (the more children in the family, the higher the risk of chronic OM; OR = 2.00, 95% CI: 1.15-1.346) and consumption of dairy products rich in lactic acid bacteria. Conclusions: OME significantly more often co-exists with other conditions, particularly allergic rhinitis.

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AIMS: To explore international undergraduate pharmacy students' views on integrating artificial intelligence (AI) into pharmacy education and practice. METHODS: This cross-sectional institutional review board-approved multinational, multicentre study comprised an anonymous online survey of 14 multiple-choice items to assess pharmacy students' preferences for AI events in the pharmacy curriculum, the current state of AI education, and students' AI knowledge and attitudes towards using AI in the pharmacy profession, supplemented by 8 demographic queries. Subgroup analyses were performed considering sex, study year, tech-savviness, and prior AI knowledge and AI events in the curriculum using the Mann-Whitney U-test. Variances were reported for responses in Likert scale format. RESULTS: The survey gathered 387 pharmacy student opinions across 16 faculties and 12 countries. Students showed predominantly positive attitudes towards AI in medicine (58%, n = 225) and expressed a strong desire for more AI education (72%, n = 276). However, they reported limited general knowledge of AI (63%, n = 242) and felt inadequately prepared to use AI in their future careers (51%, n = 197). Male students showed more positive attitudes towards increasing efficiency through AI (P = .011), while tech-savvy and advanced-year students expressed heightened concerns about potential legal and ethical issues related to AI (P < .001/P = .025, respectively). Students who had AI courses as part of their studies reported better AI knowledge (P < .001) and felt more prepared to apply it professionally (P < .001). CONCLUSIONS: Our findings underline the generally positive attitude of international pharmacy students towards AI application in medicine and highlight the necessity for a greater emphasis on AI education within pharmacy curricula.

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OBJECTIVE: To examine patient-described experiences of endometriosis diagnosis. DESIGN: Mixed-methods study. SETTING: Online patient-led endometriosis support groups. POPULATION OR SAMPLE: People with endometriosis aged over 18. METHODS: A survey with qualitative and quantitative questions was distributed through online patient-led endometriosis support groups. Descriptive statistics were used to analyse quantitative data, and thematic analysis was used for qualitative responses. Quantitative and qualitative data were triangulated to examine patient experiences of endometriosis diagnosis across age groups. MAIN OUTCOME MEASURES: Experiences of endometriosis diagnosis among people with endometriosis. RESULTS: A total of 2017 people with endometriosis from 63 countries responded to the questionnaire. Patients experienced an average delay of 3.7 years between symptom onset and first presentation of symptoms to a physician (the care-seeking delay) and an average delay of 5.8 years between first presentation of symptoms to a physician and diagnosis of endometriosis (the healthcare-related delay). Patients experienced an average total diagnostic delay of 9.6 years. Participants aged over 35 at the time of the study reported significantly longer times to receive an endometriosis diagnosis (mean 10.7, 95% confidence interval [CI] 10.2-11.2) compared with participants age 18-24 (6.8, 95% CI 6.1-7.5 years). The qualitative analysis identified the following themes: physicians normalised endometriosis symptoms, patients felt their symptoms were ignored by physicians because they were considered unreliable, and participant character attributes (e.g. age, appearance, weight or physical ability) led to clinician dismissal. CONCLUSIONS: People with endometriosis of all age groups reported pervasive negative healthcare experiences during their adolescence. Patients experience delays in seeking care and in receiving a diagnosis once presenting for care.

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CONTEXT: Change in ability realization reflects the main contribution of rehabilitation to improvement in the performance of daily activities in patients with spinal cord lesions (SCL). OBJECTIVE: To assess the net effect of rehabilitation of patients with SCL and compare it between countries. METHODS: We calculated the Spinal Cord Ability Realization Measurement Index (SCI-ARMI) and its change from admission to rehabilitation to discharge, for inpatients admitted to SCL units in five countries, between 2016 and 2019. We used chi-square tests, analysis of variance (ANOVA), McNemar's test, Pearson's correlations, and analysis of covariance (ANCOVA) to compare countries and patient groups and assess the relationships of various factors with SCI-ARMI gain during rehabilitation. RESULTS: The study included 218 inpatients (67% males, age 52 ± 17). In Brazil, Israel, Italy, Portugal, and Turkiye, respectively, SCI-ARMI gain was 2 (SD = 15), 19 (SD = 17), 31 (SD = 23), 13 (SD = 15), and 16 (SD = 12). Yet, after controlling for admission SCI-ARMI and the time from SCL onset to the examination, the effect of the country on ability realization gain was found non-significant (P = 0.086). CONCLUSION: The study confirmed that rehabilitation makes a net contribution to improvement in performance in patients with SCL, beyond the contribution of neurological recovery. After controlling for affecting factors, this contribution was quite similar in the participating units from different countries.

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OBJECTIVE: Systematic understanding of patients' unmet needs is essential for providing effective supportive care. This study sought to compare the unmet needs of patients with cancer identified by health care providers (HCPs) among four major healthcare systems. METHODS: HCPs (n = 247) participated in the International Psycho-Oncology Society (IPOS) Survivorship Online Survey, evaluating their patients' unmet needs. The country of HCPs was grouped into four major healthcare systems: Beveridge model, Bismarck model, National Health Insurance model, and out-of-pocket model. RESULTS: Most HCPs were from countries with the Bismarck model. Substantial levels (> 50%) of unmet needs in all domains are reported across the four healthcare systems. Pediatric patients/survivors living in countries under out-of-pocket healthcare model were evaluated to have less unmet needs for managing decline in physical or cognitive functioning and insomnia/sleep difficulty/fatigue, than those in countries under Beveridge, Bismarck, and National Health Insurance models. Moreover, middle-aged patients/survivors under Beveridge and National Health Insurance models were likely to have greater unmet needs for dealing with cancer-related financial concerns than those under Bismarck model. CONCLUSION: This study provides valuable insights into the unmet needs of patients with cancer in different healthcare systems, highlighting the significance of targeted interventions to address the unique needs of patients across diverse healthcare systems. Further investigation is warranted to identify the system factors associated with patients' unmet needs, enabling the development of effective healthcare policies and interventions to comprehensively address the multifaceted needs of patients with cancer.

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BACKGROUND: As Artificial Intelligence and social robots are increasingly used in health and social care, it is imperative to explore the training needs of the workforce, factoring in their cultural background. OBJECTIVES: Explore views on perceived training needs among professionals around the world and how these related to country cultures. DESIGN: Cross-sectional, descriptive, mixed-methods international online survey. METHODS: Descriptive statistical analysis explored the ranking across countries and relationships with three Hofstede cultural dimensions. Thematic analysis was conducted on the open-ended text responses. RESULTS: A sample of N = 1284 participants from eighteen countries. Knowing the capabilities of the robots was ranked as the top training need across all participating countries and this was also reflected in the thematic analysis. Participants' culture, expressed through three Hofstede's dimensions, revealed statistically significant ranking differences. CONCLUSIONS: Future research should further explore other factors such as the level of digital maturity of the workplace. IMPACT STATEMENT: Training needs of health and social care staff to use robotics are fast growing and preparation should factor in patient safety and be based on the principles of person- and culture-centred care.

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Behcet's disease (BD) is a chronic, multi-systemic inflammatory disorder mainly characterized by recurrent oral and genital ulcers, skin lesions, and uveitis. As no pathognomonic laboratory test exists for BD, the diagnosis relies solely on clinical features. Over the years, great efforts have been invested in creating clinical diagnostic and classification criteria. The international study group criteria introduced in 1990 were the first true multinational set of criteria. Despite improving the ability to diagnose BD, these criteria still have limitations, including the inability to diagnose patients presenting without oral ulcers or presenting with rare manifestations of the disease. This led to the introduction of the international criteria for BD in 2013, which improved the sensitivity with minimal compromise on specificity. Despite the efforts made and as our understanding of the clinical manifestations of BD and genetic pathogenesis continue to evolve, efforts should be made to further enhance the currently accepted international classification criteria, perhaps by incorporating genetic testing (e.g., family history or HLA typing) as well as ethnic group-specific features.

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Patient experience is positively associated with clinical effectiveness, quality care, and patient safety. This study examines the experience of care of adolescents and young adult (AYA) cancer patients from Australia and the United States, allowing a comparison of patient experiences in the context of different national models of cancer care delivery. Participants (n = 190) were aged 15-29 years and received cancer treatment from 2014 to 2019. Australians (n = 118) were recruited nationally by health care professionals. U.S. participants (n = 72) were recruited nationally via social media. The survey included demographic and disease variables, and questions regarding medical treatment, information and support provision, care coordination, and satisfaction across the treatment pathway. Sensitivity analyses examined the possible contribution of age and gender. Most patients from both countries were satisfied or very satisfied with their medical treatment (chemotherapy, radiotherapy, and surgery). There were significant differences between countries in the provision of fertility preservation services, age-appropriate communication, and psychosocial support. Our findings suggest when a national system of oversight with both state and federal funding is implemented, as is the case in Australia but not in the United States, significantly more AYAs with cancer receive age-appropriate information and support services, and improved access to specialist services such as fertility care. A national approach with government funding and centralized accountability appears to be associated with substantial benefits for the well-being of AYAs undergoing cancer treatment.

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The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990).

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OBJECTIVES: The development of allergic conditions is largely dependent on the interactions between genetic (individual genetic predisposition) and environmental factors (exposure to risk factors). The aim of this study was an attempt to assess the influence of selected elements of the hygiene theory in the development of allergic diseases such as allergic rhinitis and asthma. MATERIAL AND METHODS: The study group consisted of 5518 women and 3868 men. The method that was used was the European Community Respiratory Health Survey II and International Study of Asthma and Allergies in Childhood questionnaire validated and adapted to Central and Eastern European conditions. The project was conducted in 8 urban areas (Gdansk, Wroclaw, Poznan, Katowice, Kraków, Lublin, Bialystok, Warsaw) and 1 rural area (Krasnystaw county). This study had 2 stages; the first stage involved grouping the 22 500 respondents based on their questionnaire responses with the use of a Personal Digital Assistant (PDA); the second stage involved 7000 subjects, who underwent additional assessments: skin prick tests (birch, grasses/cereals, Dermatophagoides pteronyssinus and Dermatophagoides farinae, molds [set I: Botrytis cinerea, Cladosporium herbarum, Alternaria tenuis, Curvularia lunata, Fusarium moniliforme, Helminthosporium], molds [set II: Aspergillus fumigatus, Mucor mucedo, Penicillium notatum, Pullularia pullulans, Rhizopus nigricans, Serpula lacrymans], cat, dog, molds Cladosporium herbarum, Alternaria tenuis) and spirometry tests. RESULTS: The age at which children attend the nursery school is critical to the development of allergic diseases; in allergic rhinitis, the risk of an IgE-dependent reaction is 2 times higher in the second than in the first year of life (p = 0.00147, p < 0.05), while in asthma, having a large number of siblings increases the risk of developing obstructive disease by almost 6 times (p = 0.00316, p < 0.05).The age at which children attend the nursery school is critical to the development of allergic diseases; in allergic rhinitis, the risk of an IgE-dependent reaction is 2 times higher in the second than in the first year of life (p = 0.00147, p < 0.05), while in asthma, having a large number of siblings increases the risk of developing obstructive disease by almost 6 times (p = 0.00316, p < 0.05). CONCLUSIONS: The hygiene theory is particularly applicable and can explain the relationship of selected habits in the development of allergic diseases. Int J Occup Med Environ Health. 2023;36(1):69-83.

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This study explores the romantic love in intercultural couples and investigates the qualities that challenge them and help them succeed in their relationships. It uses a qualitative research design within the hermeneutical interpretative research paradigm, aiming to understand the phenomenon of love from different cultural perspectives. Data were collected through semi-structured interviews and analysed through content analysis. Qualitative quality criteria and ethical considerations were applied. Ethical consent was provided by Northumbria University, Newcastle upon Tyne, UK. The findings represent the views of couples on their love and their relationship, in particular the challenged experienced and the coping strategies to overcome them. Challenges highlighted are the non-acceptance of the relationship by family members and friends; disagreement on cultural values, norms, rules, and rituals; communication in a third language; no language in common with family members; differences in concepts, such as religion, love, feelings, communication; building a common future, and minor differences in personality traits. The participants use individual and joint coping mechanisms to deal with challenges and stressors. These coping mechanisms include attitudes and behaviours regarding culture, awareness, faith and religion, learning, future orientation, and fighting together for the relationship. Conclusions are provided and recommendations for leading intercultural romantic relationships are given.

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Background and aims: Allergy prevention strategies have gained significant traction as a means to attenuate the growing burden of allergic diseases over the past decade. As the evidence base for primary prevention of food allergy (FA) and atopic dermatitis (AD) is constantly advancing, clinical practice guideline (CPG) recommendations on interventions for FA and AD prevention vary in quality and consistency among professional organizations. We present a protocol for a systematic review of CPGs on primary prevention of FA and AD. Methods: We will systematically review and appraise all CPGs addressing primary prevention of FA and AD and report our findings according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases and manual website searches from January 2011 to March 2021 without language or geographical restrictions, and supplemented by author contact, will generate the list of potentially relevant CPGs to screen. Evaluation of the methodological quality, consistency, and global applicability of shortlisted CPGs will be performed by members of the Allergy Prevention Work Group of the World Allergy Organization (WAO) using the Appraisal of Guidelines for Research and Evaluation (AGREE) II and AGREE-REX (Recommendations EXcellence). instruments. Guideline contents, consistency, and quality of the recommendations will be summarised in tabular and narrative formats. We aim to present consolidated recommendations from international guidelines of the highest methodological quality and applicability, as determined by AGREE II and AGREE-REX. Dissemination: This systematic review will provide a succinct overview of the quality and consistency of recommendations across all existing CPGs for FA and AD prevention, as well as crucial perspectives on applicability of individual recommendations in different geographical contexts. Results from this systematic review will be reported in a peer-reviewed journal. It will also inform a position statement by WAO to provide a practical framework to guide the development of future guidelines for allergy prevention worldwide. Prospero registration number: CRD42021265689.

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BACKGROUND: Vasoreactivity testing with high-dose acetylcholine is considered vasospasm provocation and low-dose as endothelial function testing. AIMS: To assess the changes in reaction to low- and high-dose acetylcholine in the endotypes of CAS as defined by the Coronary Vasomotor Disorders International Study Group (COVADIS) working group. METHODS: Changes in coronary epicardial diameter, coronary blood flow (CBF) and vascular resistance were determined at low-dose acetylcholine. RESULTS: A total of 88 ANOCA patients were included in this analysis. In the negative group (n = 14) incremental infusion of acetylcholine produced a progressive increase in CBF (p = 0.008). In reaction to low-dose acetylcholine, the epicardial vasospasm group (n = 30) is characterised by epicardial vasoconstriction that is significantly more severe compared to the microvascular vasospasm group (p = 0.004)(n = 23). The equivocal group (n = 21) is characterised by an increase in CBF and reduction in vascular resistance that are both significantly different compared to the epicardial vasospasm group (p = 0.036 and p = 0.007, respectively). High-dose acetylcholine decreased epicardial diameter and CBF significantly in the epicardial vasospasm, microvascular vasospasm and in the equivocal group (all p < 0.05. Vascular resistance increased significantly in the epicardial vasospasm group (p < 0.001) and equivocal group (p = 0.009). CONCLUSION: In reaction to low-dose acetylcholine the negative and equivocal endotype has haemodynamic changes that suggest intact endothelium. In reaction to high-dose acetylcholine the epicardial vasospasm, microvascular vasospasm and equivocal endotype have hemodynamic changes that suggest VSMC-hyperreactivity. These results suggest that the equivocal endotype is a positive test comparable to microvascular vasospasm in the presence of normal endothelial function.

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Background: Allergic sensitization is linked to allergy development, with early sensitization often associated with worse outcomes. We aimed to identify if distinct allergic sensitization trajectories existed within a diverse and multi-ethnic Asian cohort. Methods: We administered modified ISAAC questionnaires in the first 8 years and conducted skin prick testing at ages 18 months, 3, 5 and 8 years in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort. We used latent class analysis to derive allergic sensitization trajectories, and adjusted odds ratios (AOR) to evaluate predictive risk factors and associations with allergic comorbidities. Results: Among 997 children, three trajectories were identified: early food and mite sensitization (16.2%), late mite sensitization (24.2%) and no/low sensitization (59.6%). Early food and mite sensitization was associated with early eczema by 6 months [AOR (95%CI) 4.67 (1.78-12.28)], increased risk of wheeze by 3-8 years (ARR 1.72-1.99) and eczema in the first 8 years of life (ARR 1.87-2.41). Late mite sensitization was associated with female sex [AOR 0.58 (0.35-0.96)], cesarean section [AOR 0.54 (0.30-0.98)], early eczema by 6 months [AOR 3.40 (1.38-8.42)], and increased risk of eczema by 18 months [ARR 1.47 (1.03-2.08)] and 8 years [ARR 1.35 (1.05-1.73)]. Conclusion: Early onset of eczema and early allergic sensitization were strongly associated. Early sensitization, especially to house dust mites, was associated with increased risks of developing wheeze and eczema, pointing to the importance of developing preventive perinatal interventions and effective therapeutics for sensitized toddlers.

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BACKGROUND: Screen time (ST) drastically increased during the COVID-19 pandemic, but there is little research on the specific type of ST use, degree of change from before COVID-19, and possible associations with other factors. Young adults are a particular interest since previous studies have shown the detriment ST has on a young person's health. With the combination of a life-changing pandemic, there are unreached depths regarding ST and young adults. This study aims to provide insight into these unknowns. OBJECTIVE: This study aims to assess ST in 3 domains (entertainment, social media [SM], and educational/professional) in young adults early in the COVID-19 pandemic; identify trends; and identify any correlations with demographics, mental health, substance abuse, and overall wellness. METHODS: An online, cross-sectional observational study was performed from September 2020 to January 2021 with 183 eligible respondents. Data were collected on ST, trauma from COVID-19, anxiety, depression, substance use, BMI, and sleep. RESULTS: The average total ST during COVID-19 was 23.26 hours/week, entertainment ST was 7.98 hours/week, SM ST was 6.79 hours/week, and ST for educational or professional purposes was 8.49 hours/week. For all categories, the average ST during COVID-19 was higher than before COVID-19 (P<.001). We found ST differences between genders, student status, and continent of location. Increased well-being scores during COVID-19 were correlated with greater change in total ST (P=.01). Poorer sleep quality (P=.01) and longer sleep duration (P=.03) were associated with a greater change in entertainment ST (P=.01). More severe depression and more severe anxiety was associated with the amount of entertainment ST (P=.047, P=.03, respectively) and greater percent change in SM (P=.007, P=.002, respectively). Greater stress from COVID-19 was associated with the amount of ST for educational/professional purposes (P=.05), change in total ST (P=.006), change in entertainment ST (P=.01), and change in ST for educational/professional purposes (P=.02). Higher Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) tobacco scores were associated with greater change in total ST (P=.004), and higher pack-years were associated with greater change in SM ST (P=.003). Higher alcohol scores (P=.004) and servings of alcohol per week (P=.003) were associated with greater change in entertainment ST. Quarantining did not negatively impact these variables. CONCLUSIONS: There is no doubt ST and worsening mental health increased during COVID-19 in young adults. However, these findings indicate there are many significant associations between ST use and mental health. These associations are more complex than originally thought, especially since we found quarantining is not associated with mental health. Although other factors need to be further investigated, this study emphasizes different types of ST and degree of change in ST affect various groups of people in discrete ways. Acknowledging these findings can help young adults optimize their mental health during pandemics.

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International internet-based studies could be accessible by participants from various countries worldwide. However, the jurisdiction of research ethics committees (RECs) or institutional review boards (IRBs) is bound to geographical state or country borders. How can researchers deal with the geographical boundaries in the jurisdiction of RECs/IRBs versus the worldwide, open character of international internet-based research? Should ethical approval be sought in each country where participants will be recruited? In this paper, we want to share our challenges in setting up the ethical review procedures in an international internet-based mHealth intervention study, to further the discussion on ethical procedures in internet-based research.

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