Perceived risk, illness perception and dispositional optimism related to COVID-19 among oncologic outpatients undergoing in-hospital treatments and healthy controls

OBJECTIVE

This study aimed to explore risk estimations (perceived risk, dispositional optimism) related to COVID-19 perception and distress in oncologic outpatients undergoing active hospital treatments compared to the general population.

DESIGN AND MAIN OUTCOME MEASURES

Data were collected during the Italian lockdown on 150 oncologic outpatients and a sample of 150 healthy subjects. They completed a battery of questionnaires including the Perceived Risk scale, the Brief Illness Perception Questionnaire, the Life Orientation Test- Revised and the Patient Health Questionnaire-4. Descriptive statistics, correlation analysis, and a moderated mediation model were performed to test the study hypotheses.

RESULTS

The moderated mediation model attested significant conditional indirect associations of both clinical status and dispositional optimism with distress through the mediation of COVID-19 perceived risk. Healthy individuals and less optimistic people were more likely than others to report higher psychological distress only when they showed neutral or negative COVID-19-related illness perception.

CONCLUSIONS

Cancer patients manifest a lower risk perception and a more positive illness representation related to COVID-19 compared to control subjects; the distress level is not associated with the clinical status, but it is moderated by illness perception. Adequate protective behaviors in cancer patients may avoid a dangerous underestimation of objective risks.

Cardiac autonomic profile, perceived stress and environmental comfort in healthy employees during remote and in-office work

Remote work (REMOTE) causes an overlap between working and domestic demands. The study of the cardiac autonomic profile (CAP) by means of heart rate variability (HRV) provides information about the impact of REMOTE on workers' health. The primary aim was to determine whether CAP, self-perceived stress, environmental and workstation comfort are modified during REMOTE. The secondary aim was to explore how these indices are influenced by individual and environmental work-related factors. Fifty healthy office employees alternating REMOTE and in-office (OFFICE) working were enrolled, rated self-perceived stress, environmental and workstation comfort using a visual analogue scale and performed a 24-h electrocardiogram during REMOTE and OFFICE. Stress was lower (5.6 ± 2.2 vs. 6.4 ± 1.8), environmental comfort higher (7.7 ± 1.9 vs. 7.0 ± 1.5), and the workstation comfort poorer (6.2 ± 1.8 vs. 7.5 ± 1.2) during REMOTE. CAP was similar during REMOTE and OFFICE. CAP was influenced by some work-related factors, including the presence of offspring, absence of a dedicated workspace during REMOTE and number of working hours. All these variables determined a decreased vagal modulation. The working setting seems to impact the levels of perceived stress and comfort, but not the CAP. However, individual and environmental work-related factors reduce cardiac vagal modulation during REMOTE, potentially increasing the risk of developing cardiovascular diseases.

Psychological couple-oriented interventions for patients with heart disease and their partners: a scoping review and guidelines for future interventions

Objective

This scoping review aims to provide an accessible summary of available evidence on the efficacy of psychological couple-based interventions among patients with heart disease and their partners focusing on specific aspects and strategies by assessing different emotional and physical cardiac-related outcome measures.

Methods

A literature search was performed in PubMed, Scopus, Medline, PsycINFO, and Web of Science databases using the keywords "heart diseases" and "couple-based intervention." A literature search using systematic methods was applied. Data were extracted to address the review aims and were presented as a narrative synthesis.

Results

The database search produced 11 studies. Psychological couple-based interventions varied in terms of the type of intervention, personnel, format (group or individual, phone or in person), number of sessions, and duration. Most of the contributions also lacked adequate details on the training of professionals, the contents of the interventions, and the theoretical models on which they were based. Finally, although partners were involved in all the treatment, in most studies, the psychological strategies and outcomes were focused on the patient.

Conclusion

The variability of the psychological couple-based interventions of included studies represents a challenge in summarizing the existing literature. Regarding their impact, psychological interventions for patients with cardiovascular disease and their partners were found to moderately improve patients' and partners' outcomes.

Patients' Clinical and Psychological Status in Different COVID-19 Waves in Italy: A Quanti-Qualitative Study

BACKGROUND

COVID-19 waves have been characterized by different clinical manifestations, a decrease of functional abilities, and the presence of psychological symptoms. The aims of this study were to investigate differences in physical and psychological symptoms during the three Italian waves of the coronavirus pandemic.

METHODS

Patients undergoing a functional, cardiological and pneumological check-up follow-up at ICS Maugeri Institutes, 2-3 months after recovery from COVID-19 were consecutively recruited to participate in the study, completing a quanti-qualitative questionnaire about anxiety, depression, PTSD symptoms, and personal resources.

RESULTS

104 patients were recruited: 44 and 60 during the first and second/third pandemic waves, respectively. Physical comorbidities were more present in the second/third waves compared to the first one, while no significant differences were found in anxious and depressive symptoms, which were significantly higher than normal during the three waves; PTSD symptoms were reported by 56.3% of patients. Family, social support, and a positive mindset were described as resources to cope with the COVID-19 burden. Negative affects arose during outbreaks (panic) and the disease (fear), while positive affect (joy) characterized only the follow-up period.

CONCLUSION

This study shows how psychophysical symptoms might change during the pandemic waves and highlights the importance of protective factors to balance the subjective distress.

Rationale and design of the CV-PREVITAL study: an Italian multiple cohort randomised controlled trial investigating innovative digital strategies in primary cardiovascular prevention

INTRODUCTION

Prevention of cardiovascular disease (CVD) is of key importance in reducing morbidity, disability and mortality worldwide. Observational studies suggest that digital health interventions can be an effective strategy to reduce cardiovascular (CV) risk. However, evidence from large randomised clinical trials is lacking.

METHODS AND ANALYSIS

The CV-PREVITAL study is a multicentre, prospective, randomised, controlled, open-label interventional trial designed to compare the effectiveness of an educational and motivational mobile health (mHealth) intervention versus usual care in reducing CV risk. The intervention aims at improving diet, physical activity, sleep quality, psycho-behavioural aspects, as well as promoting smoking cessation and adherence to pharmacological treatment for CV risk factors. The trial aims to enrol approximately 80 000 subjects without overt CVDs referring to general practitioners' offices, community pharmacies or clinics of Scientific Institute for Research, Hospitalization and Health Care (Italian acronym IRCCS) affiliated with the Italian Cardiology Network. All participants are evaluated at baseline and after 12 months to assess the effectiveness of the intervention on short-term endpoints, namely improvement in CV risk score and reduction of major CV risk factors. Beyond the funded life of the study, a long-term (7 years) follow-up is also planned to assess the effectiveness of the intervention on the incidence of major adverse CV events. A series of ancillary studies designed to evaluate the effect of the mHealth intervention on additional risk biomarkers are also performed.

ETHICS AND DISSEMINATION

This study received ethics approval from the ethics committee of the coordinating centre (Monzino Cardiology Center; R1256/20-CCM 1319) and from all other relevant IRBs and ethics committees. Findings are disseminated through scientific meetings and peer-reviewed journals and via social media. Partners are informed about the study's course and findings through regular meetings.

TRIAL REGISTRATION NUMBER

NCT05339841.

Physiological and Psychological Response to Acute Mental Stress in Female Patients Affected by Chronic Pulmonary Arterial Hypertension: An Explorative Controlled Pilot Trial

Little is known about physiological and psychological responses to mental stress in stable patients affected by pulmonary arterial hypertension (PAH). The current explorative controlled pilot study was conducted to investigate whether heart rate (HR) and perceived stress would differ during standardized mental stress testing in PAH patients compared to healthy subjects. Correlation analysis between HR, perceived stress, participants’ psychological status and performance on the mental stress task was also performed. The study included 13 female PAH patients (average age: 44.38 ± 10.88 years; average education: 14 ± 3.07 years; mean duration of illness: 9.15 ± 5.37 years) and 13 female controls similar in age (mean age: 47.85 ± 6.36 years) and education (15.92 ± 1.55 years). Participants performed a standardized 9 min mental stress test (computer based, adaptive math task). HR and perceived stress during the task were compared to resting baseline and correlated with psychological state and task performance. Both HR and perceived stress significantly increased during mental stress in a similar way in both groups. A significant correlation was found between HR and perceived stress. Our data show that moderate mental stress has a comparable effect on HR and perceived stress increase in stable PAH patients and control subjects.

Prevalence of Psychopathological Symptoms and Their Determinants in Four Healthcare Workers' Categories during the Second Year of COVID-19 Pandemic

Highly stressful situations, such as the current COVID-19 pandemic, induce constant changes in the mental state of people who experience them. In the present study, we analyzed the prevalence of some psychological symptoms and their determinants in four different categories of healthcare workers during the second year of the pandemic. A total of 265 physicians, 176 nurses, 184 other healthcare professionals, and 48 administrative employees, working in different Italian healthcare contexts, answered a questionnaire including variables about their mental status and experience with the pandemic. The mean scores for anxiety and depressive symptoms measured more than one year after the onset of the pandemic did not reach the pathological threshold. In contrast, post-traumatic and burnout symptoms tended toward the critical threshold, especially in physicians. The main determinant of psychological distress was perceived stress, followed by job satisfaction, the impact of COVID-19 on daily work, and a lack of recreational activities. These results increase the knowledge of which determinants of mental distress would be important to act on when particularly stressful conditions exist in the workplace that persist over time. If well-implemented, specific interventions focused on these determinants could lead to an improvement in employee well-being and in the quality of care provided.

Uptake and effectiveness of a primary cardiovascular prevention program in an underserved multiethnic urban community

BACKGROUND AND AIMS

Cardiometabolic risk is increased among disadvantaged people and ethnic minorities. Paradoxically, their uptake of primary cardiovascular prevention is relatively low. New strategies are needed to tackle this public health problem. Aims of this study were to assess the uptake (as well as its determinants) and effectiveness of a primary cardiovascular prevention program for communities devised to facilitate access of disadvantaged and inclusion of ethnic minorities in addition to providing a state-of-the-art interdisciplinary personalized care.

METHODS AND RESULTS

Single center, hospital-based, open study. All the residents in an underserved multiethnic urban community aged 40-65 years (n = 1646, 43.6% immigrants) were proactively invited by post mail to participate in a cardiovascular prevention program and different approaches were adopted to promote accessibility and inclusiveness. Program uptake was 23% and individual features independently associated with program uptake were status of immigrant (OR [CI 95%]: 3.6 [2.6-5.1]), higher educational level (3.6 [2.8-4.7]), and female gender (1.6 [1.2-2.1]). Retention was 82% at 6 months and 69% at 12 months. A predefined outcome of global cardiovascular risk improvement at 12 months in subjects with glycaemia >126 mg/dl, LDL-C >115 mg/dl, systolic blood pressure ≥140 mmHg or BMI >28 at baseline was reached in 35%, 33%, 37% and 7% of the patients, respectively. 20% of smokers quitted and significant favorable changes were reported in diet quality, anxiety, depression and physical activity.

CONCLUSION

Access inequalities to effective prevention may be counteracted, but increasing global uptake requires further upstream sensitization and awareness actions. REGISTERED IN CLINICALTRIALS.GOV: NCT03129165.

Genetic testing users in Italy and Germany: Health orientation, health-related habits, and psychological profile

Background

Rapid advances in genomic knowledge and widespread access to the web contributed to the development of genetic services by private companies or medical laboratories. In the European landscape, though, there is not a single coherent regulatory approach to genetic testing (GT). The study aimed to investigate differences and similarities between two populations of GT users, Italians and Germans, in terms of health‐related behaviors, psychological characteristics, and attitudes toward genetic information.

Methods

Ninety‐nine Italian GT users from one private genetic company and 64 Germans GT users from one medical laboratory, completed an ad hoc self‐administered questionnaire.

Results

Results showed significant differences in health‐related behaviors (unhealthy eating behaviors, smoking behaviors, and frequency in medical check‐ups), with Germans reporting higher levels of unhealthy eating habits and smoking behaviors than Italians; Italian users also were more medically controlled. Furthermore, German participants were less willing to change their lifestyle following the GT results compared to Italian participants. Regarding psychological variables, German users felt more confident about their physical well‐being and they seemed more motivated than Italians to avoid becoming unhealthy. Finally, two samples differed in the way they accessed genetic testing (with the Italians guided predominately by a physician in contrast with the Germans who were recommended by friends) and managed genetic testing results (with Italian participants significantly more willing to share results with doctors than German participants, who preferred sharing with the family).

Conclusion

The analysis of cultural and organizational differences could help in defining adequate guidelines for counseling, and provide inputs for regulators in different European contexts.

COVID-19 and mental disorders in healthcare Personnel: A novel framework to develop Personas from an online survey

BACKGROUND

In this paper we propose a novel framework for the definition of Personas for healthcare workers based on an online survey, with the aim of highlighting different levels of risk of developing mental disorders induced by COVID-19 and tailor psychological support interventions.

METHODS

Data were gathered from Italian healthcare workers between April and May 2020. Information about socio-demographic characteristics, current lifestyle, occupational, COVID-19 infection, and psychological indexes (Maslach Burnout Inventory, Impact of Event Scale and Patient Health Questionnaire) was collected. Respondents were divided in four subgroups based on their health profession: physicians (P), nurses (N), other medical professionals (OMP) and technical-administrative (TA). For each sub-group, collected variables (46) were reduced using Principal Component Analysis and clustered by means of k-medoids clustering. Statistical analysis was then applied to define which variables were able to differentiate among the k clusters, leading to the generation of a Persona card (i.e., a template with textual and graphical information) for each of the obtained clusters.

RESULTS

From the 538 respondents (153 P, 175 N, 176 OMP, 344 TA), the highest stress level, workload impact and risk of mental disorders were found in the N subgroup. Two clusters were identified for P, three clusters for N, two for OMP and one for TA.

CONCLUSIONS

The proposed framework was able to stratify different risk levels of possible development of mental health issues in healthcare workers due to COVID-19. This approach could represent the first step towards the development of mobile health tools to tailor psychological interventions in pandemic situations.

Stress, the autonomic nervous system, and sudden death

The existence of an important relationship between stress, the autonomic nervous system, and sudden cardiac death (SCD) has been long recognized. In the present essay we review the large number of conditions, acting at individual or at population level, that have been causally associated to SCD and discuss the mechanistic and translational value of the studies exploring such associations. These conditions include external stressors (earthquakes, wars) and internal stressors (anger, fear, loss of a loved one) and emotions of even opposite sign. Most situations confirm the time-honored view that increases in sympathetic activity are proarrhythmic whereas increases in vagal activity are protective; however, we will also show and discuss a condition in which the culprit appears to be the excess of vagal activity. The physiologic rationale underlying the most typical situations is on one hand the profibrillatory effect of the increase in the heterogeneity of repolarization secondary to the release of norepinephrine, and on the other the combined effect of acetylcholine to lower heart rate and to antagonize the cardiac effects of norepinephrine at ventricular level. An interesting facet of this potentially lethal relationship is that the elements involved are by no means always exceptional, and they can actually represent part of our everyday life.

Stereotactic radioablation for the treatment of ventricular tachycardia: preliminary data and insights from the STRA-MI-VT phase Ib/II study

Purpose

We present the preliminary results of the STRA-MI-VT Study (NCT04066517), a spontaneous, phase Ib/II study, designed to prospectively test the safety and efficacy of stereotactic body radiotherapy (SBRT) in patientswith advanced cardiac disease and intractable ventricular tachycardia (VT).

Methods

Cardiac computed tomography (CT) integrated by electroanatomical mapping was used for substrate identification and merged with dedicated CT scans for treatment plan preparation. A single 25-Gy radioablation dose was delivered by a LINAC-based volumetric modulated arc therapy technique in a non-invasive matter. The primary safety endpoint was treatment-related adverse effects during acute and long-term follow-up (FU), obtained by regular in-hospital controls and implantable cardioverter defibrillator (ICD) remote monitoring. The primary efficacy endpoint was the reduction at 3 and 6 months of VT episodes and ICD shocks.

Results

Seven out of eight patients (men; age, 70 ± 7 years; ejection fraction, 27 ± 11%; 3 ischemic, 4 non-ischemic cardiomyopathies) underwent SBRT. At a median 8-month FU, no treatment-related serious adverse event occurred. Three patients died from non-SBRT-related causes. Four patients completed the 6-month FU: the number of VT decreased from 29 ± 33 to 11 ± 9 (p = .05) and 2 ± 2 (p = .08), at 3 and 6 months, respectively; shocks decreased from 11 to 0 and 2, respectively. At 6 months, all patients. showed a significant reduction of VT episodes and no electrical storm recurrence, with the complete regression of iterative VTs in 2/2 patients.

Conclusion

The STRA-MI-VT Study suggests that SBRT can be considered an alternative option for the treatment of VT in patients with structural heart disease and highlights the need for further clinical investigation addressing safety and efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10840-021-01060-5.

Psychological and work-related factors associated with emotional exhaustion among healthcare professionals during the COVID-19 outbreak in Italian hospitals

The coronavirus disease 2019 (COVID‐19) pandemic has induced considerable psychological distress in healthcare workers, increasing the risk of burnout. This research aimed to investigate sociodemographic, work‐related, COVID‐19‐related, and psychological factors associated with emotional exhaustion (the core component of burnout) among healthcare professionals during the first wave of the COVID‐19 pandemic in Italy. A cross‐sectional study was conducted to assess risk (e.g. perceived risk and fear of contagion, stress) and protective factors (e.g. job satisfaction, resilience) for emotional exhaustion among 616 hospital staff. Women, nurses, shift workers, those with a permanent contract, and frontline workers reported significantly higher levels of emotional exhaustion compared to others. Significant risk factors predicting emotional exhaustion were prolonged use of personal protective equipment, increased work pressure, lack of support, and prolonged working hours; psychologically protective factors were resilience and job satisfaction, while perceived stress was found to be a significant psychological risk factor. Organizational interventions should focus on these factors to prevent the onset of burnout.

A framework for risk stratification of burnout due to Covid-19 in nurses using personas" creation

Funding Acknowledgements

Type of funding sources: None.

Background

Covid-19 pandemic has generated a huge amount of stress upon all healthcare workers, with an increased risk of developing burnout syndrome and Post Traumatic Stress Disorder (PTSD). Mobile health could provide tools for preventive interventions, whose efficacy could be improved by applying User-Centered Design (UCD) techniques to create personas to stratify the associated risk and tailor those interventions.

Purpose

We propose a framework for the definition of personas applied to an Italian nurse population to highlight different levels of risk relevant to burnout, anxiety, depression, and PTSD induced by Covid-19.

Methods

Data was gathered by web-questionnaire delivered to nurses in Italy between April and May 2020. Quantitative information about respondents’ lifestyle, professional experience, impact of Covid-19 pandemic on both work conditions and personal life were collected, together with psychological indexes as Maslach Burnout Inventory (MBI), Impact of Event Scale (IES) and Patient Health Questionnaire (PHQ), used to define the risk level of burnout, PTSD, and anxiety and depression, respectively. Collected variables (55) were first reduced using Principal Component Analysis; then, k-medoids clustering with Partitioning Around Medoids algorithm was applied, where the best value of k was determined by silhouette and total within sum of square differences heuristics, together with evaluation from domain experts. Statistical analysis was applied to define which variables were able to differentiate among the k clusters, constituting the basis for the definition of a Persona card (i.e., a template with textual and graphical information) for each of the obtained clusters.

Results

From the 175 respondents nurses, a total of three clusters (personas) were identified. They presented very strong dissimilarities both in lifestyle and in how nurses reacted to the pandemic, showing distinct profiles associated to three different levels of risk of developing burnout and PSTD: the highest (representing 38.3% of all respondents), associated to a married nurse with children living with family, also using Personal Protective Equipment (PPE) at home, with workload highly impacted by COVID-19; the middle one, associated to an engaged nurse living alone with workload highly impacted by COVID-19; the lowest, associated to a married nurse living only with the husband/wife and wearing PPE at home, with workload moderately impacted by the pandemic. All personas showed a good amount of knowledge about burnout.

Conclusions

The application of the proposed framework to nurses showed three clusters that evidenced three risk profiles associated to different personas, each requiring distinctive treatment. This approach constitutes the first step for the development of tailored m-health interventions aimed at monitoring and preventing burnout and PTSD among healthcare workers in critical situations, such as the one provoked by Covid-19 pandemic.

Who Is Willing to Get Vaccinated? A Study into the Psychological, Socio-Demographic, and Cultural Determinants of COVID-19 Vaccination Intentions

Crucial to the success of the COVID-19 vaccination campaign is the rate of people who adhere to it. This study aimed to investigate the reasons underlying people’s willingness to get vaccinated in a sample of Italian adults, considering the effects of different individual characteristics and psychological variables upon positive vs. negative/hesitant vaccination intentions, as well as subjects’ self-reported motivations for such intentions. An anonymous cross-sectional survey was distributed online in February 2021. The results showed that trust in science, number of vaccinations received in 2019, and belief that COVID-19 is more severe than the common flu, were associated with positive vaccination intentions. “Chance externality” health locus of control showed both direct and indirect effects upon positive vaccination intentions. Anxiety symptoms and participants’ perceived psychological status also showed indirect positive effects. Subjects’ self-reported motivations varied interestingly across positive vs. negative/hesitant intentions. Implications of these findings for identifying effective pro-vaccination messages are discussed in the final section of the paper.

What people really change after genetic testing (GT) performed in private labs: results from an Italian study

Despite the widespread diffusion of direct-to-consumer genetic testing (GT), it is still unclear whether people who learn about their genetic susceptibility to a clinical condition change their behaviors, and the psychological factors involved. The aim of the present study is to investigate long-term changes in health-related choices, individual tendencies and risk attitudes in an Italian sample of GT users. In the context of the Mind the Risk study, which investigated a sample of Italian adults who underwent GT in a private laboratory, 99 clients participated in the follow up assessment. They completed a self-administered questionnaire investigating: (a) clinical history and motivation for testing, (b) lifestyle and risk behaviors, (c) individual tendencies toward health, and (d) risk-taking attitude and risk tolerance. Such variables were measured at three different time-points: T0—before GT, T1—at 6 months after genetic results, and T2—at 1 year from results. Results showed that, at baseline, participants who stated they intended to modify their behavior after GT results, effectively did so over time. This result held both for participants who received a positive or negative test result. In general, a healthier diet was the most frequently observed long-term behavioral change. As regards psychological variables, a risk-taking attitude and risk tolerance did not seem to affect the decision to change the lifestyle. Finally, we found an overall reduction in anxiety and worry over health over time, but also a reduction in the motivation for health promotion and prevention, health esteem, and positive expectations for their health in the future.

Persistent long-term platelet activation and endothelial perturbation in women with Takotsubo syndrome

BACKGROUND

Takotsubo (TTS) syndrome is an acute cardiac condition characterized by transient and reversible left ventricle dysfunction that mainly affects postmenopausal women. Catecholamine burst is the most accredited mechanism underpinning TTS onset and leading to endothelial dysfunction and platelet activation. Even if the use of low dose acetylsalycilic acid (ASA) in this clinical setting is based on both clinical presentation and unfavorable long-term prognosis, its efficacy has been recently challenged.

AIM

This study was designed to assess endothelial function, residual thromboxane formation and platelet aggregation in TTS women on low-dose ASA treatment at long-term follow-up.

METHODS

Twenty-eight females with previously diagnosis of TTS syndrome were enrolled. Data were compared to those obtained from 23 coronary artery disease (CAD) women with a history of acute myocardial infarction, and 26 control subjects with no TTS or clinically evident CAD. Psychological and clinical profile were assessed in all study groups at the enrollment. Main metabolites involved in L-arginine/nitric oxide pathway, urinary prostacyclin, serum and urine thromboxane metabolites were measured by LCMS/MS methods. Thrombomodulin levels were quantified using an ELISA kit, and platelet aggregation, carried out on platelet rich-plasma, was induced by ADP or by epinephrine (EPI), norepinephrine (NORE) and TRAP-6, alone or in association with ADP and evaluated by Born's method.

RESULTS

In TTS women an endothelial derangement, characterized by reduced citrulline production and increased thrombomodulin concentration, with no perturbation in prostacyclin levels, was evidenced. In addition, despite ASA treatment, TTS displayed a higher residual thromboxane formation, in parallel with an enhanced platelet response to compared to CAD.

CONCLUSIONS

Our study highlighted the presence of endothelial perturbation in TTS patients even at long-term from the index event. The residual thromboxane production and platelet aggregation still leave open the question about the use of low dose ASA in this clinical setting.

Mental health and risk perception among Italian healthcare workers during the second month of the Covid-19 pandemic

A multicentre cross-sectional study was conducted to assess perceived risk and fear of contagion, as well as mental health outcomes among 650 Italian healthcare workers during the COVID-19 outbreak. A relevant proportion of the sample reported symptoms of anxiety, depression, and distress. Female sex, nursing profession, fear of being infected, as well as the time of exposure to the COVID-19 spread and the fact of directly attending infected patients were the main risk factors for developing mental health disturbances. Tailored interventions need to be implemented to reduce psychological burden in healthcare workers, with a particular attention to nurses.

Examination of the best cut-off points of PHQ-2 and GAD-2 for detecting depression and anxiety in Italian cardiovascular inpatients

OBJECTIVE

Despite the frequent association between anxiety, depression and cardiovascular diseases (CVD), cardiovascular inpatients are not usually screened for these psychopathological conditions. To fill this gap, especially in hospital environments, there is the need of brief screening instruments that provide reliable information in a very short time. According to this need, the aim of this study was to examine the best cut-off points of two brief and easy-to-use questionnaires in a sample of Italian cardiovascular inpatients: the 2-item Patient Health Questionnaire (PHQ-2) and the 2-item Generalized Anxiety Disorder (GAD-2).

DESIGN

3500 cardiovascular inpatients were recruited and completed both the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7). PHQ-2 and GAD-2 were then obtained extracting the first two item from PHQ-9 and GAD-7.

MAIN OUTCOME MEASURES

The PHQ-2 and GAD-2 psychometric properties were calculated comparing them with PHQ-9 and GAD-7, respectively.

RESULTS

The PHQ-2 threshold of ≥ 2 and the GAD-2 threshold of ≥ 3 are the best solutions in balancing between sensitivity and specificity, also providing acceptable rates of false positives and false negatives.

CONCLUSIONS

the PHQ-2 and GAD-2 Italian versions showed good diagnostic features for measuring depression and anxiety in CVD patients.

Genetic Testing Consumers in Italy: A Preliminary Investigation of the Socio-Demographic Profile, Health-Related Habits, and Decision Purposes

Aim of the study: Genetic testing is becoming increasingly common in clinical practice and health management; nonetheless, little is known about how the population approaches genetic services through private companies. Our study aims to describe socio-demographic aspects, health-related habits, and overall beliefs and knowledge about genetic risk and testing in a population of Italian citizens who decided to undergo a genetic examination through a private genetic company.

Study design: A sample of 152 clients from an Italian private genetic company completed an ad-hoc survey from September 2016 to February 2018, addressing socio-demographic data, health habits, psycho-physic condition, perceived utility of genetic results, decision purposes about data sharing, and behavioral changes after results.

Results: Participants (mean age 42.4) were predominantly female (82.2%) and were overall well-educated. Their main source of information were physicians (77%), and 41.1% entrusted the management of results to the same. Thirty-eight percentage underwent genetic analysis for cancer predisposition, 31.3% for fertility problems, 24% for dietary or intolerance issues in the period of enrolment. More than half of them (62.7%) reported a family history of the disease, and overall 69% had a current or past experience with a disease. Clients perceived the genetic screening as useful to adopt behaviors that may prevent disease onset (37.7%), to know their “real health status” (27.4%), and to adopt health-related behaviors (23.3%). 62.8% claimed they were motivated to change behaviors after results (healthier diet, practice exercise, medical checks), and they wanted to share results with their physician and family members.

Discussion/Conclusion: The overview of consumers' profiles in Italy and other European countries can contribute to tailoring and regulating genetic services in a way that could be efficient in terms of healthy choices, behaviors, and health resource expenditures for the general public.

Brief report - "Every little thing gonna be all right" (at least for me): Dispositional optimists display higher optimistic bias for infection during the Italian COVID-19 outbreak

Dispositional optimism (DO) and optimistic bias (OB) in risk perception are two distinct phenomena and previous studies about their reciprocal relationship report contrasting results. In the present study, we focused on the relationship between DO and OB when reporting the personal and the other persons' risk about COVID-19. We hypothesized that, when facing a largely uncontrollable risky situation (like the recent pandemic), dispositional optimists would defensively increase their OB about the current risks. A convenience sample of 414 Italian participants aged 18 or older were recruited. They completed a questionnaire investigating past protective behaviors, DO, perceived personal and other persons' COVID-19-related risk. Results of the mixed regression model showed that more optimistic people were more likely to underestimate their COVID-19 personal risk over the other's person risk. These results shed light on the relationship between different forms of optimism and provide useful insight about the potential implications of risk communication approaches to face the current pandemic.

Spontaneous Participation in Secondary Prevention Programs: The Role of Psychosocial Predictors

Disease prevention is a multifaceted construct that has been widely studied. Nevertheless, in spite of its importance, it is still not sufficiently considered by the general population. Since the reasons for this lack of consideration are not yet fully understood, we created an Online Prevention Survey (OPS) to investigate the role of both sociodemographic and psychological factors in predicting individuals’ spontaneous participation in secondary prevention programs. The results revealed that younger people, men, manual workers, unemployed people, and those who do not regularly practise physical activity were less likely to spontaneously participate in such programs. Furthermore, an analysis of the psychological determinants of the willingness to participate in secondary prevention programs showed that depressive symptoms negatively predict it, while an individual’s perception of receiving high social support acts as a positive predictor. Based on these results, we suggest the need for implementing new tailored approaches to promote prevention initiatives to those segments of the population which are more reluctant to spontaneously undertake prevention paths.

Depressive and Anxiety Symptoms Screening in Cardiac Inpatients: A Virtuous Italian Approach to Psychocardiology

Despite the fact that American Heart Association (AHA) recommended a systematic screening for depression in cardiovascular inpatients, poor attention has been given to this issue. Furthermore, no specific guidelines exist for anxiety screening in cardiovascular inpatients. Thus, the aims of this study were to verify the feasibility of a depressive and anxiety symptoms screening protocol in an Italian hospital specializing in cardiovascular diseases and to evaluate both anxiety and depressive symptoms prevalence. A group of 2009 consecutive inpatients completed the 9-item Patient Health Questionnaire (PHQ-9) and the 7-item Generalized Anxiety Disorder (GAD-7). The rates of depressive and anxiety symptoms were almost 9% and 16% respectively. Men were less likely than women to experience both depressive and anxiety symptoms. Patients who were admitted to the heart failure unit reported higher risk of experiencing both symptoms compared to patients in other wards. Similarly, patients admitted to the cardiac surgery unit showed a higher risk of experiencing anxiety symptoms compared to other patients. The proposed screening procedure showed a good feasibility and acceptance. This study highlighted the importance of implementing a short screening procedure in hospitals dealing with cardiovascular inpatients to identify those individuals who require specific attention and interventions.

Health orientation and individual tendencies of a sample of Italian genetic testing consumers

Background

Over the last decade, genetic testing (GT) had markedly spread in European countries and struggled the debate concerning the psychological effects on the population. The aim of this study was to investigate the individual tendencies of GT consumers in a sample of Italian citizens.

Methods

A total of 152 Italian clients from GenomaLab, a private genetic company, were enrolled from February 2016 to September 2018 and completed an ad hoc survey.

Results

Results showed that GT consumers were motivated to preserve their well‐being, they felt responsible for their health, they were neither pessimistic nor optimistic toward negative occurrences, and poorly inclined to take high risks in their lives. Participants who had suffered from a disease in the past appear to be less tolerant to the uncertainty for future negative events.

Conclusion

Our results depict Italian GT consumers as health‐oriented, focused on prevention, who do not have a pessimistic perception of their condition but do not like to “bet” on their health, and probably their intention (and belief) is to acquire genetic information in order to reduce uncertainty and increase their decision‐making “power” related to their health. Taken together, all these results contribute to describe the population of GT users in European countries, to regulate the provision of GT results and to entail the communication of genetic risk information based on a consumers’ personal profile.

Avatars and the Disease: Digital Customization as a Resource for Self-Perception Assessment in Breast Cancer Patients

Avatars, or users' renditions within digital environments, may change depending on modifications of users' self-conception. According to literature, chronic health conditions influence patients and survivors' identity, because living with a disease requires people to reconfigure their self-representation and their own daily life and future plans. This is especially true for breast cancer, whose treatment and surgery also affect patients' body image, sexual identity, and sense of womanhood. In this study, 22 breast cancer survivors were asked to create multiple avatars resembling their actual self (AS), their ideal self (IS), and their self connected to the disease experience; then, they were asked to rate their attitudes toward their three avatars. Results show that disease avatars are significantly different in patients' attitudes toward them from AS and IS avatars. In addition, attitudes toward one's own avatars appeared partially related to clinically relevant psychological states, such as anxiety and depression. Discussion explores suggestions for usage of avatars in interventions for assessment and quality-of-life promotion among chronic patients.

Usability Testing of Two Mini-Games and One Serious Game to Educate People About Genetics

The lowering costs of DNA sequencing and the diffusion of numerous Direct to Consumer Genetic Testing (DTC-GT) services have made genetic testing easily available to the general public who can buy them without any medical prescription or consultation. Nevertheless, the knowledge required to understand the provided results and their implications is still scarce in the general public. Starting from these considerations, we developed two mini-games and one serious game to increase people genetic literacy through experiential learning. The three games were tested for usability on a sample of 30 participants, 10 for each game, who were asked to report any positive or negative issue related to the games and to fulfill the Game Experience Questionnaire in order to evaluate their playing experience. Results from the three games show that players experienced moderate levels of immersion and flow, low levels of negative sensations, and a prevalence of positive emotions. In general, these encouraging results suggest that the proposed games are suitable to transmit genetic notions to the general public.

Serious Games for Improving Genetic Literacy and Genetic Risk Awareness in the General Public: Protocol for a Randomized Controlled Trial

Background

Genetic testing and genetic risk information are gaining importance in personalized medicine and disease prevention. However, progress in these fields does not reflect increased knowledge and awareness of genetic risk in the general public.

Objective

Our aim is to develop and test the efficacy of a suite of serious games, developed for mobile and Web platforms, in order to increase knowledge of basic genetic concepts and promote awareness of genetic risk management among lay people.

Methods

We developed a new ad-hoc game and modified an arcade game using mechanics suitable to explain genetic concepts. In addition, we developed an adventure game where players are immersed in virtual scenarios and manage genetic risk information to make health-related and interpersonal decisions and modulate their lifestyle. The pilot usability testing will be conducted with a convenience sample of 30 adults who will be categorized into 3 groups and assigned to one game each. Participants will be asked to report any positive or negative issues arising during the game. Subsequently, they will be asked to complete the Game Experience Questionnaire. Finally, a total of 60 teenagers and adults will be enrolled to assess knowledge transfer. Thirty participants will be assigned to the experimental group and asked to play the serious games, and 30 participants will be assigned to the control group and asked to read leaflets on the genetic concepts conveyed by the games. Participants of both groups will fill out a questionnaire before and after the intervention to assess their topic-specific knowledge of genetics. Furthermore, both groups will complete the self-efficacy questionnaire, which assesses the level of confidence in using genetic information.

Results

We obtained evidence of game usability in 2017. The data will be submitted to a peer-reviewed journal and used to improve the game design. Knowledge-transfer testing will begin in 2018, and we expect to collect preliminary data on the learning outcomes of serious games by December 2018.

Conclusions

It is important to educate the general public about the impact of genetics and genetic testing on disease prevention and the consequent decision-making implications. Without such knowledge, individuals are more likely to make uninformed decisions or handover all decisions regarding genetic testing to their doctors. Technological innovations such as serious games might become a valid instrument to support public education and empowerment.

International Registered Report Identifier (IRRID)

DERR1-10.2196/9288

A P5 Approach to m-Health: Design Suggestions for Advanced Mobile Health Technology

In recent years, technology has been developed as an important resource for health care management, especially in regard to chronic conditions. In the broad field of eHealth, mobile technology (mHealth) is increasingly used to empower patients not only in disease management but also in the achievement of positive experiences and experiential growth. mHealth tools are considered powerful because, unlike more traditional Internet-based tools, they allow patients to be continuously monitored and followed by their own mobile devices and to have continual access to resources (e.g., mobile apps or functions) supporting health care management activities. However, the literature has shown that, in many cases, such technology not accepted and/or adopted in the long term by its users. To address this issue, this article reviews the main factors influencing mHealth technology acceptance/adoption in health care. Finally, based on the main aspects emerging from the review, we propose an innovative approach to mHealth design and implementation, namely P5 mHealth. Relying on the P5 approach to medicine and health care, this approach provides design suggestions to address mHealth adoption issues already at the initial stages of development of the technologies.

[Barriers and facilitators for physical activity in sedentary people residing in a disadvantaged Italian neighbourhood]

OBJECTIVES

to explore which factors have a personal significance of barrier or facilitator for physical activity (PA) in sedentary subjects living in a peripheral, multiethnic, and economically disadvantaged Italian neighbourhood.

DESIGN

qualitative, descriptive phenomenological study.

SETTING AND PARTICIPANTS

the study was carried out in Ponte Lambro, a neighbourhood in the South-eastern outskirts of Milan (Lombardy Region, Northern Italy). Among the first 260 participants in a primary cardiovascular prevention programme (called ProSALUTE) targeted to this community, 63 subjects were categorized as sedentary. Out of these, 45 were selected through purposive sampling and 24 of them participated in this study.

MAIN OUTCOME MEASURES

• qualitative content analysis of semi-structured interviews conducted through motivational interviewing; • analysis of values acquired by personal value cards.

RESULTS

the factors emerged throughout the interviews were external (social support, environment, and tools) and individual (health status, self-confidence, reliance on the beneficial effects of PA, psychological issues). Barriers or facilitators were recognized in each of these factors according to the expressed significance. The most frequently chosen personal values (health, family, delight, strength and autonomy) were concordant with the contents of the interviews.

CONCLUSION

distinctive barriers and facilitators to PA are identifiable among the significances expressed by residents in a disadvantaged neighbourhood. These barriers and facilitators may be the targets of socio-environmental or personal interventions aimed to promote an active life-style.

A web-based interactive tool to improve breast cancer patient centredness

The uniqueness of a patient as determined by the integration of clinical data and psychological aspects should be the aspired aim of a personalized medicine approach. Nevertheless, given the time constraints usually imposed by the clinical setting, it is not easy for physicians to collect information about the patient’s unique mental dimensions and needs related to her illness. Such information may be useful in tailoring patient–physician communication, improving the patient’s understanding of provided information, her involvement in the treatment process, and in general her empowerment during and after the therapeutic journey. The primary objective of this study is to evaluate the effect of an interactive empowerment tool (IEm) on enhancing the breast cancer patient–physician experience, in terms of increasing empowerment, i.e. by providing physicians with a personalised patient’s profile, accompanied by specific recommendations to advise them how to interact with each individual patient on the basis of her personal profile.

The study will be implemented as a two-arm randomised controlled trial with 100 adult breast cancer patients who fill in the ALGA-BC questionnaire, a computerised validated instrument to evaluate the patient’s physical and psychological characteristics following a breast cancer diagnosis. The IEm tool will collect and analyse the patient’s answers in real time and send them, together with specific recommendations to the physician’s computer immediately before physician’s first encounter with the patient. Patients will be randomised to either the intervention group using the IEm tool or to a control group who will only fill in the questionnaire without taking advantage of the tool (physicians will not receive the patient’s profile).

The proposed approach is supposed to improve the patient–physician communication leading to increased patient participation in the therapeutic process as a consequence leading to improvement in patient empowerment and personalisation of care.

Psycho-emotional tools for better treatment adherence and therapeutic outcomes for cancer patients

Personalized medicine should target not only the genetic and clinical aspects of the individual patients but also the different cognitive, psychological, family and social factors involved in various clinical choices. To this direction, in this paper, we present instruments to assess the psycho-emotional status of cancer patients and to evaluate the resilience in their family constructing in such a way an augmented patient profile. Using this profile, 1) information provision can be tailored according to patients characteristics; 2) areas of functioning can be monitored both by the patient and by the clinicians, providing suggestions and alerts; 3) personalized decision aids can be develop to increase patient's participation in the consultation process with their physicians and improve their satisfaction and involvement in the decision-making process. Our preliminary evaluation shows promising results and the potential benefits of the tools.

Clinical Trials, Data Protection and Patient Empowerment in the Era of the New EU Regulations

Cancer clinical trials and, in general, cancer clinical research by definition need a multi-modality approach. It is not enough to discover and register new drugs. To get cancer under control requires us to perform complex clinical studies that integrate drugs, companion diagnostics, new or improved surgical procedures and new radiotherapy approaches as well as, most importantly, to integrate all available information. This includes biological material and, of increasing importance, large amounts of data using big data technologies. To personalise treatment, genetic data are more and more frequently used. Therefore, the general approach is holistic. Legislators, on the other hand, work in a silo mentality; the needs of clinical research are poorly understood, and legislation focuses on either health care or the commercialisation of a product, and not on clinical research. In the last 2 years the EU has drafted several major regulations touching on clinical trials, in vitro diagnostics, medical devices and data protection, all of which will impact clinical research, although the silo mentality makes the overall framework inconsistent and potentially highly damaging to the EU's capacity to make rapid progress in the field of personalised medicine.

Decision-Making Process Related to Participation in Phase I Clinical Trials: A Nonsystematic Review of the Existing Evidence

Due to the lack of other treatment options, patient candidates for participation in phase I clinical trials are considered the most vulnerable, and many ethical concerns have emerged regarding the informed consent process used in the experimental design of such trials. Starting with these considerations, this nonsystematic review is aimed at analyzing the decision-making processes underlying patients' decision about whether to participate (or not) in phase I trials in order to clarify the cognitive and emotional aspects most strongly implicated in this decision. Considering that there is no uniform decision calculus and that many different variables other than the patient-physician relationship (including demographic, clinical, and personal characteristics) may influence patients' preferences for and processing of information, we conclude that patients' informed decision-making can be facilitated by creating a rigorously developed, calibrated, and validated computer tool modeled on each single patient's knowledge, values, and emotional and cognitive decisional skills. Such a tool will also help oncologists to provide tailored medical information that is useful to improve the shared decision-making process, thereby possibly increasing patient participation in clinical trials.

Development and psychometric testing of a breast cancer patient-profiling questionnaire

Introduction

The advent of “personalized medicine” has been driven by technological advances in genomics. Concentration at the subcellular level of a patient’s cancer cells has meant inevitably that the “person” has been overlooked. For this reason, we think there is an urgent need to develop a truly personalized approach focusing on each patient as an individual, assessing his/her unique mental dimensions and tailoring interventions to his/her individual needs and preferences. The aim of this study was to develop and test the psychometric properties of the ALGA-Breast Cancer (ALGA-BC), a new multidimensional questionnaire that assesses the breast cancer patient’s physical and mental characteristics in order to provide physicians, prior to the consultation, with a patient’s profile that is supposed to facilitate subsequent communication, interaction, and information delivery between the doctor and the patient.

Methods

The specific validation processes used were: content and face validity, construct validity using factor analysis, reliability and internal consistency using test–retest reliability, and Cronbach’s alpha correlation coefficient. The exploratory analysis included 100 primary breast cancer patients and 730 healthy subjects.

Results

The exploratory factor analysis revealed eight key factors: global self-rated health, perceived physical health, anxiety, self-efficacy, cognitive closure, memory, body image, and sexual life. Test–retest reliability and internal consistency were good. Comparing patients with a sample of healthy subjects, we also observed a general ability of the ALGA-BC questionnaire to discriminate between the two.

Conclusion

The ALGA-BC questionnaire with 29 items is a valid instrument with which to obtain a patient’s profile that is supposed to help physicians achieve meaningful personalized care which supplements biological and genetic analyses.

A neurofeedback-based intervention to reduce post-operative pain in lung cancer patients: study protocol for a randomized controlled trial

Background

Thoracic surgery appears to be the treatment of choice for many lung cancers. Nevertheless, depending on the type of surgery, the chest area may be painful for several weeks to months after surgery. This painful state has multiple physical and psychological implications, including respiratory failure, inability to clear secretions by coughing, and even anxiety and depression that have negative effects on recovery.

Objective

The aim of this study is to evaluate the effect of a neurofeedback-based intervention on controlling acute post-surgery pain and improving long-term recovery in patients who undergo thoracotomy for lung resection for non-small cell lung cancer (NSCLC) at an academic oncologic hospital.

Methods

This study will be based on a 2-parallel group randomized controlled trial design, intervention versus usual care, with multiple in-hospital assessments and 2 clinical, radiological, and quality of life follow-ups. Participants will be randomized to either the intervention group receiving a neurofeedback-based relaxation training and usual care, or to a control group receiving only usual care. Pain intensity is the primary outcome and will be assessed using the Numeric Pain Rating Scale (NRS) in the days following the operation. Secondary outcomes will include the effect of the intervention on hospital utilization for pain crisis, daily opioid consumption, anxiety, patient engagement, blood test and chest x-ray results, and long-term clinical, radiological, and quality of life evaluations. Outcome measures will be repeatedly taken during hospitalization, while follow-up assessments will coincide with the follow-up visits. Pain intensity will be assessed by mixed model repeated analysis. Effect sizes will be calculated as mean group differences with standard deviations.

Results

We expect to have results for this study before the end of 2016.

Conclusions

The proposed innovative, neurofeedback- and relaxation-based approach to support post-surgery pain management could lead to significant improvements in patient short and long-term outcomes.

[Cardiac magnetic resonance and uremic cardiomyopathy]

Cardiovascular disease (CV) represents the main risk factor for morbidity and mortality in chronic kidney disease (CKD) patients. Large epidemiological studies have shown direct association between severity of CKD and CV event rates. Although patients with end-stage renal disease (ESRD), including dialysis ones, are at greater CV risk, cardiovascular involvement is already evident at the early stages of CKD. End-stage CKD is characterized conventional atherosclerotic risk factor but they cannot account for CV risk as reflected in high rates of sudden cardiac death, heart failure and myocardial infarction. Non-atherosclerotic processes, including left ventricular hypertrophy and fibrosis, mostly account for the excess risk of CV. Employment of cardiac magnetic resonance (CMR) in CKD has brought an improved understanding of the adverse CV changes, known as uremic cardiomyopathy. It is due to ability of cardiac magnetic resonance to provide a comprehensive non - invasive examination of cardiac structure and function, arterial function, myocardial tissue characterization (T1 mapping and inversion recovery imaging), and myocardial metabolic function (spectroscopy).

Modulation of risky choices in recently abstinent dependent cocaine users: a transcranial direct-current stimulation study

Previous neurobiological and neuropsychological investigations have shown that risk-taking behaviors and addictions share many structural and functional aspects. In particular, both are characterized by an irresistible need to obtain immediate rewards and by specific alterations in brain circuits responsible for such behaviors. In this study, we used transcranial direct-current stimulation over the dorsolateral prefrontal cortex (DLPFC) of two samples of subjects (18 dependent cocaine users and 18 control subjects) to investigate the effects of left and right cortical excitability on two risk tasks: (1) the balloon analog risk task (BART) and (2) the game of dice task (GDT). All subjects randomly received a left anodal/right cathodal stimulation (LAn+), a right anodal/left cathodal stimulation (RAn+), and a sham (placebo) stimulation each run at least 48 h apart. Participants were asked to perform the BART and the GDT immediately before and after each stimulation. Our results reveal that the activation of the DLPFC (left and right) results in a reduction of risky behaviors at the BART task both in controls subjects and cocaine dependent users. The effect of tDCS on GDT, instead, is more complex. Cocaine users increased safe behavior after right DLPFC anodal stimulation, while risk-taking behavior increased after left DLPFC anodal stimulation. Control subjects’ performance was only affected by the anodal stimulation of the right DLPFC, resulting in an increase of safe bets. These results support the hypothesis that excessive risk propensity in dependent cocaine users might be due to a hypoactivation of the right DLPFC and an unbalance interhemispheric interaction. In conclusion, since risky decision-making seems to be, at least in part, responsible for maintenance and relapse of addiction, we argue that a neuromodulation-based approach could represent a valuable adjunct in the clinical treatment of addiction.

Development of interactive empowerment services in support of personalised medicine

In an epoch where shared decision making is gaining importance, a patient’s commitment to and knowledge about his/her health condition is becoming more and more relevant. Health literacy is one of the most important factors in enhancing the involvement of patients in their care. Nevertheless, other factors can impair patient processing and understanding of health information: psychological aspects and cognitive style may affect the way patients approach, select, and retain information. This paper describes the development and validation of a short and easy to fill-out questionnaire that measures and collects psycho-cognitive information about patients, named ALGA-C. ALGA-C is a multilingual, multidevice instrument, and its validation was carried out in healthy people and breast cancer patients. In addition to the aforementioned questionnaire, a patient profiling mechanism has also been developed. The ALGA-C Profiler enables physicians to rapidly inspect each patient’s individual cognitive profile and see at a glance the areas of concern. With this tool, doctors can modulate the language, vocabulary, and content of subsequent discussions with the patient, thus enabling easier understanding by the patient. This, in turn, helps the patient formulate questions and participate on an equal footing in the decision-making processes. Finally, a preview is given on the techniques under consideration for exploiting the constructed patient profile by a personal health record (PHR). Predefined rules will use a patient’s profile to personalise the contents of the information presented and to customise ways in which users complete their tasks in a PHR system. This optimises information delivery to patients and makes it easier for the patient to decide what is of interest to him/her at the moment.