ALGA: A cancer patient profiling tool to improve physician-patient communication—An analysis in breast cancer patients

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Background: Considerable improvement of communication between physicians and patients (pts) will need to occur as personalised medicine becomes the norm. An accurate profile of the pt’s cognitive and psychological status should help the physician shape his language and his messages to maximise the pt’s understanding of her management options. To this aim a computerized tool (ALGA questionnaire) has been created and validated. Methods: The validation process produced a questionnaire with 4 main factors: Health State Perception, Psychological, Psychosocial and Cognitive aspects. To test its ability to discriminate between healthy people and pts, ALGA has been administered to 50 newly diagnosed primary Breast Cancer (BC) pts prior to their first visit with the oncologist to discuss their adjuvant treatment, and to 50 healthy women (age range:20-60), using an iPad. Results: A multivariate analysis showed a significant difference between BC pts and healthy women relatively to the four aforementioned broad areas: Psychosocial (F(1,56)=13.42, p<.001), Cognitive (F(1,56)=6.53, p<.01), and Psychological Aspect (F(1,56)=2.77, p=.05). ALGA detected pts with higher levels of anxiety and depression. Pts tended to ruminate more than healthy subjects. Finally, pts showed higher level of positive Health State Perception, suggesting a dissociation between cancer illness and general health. Cognitive and Psychological aspects and Health State Perception interacted with participants’ level of education (respectively: F(1,56)=12.23, p<.001; F(1,56)=4.58, p<.05; F(1,56)=7.9, p<.05). Starting from this results a personal profile for each pt was created. Conclusions: The ALGA confirmed ability to discriminate between healthy people and BC pts, and is a good tool to create a personal pt’s profile with which physicians can empower patient with tailored knowledge. Starting from ALGA questionnaire, a smart environment is being implemented as a decision support infrastructure to help communication, interaction and information delivery process from doctor to patient, influencing patient’s quality of life and satisfaction.

Energy metabolism of rat cerebral cortex, hypothalamus and hypophysis during ageing

Ageing is one of the main risk factors for brain disorders. According to the neuroendocrine theory, ageing modifies the sensitivity of hypothalamus-pituitary-adrenal axis to homoeostatic signals coming from the cerebral cortex. The relationships between the energy metabolism of these areas have not been considered yet, in particular with respect to ageing. For these reasons, this study was undertaken to systematically investigate in female Sprague-Dawley rats aged 4, 6, 12, 18, 24, 28 months and in 4-month-old male ones, the catalytic properties of energy-linked enzymes of the Krebs' cycle, electron transport chain, glutamate and related amino acids on different mitochondrial subpopulations, i.e. non-synaptic perikaryal and intra-synaptic (two types) mitochondria. The biochemical enzymatic pattern of these mitochondria shows different expression of the above-mentioned enzymatic activities in the investigated brain areas, including frontal cerebral cortex, hippocampus, striatum, hypothalamus and hypophysis. The study shows that: (i) the energy metabolism of the frontal cerebral cortex is poorly affected by physiological ageing; (ii) the biochemical machinery of non-synaptic perikaryal mitochondria is differently expressed in the considered brain areas; (iii) at 4-6 months, hypothalamus and hypophysis possess lower oxidative metabolism with respect to the frontal cerebral cortex while (iv), during ageing, the opposite situation occurs. We hypothesised that these metabolic modifications likely try to grant HPA functionality in response to the incoming external stress stimuli increased during ageing. It is particularly notable that age-related changes in brain bioenergetics and in mitochondrial functionality may be considered as remarkable factors during physiological ageing and should play important roles in predisposing the brain to physiopathological events, tightly related to molecular mechanisms evoked for pharmacological treatments.

A new perspective on blame culture: an experimental study

OBJECTIVES

Recently, a range of different institutions worldwide has identified the 'culture of blame' and the fear of being punished as the principal reasons for the lack of medical error reporting and, consequently, of their reiteration and of the poor quality of patient care. Despite much theoretical debate, there currently exist no experimental studies that directly investigate the presence and pervasiveness of the blame and punishment culture in health care contexts. In order to document empirical evidence for this culture in medicine and nursing, we conducted an experimental study asking physicians and nurses to express their fear of blame or punishment in the context of having made an error that would cause: (i) no; (ii) mild; (iii) severe consequences; or (iv) the death of the patient.

METHODS

Two hundred and forty-nine health care providers (38 physicians, 11 medical students, 127 nurses and 73 nursing students) were included in the study. Two main data emerged: first, in general, the fear of being blamed is higher than the fear of being punished. Second, while the fear of being blamed is equally distributed among all participants, the fear of being punished varies according to the experience of subjects (it is higher in nursing students than in seniors nurses) and to their professional role (student and senior nurses are more susceptible to it than medical students and senior physicians).

CONCLUSION

Given the relevance of these factors in medical error reporting and the evidence that they are so deep-seated not only in senior professionals, but also in students, we argue that an educational approach, together with an organization-based intervention, is desirable to shape cultural attitudes of health care providers in the direction of a 'safety culture'.

Pharmacotherapy and prevention of vascular dementia

Vascular dementia (VAD), the second most common form of dementia after Alzheimer's disease (AD) is characterized by a cognitive deficit of cerebrovascular origin. As for AD, the main proposed treatment is based on cholinesterase inhibitors. However, randomized clinical trials (RCTs) with cholinesterase inhibitors in VAD reported modest - though sometimes statistically significant - clinical efficacy. Non-cholinergic drugs with diverse rationales and mechanisms of action have also been tested in a few RCTs for VAD; the outcomes measured are variable and the evidence of efficacy is weak. The limitations of pharmacological treatment for VAD have prompted a different strategy, i.e. primary prevention aimed at reducing vascular risk factors. Several epidemiological studies reported associations of hypertension, type 2 diabetes, obesity, and inflammation with VAD and in some cases, AD. These all coincide with those of stroke, which in turn is an established factor for cognitive decline and VAD. Here too, only a few RCTs have looked at prevention of these factors, except hypertension. Some pharmacological classes are particularly promising from the clinical and experimental viewpoints: Ca2+ channel blockers and drugs affecting the renin-angiotensin system may act independently of the effects on blood pressure. Despite some conflicting results and the need for further work, the control of risk factors might prevent cognitive decline and VAD in the elderly. The benefit of tackling vascular factors is probably larger when also considering the prevention of stroke. The objective of this review is to analyze the pharmacological treatment and prevention of VAD and their outcome. The literature on Pubmed from 1980 to 2009 was examined.

An overview on cognitive aspects implicated in medical decisions

Cognitive theories on decision making show that individuals often do not decide in a full and rationale way, but instead use cognitive strategies that allow them to overcome the limitations imposed by their limited rationality and the difficulties derived from uncertainty. The first part of the paper will discuss the role of heuristics and biases in medical decision making. This is an interesting field of research since medical decisions must be fast and are often complicated by rapid changes in the patient's clinical condition, uncertain prognosis and unexpected or uncontrollable treatment effects. In such contexts individuals are forced to rely on heuristics to assist them in taking decisions which can sometimes produce cognitive biases. The second part of the paper will be dedicated to discussing ways in which the patients' decisions can be improved. The role of the shared decision making approach will be discussed as well as the role of decision aids. Based on personal information coming from the physical and psychological characteristics and needs of the patient, decision aids give information about specific options and outcomes related to the patient's disease. Provided with a set of well-defined alternatives, patients are assisted in taking their preferred decisions, especially when there is more than one medically reasonable opinion available. Moreover, decision aids facilitate and support the shared decision-making, a process by which patients and physicians discuss and evaluate the alternatives for a particular medical decision together.

A P5 cancer medicine approach: why personalized medicine cannot ignore psychology

A system approach termed P4 medicine has recently been proposed in the field of oncology. This approach has been advanced as an extension of what is usually called 'personalized' or 'genomic medicine'. P4 medicine creates effective predictive, personalized, preventive and participatory models to treat patients. In order to give more relevance to the behavioural component that impinges on the way individuals act to prevent, cope and react to illnesses, how they decide between different therapeutic options and interact with physicians and adhere to treatment, we propose that P4 medicine should be transformed into P5 medicine. The fifth P represents the psycho-cognitive aspects to be considered in order to empower the patient, increase his/her quality of life and transform him/her from a passive recipient into an active decision-maker in the treatment process.

Nonhomogeneous results in place learning among panic disorder patients with agoraphobia

Patients affected by panic disorder with agoraphobia (PDA) often suffer from visuo-spatial disturbances. In the present study, we tested the place-learning abilities in a sample of 31 PDA patients compared to 31 healthy controls (CTR) using the computer-generated arena (C-G Arena), a desktop-based computer program developed at the University of Arizona (Jacobs et al 1997, for further detail about the program, see http://web.arizona.edu/~arg/data.html). Subjects were asked to search the computer-generated space, over several trials, for the location of a hidden target. Results showed that control subjects rapidly learned to locate the invisible target and consistently returned to it, while PDA patients were divided in two subgroups: some of them (PDA-A) were as good as controls in place learning, while some others (PDA-B) were unable to learn the correct strategies to find the target. Further analyses revealed that PDA-A patients were significantly younger and affected by panic disorder from less time than PDA-B, indicating that age and duration of illness can be critical factors that influence the place-learning abilities. The existence of two different subgroups of PDA patients who differ in their spatial orientation abilities could provide new insight into the mechanisms of panic and open new perspectives in the cognitive-behavioral treatment of this diffuse and disabling disorder.

The role of immersion and narrative in mediated presence: the virtual hospital experience

The "mediated sense of presence" is a technology-induced illusion of being present in one (simulated) place when one is actually present in another (physical) place. Typically experienced in virtual worlds, mediated presence is generated by different technological, cognitive, and emotional factors. The aim of this study was to test how to optimise the virtual experience by manipulating some of these factors. Specifically, we tested if an immersive technology and/or a meaningful narrative context influence the users' sense of presence, providing a more compelling experience than a non-immersive and non-contextualized virtual space. Eighty-four students, randomly divided into four groups, were asked to find a blood container inside a virtual hospital in an immersive or non-immersive condition and with or without an emotionally related narrative. Two presence questionnaires and heart-rate variations were used to measure the effects of the four conditions on the users' sense of presence. Results showed a significant effect of narrative, F(8, 73) = 30.346, p < 0.001, and level of immersion, F (8, 73) = 10.913, p < 0.001, and a significant interaction between narrative and immersion, F(8, 73) = 2.062, p = 0.05, both on the presence questionnaires and on the heart-rate variations. Moreover, considering the factors immersion (I) and narrative (N) together, we found that the I-N condition generated the highest level of presence. We argue that both immersion and narrative are important in creating an effective virtual reality experience because they contribute differently to increasing the sense of presence. Immersion increases the place illusion, while the narrative contributes to generating an emotional response and strengthening the subjects' sense of inner presence.

Assessment of the emotional responses produced by exposure to real food, virtual food and photographs of food in patients affected by eating disorders

BACKGROUND

Many researchers and clinicians have proposed using virtual reality (VR) in adjunct to in vivo exposure therapy to provide an innovative form of exposure to patients suffering from different psychological disorders. The rationale behind the 'virtual approach' is that real and virtual exposures elicit a comparable emotional reaction in subjects, even if, to date, there are no experimental data that directly compare these two conditions. To test whether virtual stimuli are as effective as real stimuli, and more effective than photographs in the anxiety induction process, we tested the emotional reactions to real food (RF), virtual reality (VR) food and photographs (PH) of food in two samples of patients affected, respectively, by anorexia (AN) and bulimia nervosa (BN) compared to a group of healthy subjects. The two main hypotheses were the following: (a) the virtual exposure elicits emotional responses comparable to those produced by the real exposure; (b) the sense of presence induced by the VR immersion makes the virtual experience more ecological, and consequently more effective than static pictures in producing emotional responses in humans.

METHODS

In total, 10 AN, 10 BN and 10 healthy control subjects (CTR) were randomly exposed to three experimental conditions: RF, PH, and VR while their psychological (Stait Anxiety Inventory (STAI-S) and visual analogue scale for anxiety (VAS-A)) and physiological (heart rate, respiration rate, and skin conductance) responses were recorded.

RESULTS

RF and VR induced a comparable emotional reaction in patients higher than the one elicited by the PH condition. We also found a significant effect in the subjects' degree of presence experienced in the VR condition about their level of perceived anxiety (STAI-S and VAS-A): the higher the sense of presence, the stronger the level of anxiety.

CONCLUSIONS

Even though preliminary, the present data show that VR is more effective than PH in eliciting emotional responses similar to those expected in real life situations. More generally, the present study suggests the potential of VR in a variety of experimental, training and clinical contexts, being its range of possibilities extremely wide and customizable. In particular, in a psychological perspective based on a cognitive behavioral approach, the use of VR enables the provision of specific contexts to help patients to cope with their diseases thanks to an easily controlled stimulation.

Emotional response to virtual reality exposure across different cultures: the role of the attribution process

Many studies have shown the ability of media--television, movies, and virtual reality (VR) experiences--to elicit emotions. Nevertheless, it is still unclear how the different factors involved--user related and medium related--play a role in producing an emotional response during a VR experience. We investigate this issue, analyzing the role played by the cultural and technological backgrounds of the users in the emotional responses to VR. Specifically, we use the "core affect" model of emotions developed by Russell (2003) to explore how these factors influence the way in which participants experience virtual worlds. Our sample includes 20 Mexican participants: 8 living in El Tepeyac, a small rural and isolated Mexican village characterized by a very primitive culture, and 12 high civilized inhabitants of Mexico City. The "Green Valley," a noninteractive, relaxing immersive environment showing a mountain landscape around a calm lake, was used to induce relaxation in the two groups during an ambulatory surgical operation. To investigate the effects of VR on the relaxation process, we measured participants' physiological (heart rate) and emotional (VAS-A) responses before, during, and after the operation. The results show that VR significantly modified the core affect (reduced arousal) in all participants but that the final emotional response produced by this change was influenced by the attribution process: the civilized inhabitants of Mexico City, who were able to attribute the reduced arousal to the VR experience, reported a significant reduction in the self-reported level of anxiety, while people from El Tepeyac showed a reduction in their physiological reactions but not in their perceived anxiety.

Virtual reality in the treatment of generalized anxiety disorders

Generalized anxiety disorder (GAD) is a common anxiety disorder characterized by 6 months of "excessive anxiety and worry" about a variety of events and situations. Anxiety and worry are often accompanied by additional symptoms like restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension and disturbed sleep. GAD is usually treated with medications and/or psychotherapy. In particular, the two most promising treatments seem to be cognitive therapy and applied relaxation. In this study we integrated these approaches through the use of a biofeedback enhanced virtual reality (VR) system used both for relaxation and controlled exposure. Moreover, this experience is strengthened by the use of a mobile phone that allows patients to perform the virtual experience even in an outpatient setting. This paper describe the results of a controlled trial (NCT00602212) involving 20 GAD patients randomly assigned to the following groups: (1) the VR and Mobile group (VRMB) including biofeedback; (2) the VR and Mobile group (VRM) without biofeedback; (3) the waiting list (WL) group. The clinical data underlined that (a) VR can be used also in the treatment of GAD; (b) in a VR treatment, patients take advantage of a mobile device that delivers in an outpatient setting guided experiences, similar to the one experienced in VR.

The use of biofeedback in clinical virtual reality: the INTREPID project

Generalized anxiety disorder (GAD) is a psychiatric disorder characterized by a constant and unspecific anxiety that interferes with daily-life activities. Its high prevalence in general population and the severe limitations it causes, point out the necessity to find new efficient strategies to treat it. Together with the cognitive-behavioral treatments, relaxation represents a useful approach for the treatment of GAD, but it has the limitation that it is hard to be learned. The INTREPID project is aimed to implement a new instrument to treat anxiety-related disorders and to test its clinical efficacy in reducing anxiety-related symptoms. The innovation of this approach is the combination of virtual reality and biofeedback, so that the first one is directly modified by the output of the second one. In this way, the patient is made aware of his or her reactions through the modification of some features of the VR environment in real time. Using mental exercises the patient learns to control these physiological parameters and using the feedback provided by the virtual environment is able to gauge his or her success. The supplemental use of portable devices, such as PDA or smart-phones, allows the patient to perform at home, individually and autonomously, the same exercises experienced in therapist's office. The goal is to anchor the learned protocol in a real life context, so enhancing the patients' ability to deal with their symptoms. The expected result is a better and faster learning of relaxation techniques, and thus an increased effectiveness of the treatment if compared with traditional clinical protocols.

The use of biofeedback in clinical virtual reality: the intrepid project

In our protocol for the treatment of Generalized Anxiety Disorders we use Virtual reality (VR) to facilitate emotional regulation and the relaxation process. Using a biofeedback biomonitoring system (GSR, HR, Thermal) the patient is made aware of his or her reactions through the modification of some features of the VR environment in real time. Using mental exercises the patient learns to control these physiological parameters and using the feedback provided by the virtual environment is able to gauge his or her success. To test this concept, we planned a randomized controlled trial (NCT00602212), including three groups of 15 patients each (for a total of 45 patients): (1) the VR group, (2) the non-VR group, and (3) the waiting list (WL) group.

The Intrepid project - biosensor-enhanced virtual therapy for the treatment of generalized anxiety disorders

Generalized anxiety disorder (GAD) is a psychiatric disorder characterized by a constant and unspecific anxiety that interferes with daily-life activities. Together with the cognitive-behavioural treatments, relaxation represents a useful approach for the treatment of GAD, but it has the limitation that it is hard to be learned. To overcome this limitation we propose the use of biofeedback enhanced virtual reality (VR) to facilitate the relaxation process. The VR relaxation experience will be strengthened by the use of a mobile phone able to track and visualize, in an outpatient setting too, the physiological data of the patients. To test this concept, we planned a randomized controlled trial (NCT00602212), including three groups of 15 patients each (for a total of 75 patients): (1) the VR group, (2) the non-VR group and (3) the waiting list (WL) group. This controlled trial will be able to evaluate the effects of the use of VR in relaxation while preserving the benefits of randomization to reduce bias.

NeuroVR 1.5 - a free virtual reality platform for the assessment and treatment in clinical psychology and neuroscience

At MMVR 2007 we presented NeuroVR (http://www.neurovr.org) a free virtual reality platform based on open-source software. The software allows non-expert users to adapt the content of 14 pre-designed virtual environments to the specific needs of the clinical or experimental setting. Following the feedbacks of the 700 users who downloaded the first version, we developed a new version - NeuroVR 1.5 - that improves the possibility for the therapist to enhance the patient's feeling of familiarity and intimacy with the virtual scene, by using external sounds, photos or videos. Specifically, the new version now includes full sound support and the ability of triggering external sounds and videos using the keyboard. The outcomes of different trials made using NeuroVR will be presented and discussed.

Virtual reality on mobile phones to reduce anxiety in outpatient surgery

When undergo ambulatory surgical operations, the majority of patients experience high level of anxiety. Different experimental studies have shown that distraction techniques are effective in reducing pain and related anxiety. Since Virtual reality (VR) has been demonstrated a good distraction technique, it has been repeatedly used in hospital contexts for reducing pain in burned patients, but it has never been used during surgical operations. With the present randomized controlled study we intended to verify the effectiveness of VR in reducing anxiety in patients undergoing ambulatory operations under local or regional anaesthesia. In particular, we measured the degree to which anxiety associated with surgical intervention was reduced by distracting patients with immersive VR provided through a cell phone connected to an HMD compared to a no-distraction control condition. A significant reduction of anxiety was obtained after 45 minutes of operation in the VR group, but not in the control group and, after 90 minutes, the reduction was larger in the experimental group than in other one. In conclusion, this study presents an innovative promising technique to reduce anxiety during surgical interventions, even if more studies are necessary to investigate its effectiveness in other kinds of operations and in larger numbers of patients.

NeuroVR 1.5 in Practice: Actual Clinical Applications of the Open Source VR System

At CT 2007, we presented NeuroVR (http://www.neurovr.org), a free virtual reality platform based on open-source software. The software allows non-expert users to adapt the content of 14 pre-designed virtual environments to the specific needs of the clinical or experimental setting. Following the feedbacks of the 700 users who downloaded the first version, we developed a new version - NeuroVR 1.5 - that improves the possibility for the therapist to enhance the patient's feeling of familiarity and intimacy with the virtual scene, by using external sounds, photos or videos. The key characteristics that make NeuroVR suitable for most clinical applications are the high level of control of the interaction with the tool, and the enriched experience provided to the patient. Actually, NeuroVR is used in the assessment and treatment of Obesity, Alcohol Abuse, Anxiety Disorders, Generalized Anxiety Disorders, and Cognitive Rehabilitation.