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The prime objective of this paper is to propose a new conceptual framework for how integrating corporate social responsibility (CSR) and human resources management (HRM) can impact on stakeholders’ health and wellbeing. The proposed framework argues that integrative socially responsible HRM (SR-HRM) policies coupled with public health literacy and integrative responsible leadership can play a significant role in shaping health behaviour change of internal stakeholders, which in turn can spill over to external stakeholders (family and proximate communities). From a health promotion and population health perspective, we see human resources (HR) as a leading partner in educating employees on the value of CSR and public health literacy programmes, and also as providing action plans on how to strategically and successfully implement these types of programmes. By helping to develop action plans to analyse CRS and public health literacy activities, HR professionals will be promoting both corporate citizenship and health behaviour change. Both of these are vital for developing a culture of social responsibility (and achieving the triple bottom line (TBL)) and sustainable population health promotion. Henceforth, SR-HRM policies and practices could help business organizations to contribute to the achievement of the United Nations’ Sustainable Development Goals (SDGs) and specifically Goals 3 and 8. This novel framework, which is especially pertinent to public health, has not yet been tested empirically. Hence, future studies are warranted to empirically test the theoretical framework using field data collection. Acknowledgements The authors would like to thank Dr Jesus Barrena-Martínez for his valuable comments and suggestions on the conceptual framework. GM is grateful for the support of the Department of Public Health and Sports Science at the University of Gävle, through the CSR-PhAM Programme and RELeSH project. Conflicts of interest: None declared., South Eastern European Journal of Public Health (SEEJPH), Volume XV, 2020

Purpose – This viewpoint article discusses and analyses the need and benefits of a patient safety definition within the context of nursing. Design/methodology/approach – This viewpoint article is supported by literature review, statutory documents and expert knowledge evidence. All these sources provided a unified narrative of the background, current aspects and future needs of patient safety. Findings – The need for strengthening patient safety and the nurses’ role within healthcare’s actions towards patient safety are discussed. The predominant role of nurses due to the proportionate size and significant role along with the need for clarification of patient safety in nursing terms is recognised. Research evidence of nursing areas with safety issues and relevant nursing interventions are presented. Based on all findings, a research-based nursing specific patient safety definition is proposed. This definition includes three axes: what is patient harm, how this harm can be eliminated or reduced and which are the areas of nursing practice that are identified to provide opportunity for patient harm. These axes include nursing specifications of the patient safety definition. Originality/value – It is the first time that a nurse specific patient safety definition is proposed. This definition strives to enhance nurse practitioners’ understanding and engagement with patient safety by clarifying aspects of patient safety within everyday nursing practice.

This paper answers a call from Nordic colleagues for new strategies in education to meet the needs of a new generation of bachelor nursing students regarding the development of clinical skills. We, as they, believe that educational models targeting the development of clinical skills must be customised to meet the learning style of the current and future generations of bachelor nursing students. In this paper we put forward that using a comprehensive, collaborative, student-centred approach will assist younger generations’ learning processes. We describe a pedagogical model of peer learning that combines collaboration, reflection and assessment aligned with learning outcomes. Such an approach, we believe, is likely to be in line with expectations, needs and preconditions of the current and future generations of nursing students.

Objectives: The study investigated the difficulties experienced by endodontics researchers around the world in conducting studies and writing papers. Materials and Methods: A survey consisting of 18 questions on the difficulties experienced by endodontics researchers in performing studies and writing papers was e-mailed to academics in the field of endodontics working at 202 universities. The independent risk factors were analyzed using binary logistic regression at a significance level of 0.05. Results: A total of 581 individuals (10.7%) agreed to participate in the study. Almost half the participants (48.2%) reported that they had received some type of training in conducting studies and writing papers. In response to the question, “Do you get help from a statistician to perform the statistical analyses of your studies?,” 77.1% answered “yes.” Around 40% of the participants stated that the need to obtain ethical approval negatively affected their desire to conduct studies. The participants’ regions had no effect on the reported difficulties associated with writing papers in English or conducting statistical analyses (p > 0.05). Most participants (81.8%) reported difficulties in writing the Discussion section, regardless of their region, academic degrees, or years of experience. Conclusions: The participants stated they experienced difficulties in many areas, such as conducting statistical analyses, finding new ideas, and writing in English. Engaging in a detailed examination of ethics committee rules, expanding biostatistics education, increasing the number of institutions providing research funding, and increasing the number of endodontics journals can increase the enthusiasm of endodontics researchers to publish papers.

Introduction\ud Many women experience giving birth as traumatic. Although women's subjective experiences of trauma are considered the most important, currently there is no clear inclusive definition of a traumatic birth to help guide practice, education, and research.\ud \ud Aim\ud To formulate a woman-centered, inclusive definition of a traumatic childbirth experience.\ud \ud Methods\ud After a rapid literature review, a five-step process was undertaken. First, a draft definition was created based on interdisciplinary experts’ views. The definition was then discussed and reformulated with input from over 60 multidisciplinary clinicians and researchers during a perinatal mental health and birth trauma research meeting in Europe. A revised definition was then shared with consumer groups in eight countries to confirm its face validity and adjusted based on their feedback.\ud \ud Results\ud The stepwise process confirmed that a woman-centered and inclusive definition was important. The final definition was: “A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman's health and wellbeing.”\ud \ud Conclusions\ud This definition of a traumatic childbirth experience was developed through consultations with experts and consumer groups. The definition acknowledges that low-quality provider interactions and obstetric violence can traumatize individuals during childbirth. The women-centered and inclusive focus could help women to identify and validate their experiences of traumatic birth, offering benefits for practice, education, and research, as well as for policymaking and activism in the fields of perinatal mental health and respectful maternity care.

With cancer being recognized as a chronic illness, self-management has been identified as integral to person-centered cancer care.1 Self-management is defined as “the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a chronic condition.”2 The ever-changing cancer care environment, with many aspects of the care being shifted to the home setting, has created and sustained a pressing need for patients and informal/family caregivers to self-monitor and self-manage impacts of their cancer, treatment-related adverse effects, and cancer-related symptoms. However, those tasks cannot occur without support. Cancer nurses play pivotal roles in providing self-management support (SMS) and improving patient outcomes throughout the cancer care trajectory.3–5 Systematic reviews have reported that self-management education and support, delivered by nurses educated and skilled in facilitating patient engagement, can result in positive behavioral change and better clinical outcomes in chronic conditions (eg, reduced blood pressure in hypertension, lower A1c in diabetes,6 cancer, reduced symptom severity, better quality of life).7–9 Better integration of SMS in cancer care requires effective implementation strategies at multiple levels including system-level policy change, strengthening of the evidence base through effectiveness and translational research, and workforce capacity building. This editorial argues the importance of capacity building in the cancer nursing workforce to provide high-quality SMS to cancer survivors.

The most oral surgical interventions require primary wound closure with stitches after previously raised mucoperiosteal flap. Different suture materials are used for this purpose which are classified upon their origin (organic and synthetic) or according to their durability in host tissues (absorbable and non-absorbable). The aim of the review paper was to emphasize the all-important properties of suture material include knot safety, stretch capacity, tissue reactivity, and wound safety. MEDLINE and PubMed databases were explored from the 1970 up to 2018 using the keywords in different combinations: oral surgery, suture material, flap, dental implants, nylon, periodontal, polyglecaprone, polytetrafluoroethylene, polyglycolic acid, polylactic acid, silk. Normal wound healing after oral surgery procedures requires multiple finely tuned processes that occur in a specific sequence as well as proliferation, regeneration and organization (differentiation). The final stage of the wound healing process is named the contraction phase, which begins following sufficient collagen formation in the granular tissue. Traditionally, silk has been the mostly used as suture material for oral surgical procedures, with rarely including others as: nylon, polyester, cat gut, polytetrafluoroethylene (ePTFE), polyglycolic acid (PGA) etc. Surgery with silk sutures increases the risk of infections because they react with the connective tissue, causing adhesion of dental plaque and bacteria adherence around the stitch. On the other hand, a specific form of wound healing occurs around placed dental implants. Usually the implants are placed directly under or at the same level as the bone surface at biphasic dental implant procedures. In conclusion, besides the carefully used surgical and suturing technique, and properly oral hygiene in the postoperative period, the choice of suture material may also influence the healing of the incised soft tissues. Thus the selection of the suture material should be brought under consideration during treatment planning for oral surgical interventions, periodontal surgery and dental implantation. Key words: Oral, Surgery, Periodontal, Implants, Flap, Suture, Silk, Nylon.

BACKGROUND/AIMS: As epilepsy is a complex disease group, it is difficult to diagnose and classify. Oxidative stress plays a vital role in the pathogenesis of epilepsy. This study investigated the total oxidant/antioxidant status levels in patients with focal onset and generalized onset seizures. The results we obtained may help find the etiological cause in patients with seizure complaints and may guide their treatment. In addition, knowing the seizure type of the patient can give an idea about the prognosis of their disease.MATERIALS AND METHODS: The total number of patients included in this prospective study was 58. There were also 57 people in a control group. The patients were classified according to their type of seizure: focal or generalized onset. The serum oxidative stress index (OSI) and total oxidant/antioxidant status values of all patients and control group members were measured. The patients (focal/generalized groups) and control group members were compared.RESULTS: This prospective study was completed with 58 eligible patients who met the inclusion criteria. There were 57 people in the control group. Total oxidant status (TOS) and OSI levels were higher in the seizure groups compared to the control group (p

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues – missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone – suggesting that nurses, in certain contexts, are actively engaged in rationing care – in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care – despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article is based upon work from COST Action RANCARE CA15208, supported by COST (European Cooperation in Science and Technology). peer-reviewed

INTED 2015, 9 th International Technology, Education and Development Conference, March 2 nd-4 th, 2015-Madrid, Spain, A group of lecturers from diverse areas of knowledge of the University of Alcalá have implemented an experience of teaching innovation based on “reflective diaries”. The students hand in to the lecturer every week their “Weekly Reflection Papers” (WRP), in which they schematically express the most important ideas related with the topic presented during the classes of the previous week. They must include their reflections about the aspects they found especially interesting. After having applied this tool for some academic years we introduced a modification called “Guided Weekly Reflection Papers” (GWRP), where the professors suggest a series of questions on which the students must apply the most significant concepts studied each week. This modification enhances student’s motivation, encourages them to achieve more significant and reflective knowledge and generates interest in emergent topics. However, we often detect that the information management needed to solve the proposed questions in the GWRP is not the most suitable one. Therefore our present work is aimed at helping students develop the necessary skills and acquire a searching criterion in the framework of the information literacy. The strategy was focussed on some important items for the acquisition of information competencies. In this communication we analyze the progress of the GWRP tool and we explore the response of students to the information literacy approach.

Background: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. Discussion: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. Conclusion: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

Item does not contain fulltext AIMS: Homozygous familial hypercholesterolaemia (HoFH) is a rare life-threatening condition characterized by markedly elevated circulating levels of low-density lipoprotein cholesterol (LDL-C) and accelerated, premature atherosclerotic cardiovascular disease (ACVD). Given recent insights into the heterogeneity of genetic defects and clinical phenotype of HoFH, and the availability of new therapeutic options, this Consensus Panel on Familial Hypercholesterolaemia of the European Atherosclerosis Society (EAS) critically reviewed available data with the aim of providing clinical guidance for the recognition and management of HoFH. METHODS AND RESULTS: Early diagnosis of HoFH and prompt initiation of diet and lipid-lowering therapy are critical. Genetic testing may provide a definitive diagnosis, but if unavailable, markedly elevated LDL-C levels together with cutaneous or tendon xanthomas before 10 years, or untreated elevated LDL-C levels consistent with heterozygous FH in both parents, are suggestive of HoFH. We recommend that patients with suspected HoFH are promptly referred to specialist centres for a comprehensive ACVD evaluation and clinical management. Lifestyle intervention and maximal statin therapy are the mainstays of treatment, ideally started in the first year of life or at an initial diagnosis, often with ezetimibe and other lipid-modifying therapy. As patients rarely achieve LDL-C targets, adjunctive lipoprotein apheresis is recommended where available, preferably started by age 5 and no later than 8 years. The number of therapeutic approaches has increased following approval of lomitapide and mipomersen for HoFH. Given the severity of ACVD, we recommend regular follow-up, including Doppler echocardiographic evaluation of the heart and aorta annually, stress testing and, if available, computed tomography coronary angiography every 5 years, or less if deemed necessary. CONCLUSION: This EAS Consensus Panel highlights the need for early identification of HoFH patients, prompt referral to specialized centres, and early initiation of appropriate treatment. These recommendations offer guidance for a wide spectrum of clinicians who are often the first to identify patients with suspected HoFH.

The experience gained by our team of educational innovation with the implementation of the “Weekly Reflection Papers” has led us to diversify and make more flexible the employed methodology. The modified tool, applied during the academic year 2010-2011, was called “Guided Weekly Reflection Papers”. The aim of this modification has been the development of certain abilities and skills of the students, with particular emphasis on their ability to integrate, review and apply knowledge in a critical and reflective way. The professors guide the student´s work through a series of questions on which the students must apply the most significant concepts studied each week, to prove the acquisition of such aptitudes and skills.

A group of lecturers from different teaching areas at Alcalá University concern by Innovative Education had implemented during four academic years a learning tool based on “reflective weekly papers”. With the experience gained in this process we have carried out an essential modification in the procedure which provides the students the possibility of a more active and participative learning called Guided Weekly Reflective Papers. In this communication we present the adaptation of this educational method for the first time as a valuable strategy for improving the learning environment in secondary schools, as an extension of its implementation at the University level and as a contribution to the integral formation and meaningful learning of the secondary level students.

Swallowing oral solid dosage forms is challenging in patients with dysphagia who are at risk of aspiration or choking. The most common method to facilitate drug administration in dysphagia patients is to mix the powdered drug with a small amount of thickened water, however little is known about the effects of this method on in vivo bioavailability of drugs. This study aimed to evaluate the impact of thickened liquids on dissolution rate and bioavailability of levetiracetam as a model drug. Powdered commercial tablets of levetiracetam, carbamazepine, atenolol and cefixime were mixed with water thickened with two commercial thickeners, modified maize starch (MS) and xanthan gam (XG), at three thickness levels: nectar, honey and pudding in test groups, and mixed with only water in the control group. At the first stage, the effects of thickened water on in vitro drug release of 4 drugs (levetiracetam, carbamazepine, atenolol and cefixime) were tested by using dialysis membrane method. Addition of both thickeners significantly reduced the release of three drugs compared to the control group, except carbamazepine. Levetiracetam which had the highest solubility was chosen as the model drug for in vivo experiments. In the second stage, New Zealand albino female rabbits (n=24) were divided into two groups as: control group (water+drug, n=6) and test group (thickened water+drug, n=18). Powdered levetiracetam tablets were mixed with water thickened with XG (n=9, 1.2%, 2.4%, 3.6%) and MS (n=9, 4%, 6%, 8%) at three thickness levels and administered to the rabbits by intragastric gavage. Blood samples were collected at 9 time points following administration. After two-weeks of wash-out, test groups were crossed over and sample collection was repeated. Blood samples were analysed using liquid chromatography with tandem mass spectrometry (LC-MS/MS). An in vitro-in vivo correlation (IVIVC) model was developed using in vitro drug dissolution (%) and in vivo plasma concentrations of levetiracetam for control group and test groups. The peak plasma concentration (C-max) was lower and time to reach C-max (t(max)) was relatively higher in test groups compared to control group. The lowest C-max was detected at the highest thickness level, however, the differences between groups were not statistically significant (p=0.117 and p=0.495 for C-max and t(max), respectively). No significant difference in total amount of levetiracetam absorbed (AUC) was found between groups (p=0.215 and p=0.183 for AUC(infinity) and AUC(last), respectively). The comparisons according to the type of thickener also revealed that pharmacokinetic parameters did not significantly differ between groups, except for a significantly lower C-max when drug was mixed with MS-thickened water at nectar consistency (1.2%) compared to drug mixed with XG (4%) at the same thickness level (p=0.038). A good correlation was observed between in vitro and in vivo data, which was characterized by higher r(2) values as the concentration of the thickening agents was increased, but not for all thickness levels studied, indicating an inability of this in vitro model to fully predict the in vivo response. These results suggest that regardless of the thickness level, the administration of levetiracetam with two commercial thickening agents commonly used in dysphagia for safe swallowing, do not affect the pharmacokinetic efficiency and thus, the bioavailability of the drug.

Purpose Sense of coherence (SOC) represents coping and can be considered an essential component of mental health. SOC correlates with mental health and personality, but the background of these associations is poorly understood. We analyzed the role of genetic factors behind the associations of SOC with mental health, self-esteem and personality using genetic twin modeling and polygenic scores (PGS). Methods Information on SOC (13-item Orientation of Life Questionnaire), four mental health indicators, self-esteem and personality (NEO Five Factor Inventory Questionnaire) was collected from 1295 Finnish twins at 20–27 years of age. Results In men and women, SOC correlated negatively with depression, alexithymia, schizotypal personality and overall mental health problems and positively with self-esteem. For personality factors, neuroticism was associated with weaker SOC and extraversion, agreeableness and conscientiousness with stronger SOC. All these psychological traits were influenced by genetic factors with heritability estimates ranging from 19 to 66%. Genetic and environmental factors explained these associations, but the genetic correlations were generally stronger. The PGS of major depressive disorder was associated with weaker, and the PGS of general risk tolerance with stronger SOC in men, whereas in women the PGS of subjective well-being was associated with stronger SOC and the PGSs of depression and neuroticism with weaker SOC. Conclusion Our results indicate that a substantial proportion of genetic variation in SOC is shared with mental health, self-esteem and personality indicators. This suggests that the correlations between these traits reflect a common neurobiological background rather than merely the influence of external stressors.

Filiació URV: SI Aims: Homozygous familial hypercholesterolaemia (HoFH) is a rare life-threatening condition characterized by markedly elevated circulating levels of low-density lipoprotein cholesterol (LDL-C) and accelerated, premature atherosclerotic cardiovascular disease (ACVD). Given recent insights into the heterogeneity of genetic defects and clinical phenotype of HoFH, and the availability of new therapeutic options, this Consensus Panel on Familial Hypercholesterolaemia of the European Atherosclerosis Society (EAS) critically reviewed available data with the aim of providing clinical guidance for the recognition and management of HoFH. Methods and results: Early diagnosis ofHoFHand prompt initiation of diet and lipid-lowering therapy are critical. Genetic testing may provide a definitive diagnosis, but if unavailable, markedly elevated LDL-C levels together with cutaneous or tendon xanthomas before 10 years, or untreated elevated LDL-C levels consistent with heterozygous FH in both parents, are suggestive of HoFH.We recommend that patients with suspected HoFH are promptly referred to specialist centres for a comprehensiveACVDevaluation and clinical management. Lifestyle intervention and maximal statin therapy are the mainstays of treatment, ideally started in the first year of life or at an initial diagnosis, often with ezetimibe and other lipid-modifying therapy. As patients rarely achieve LDL-C targets, adjunctive lipoprotein apheresis is recommended where available, preferably started by age 5 and no later than 8 years. The number of therapeutic approaches has increased following approval of lomitapide and mipomersen for HoFH. Given the severity of ACVD, we recommend regular follow-up, including Doppler echocardiographic evaluation of the heart and aorta

Background: Mobile phone–delivered life skills programs are an emerging and promising way to promote mental health and prevent substance use among adolescents, but little is known about how adolescents actually use them. Objective: The aim of this study is to determine engagement with a mobile phone–based life skills program and its different components, as well as the associations of engagement with adolescent characteristics and intended substance use and mental health outcomes. Methods: We performed secondary data analysis on data from the intervention group (n=750) from a study that compared a mobile phone–based life skills intervention for adolescents recruited in secondary and upper secondary school classes with an assessment-only control group. Throughout the 6-month intervention, participants received 1 SMS text message prompt per week that introduced a life skills topic or encouraged participation in a quiz or individual life skills training or stimulated sharing messages with other program participants through a friendly contest. Decision trees were used to identify predictors of engagement (use and subjective experience). The stability of these decision trees was assessed using a resampling method and by graphical representation. Finally, associations between engagement and intended substance use and mental health outcomes were examined using logistic and linear regression analyses. Results: The adolescents took part in half of the 50 interactions (mean 23.6, SD 15.9) prompted by the program, with SMS text messages being the most used and contests being the least used components. Adolescents who did not drink in a problematic manner and attended an upper secondary school were the ones to use the program the most. Regarding associations between engagement and intended outcomes, adolescents who used the contests more frequently were more likely to be nonsmokers at follow-up than those who did not (odds ratio 0.86, 95% CI 0.76-0.98; P=.02). In addition, adolescents who read the SMS text messages more attentively were less likely to drink in a problematic manner at follow-up (odds ratio 0.43, 95% CI 1.29-3.41; P=.003). Finally, participants who used the program the most and least were more likely to increase their well-being from baseline to 6-month follow-up compared with those with average engagement (βs=.39; t586=2.66; P=.008; R2=0.24). Conclusions: Most of the adolescents participating in a digital life skills program that aimed to prevent substance use and promote mental health engaged with the intervention. However, measures to increase engagement in problem drinkers should be considered. Furthermore, efforts must be made to ensure that interventions are engaging and powerful across different educational levels. First results indicate that higher engagement with digital life skills programs could be associated with intended outcomes. Future studies should apply further measures to improve the reach of lower-engaged participants at follow-up to establish such associations with certainty., Journal of Medical Internet Research, 24 (1), ISSN:1438-8871

Background: Conversational agents (CAs) for chronic disease management are receiving increasing attention in academia and the industry. However, long-term adherence to CAs is still a challenge and needs to be explored. Personalization of CAs has the potential to improve long-term adherence and, with it, user satisfaction, task efficiency, perceived benefits, and intended behavior change. Research on personalized CAs has already addressed different aspects, such as personalized recommendations and anthropomorphic cues. However, detailed information on interaction styles between patients and CAs in the role of medical health care professionals is scant. Such interaction styles play essential roles for patient satisfaction, treatment adherence, and outcome, as has been shown for physician-patient interactions. Currently, it is not clear (1) whether chronically ill patients prefer a CA with a paternalistic, informative, interpretive, or deliberative interaction style, and (2) which factors influence these preferences. Objective: We aimed to investigate the preferences of chronically ill patients for CA-delivered interaction styles. Methods: We conducted two studies. The first study included a paper-based approach and explored the preferences of chronic obstructive pulmonary disease (COPD) patients for paternalistic, informative, interpretive, and deliberative CA-delivered interaction styles. Based on these results, a second study assessed the effects of the paternalistic and deliberative interaction styles on the relationship quality between the CA and patients via hierarchical multiple linear regression analyses in an online experiment with COPD patients. Patients’ sociodemographic and disease-specific characteristics served as moderator variables. Results: Study 1 with 117 COPD patients revealed a preference for the deliberative (50/117) and informative (34/117) interaction styles across demographic characteristics. All patients who preferred the paternalistic style over the other interaction styles had more severe COPD (three patients, Global Initiative for Chronic Obstructive Lung Disease class 3 or 4). In Study 2 with 123 newly recruited COPD patients, younger participants and participants with a less recent COPD diagnosis scored higher on interaction-related outcomes when interacting with a CA that delivered the deliberative interaction style (interaction between age and CA type: relationship quality: b=−0.77, 95% CI −1.37 to −0.18; intention to continue interaction: b=−0.49, 95% CI −0.97 to −0.01; working alliance attachment bond: b=−0.65, 95% CI −1.26 to −0.04; working alliance goal agreement: b=−0.59, 95% CI −1.18 to −0.01; interaction between recency of COPD diagnosis and CA type: working alliance goal agreement: b=0.57, 95% CI 0.01 to 1.13). Conclusions: Our results indicate that age and a patient’s personal disease experience inform which CA interaction style the patient should be paired with to achieve increased interaction-related outcomes with the CA. These results allow the design of personalized health care CAs with the goal to increase long-term adherence to health-promoting behavior. --> Background: Conversational agents (CAs) for chronic disease management are receiving increasing attention in academia and the industry. However, long-term adherence to CAs is still a challenge and needs to be explored. Personalization of CAs has the potential to improve long-term adherence and, with it, user satisfaction, task efficiency, perceived benefits, and intended behavior change. Research on personalized CAs has already addressed different aspects, such as personalized recommendations and anthropomorphic cues. However, detailed information on interaction styles between patients and CAs in the role of medical health care professionals is scant. Such interaction styles play essential roles for patient satisfaction, treatment adherence, and outcome, as has been shown for physician-patient interactions. Currently, it is not clear (1) whether chronically ill patients prefer a CA with a paternalistic, informative, interpretive, or deliberative interaction style, and (2) which factors influence these preferences. Objective: We aimed to investigate the preferences of chronically ill patients for CA-delivered interaction styles. Methods: We conducted two studies. The first study included a paper-based approach and explored the preferences of chronic obstructive pulmonary disease (COPD) patients for paternalistic, informative, interpretive, and deliberative CA-delivered interaction styles. Based on these results, a second study assessed the effects of the paternalistic and deliberative interaction styles on the relationship quality between the CA and patients via hierarchical multiple linear regression analyses in an online experiment with COPD patients. Patients’ sociodemographic and disease-specific characteristics served as moderator variables. Results: Study 1 with 117 COPD patients revealed a preference for the deliberative (50/117) and informative (34/117) interaction styles across demographic characteristics. All patients who preferred the paternalistic style over the other interaction styles had more severe COPD (three patients, Global Initiative for Chronic Obstructive Lung Disease class 3 or 4). In Study 2 with 123 newly recruited COPD patients, younger participants and participants with a less recent COPD diagnosis scored higher on interaction-related outcomes when interacting with a CA that delivered the deliberative interaction style (interaction between age and CA type: relationship quality: b=−0.77, 95% CI −1.37 to −0.18; intention to continue interaction: b=−0.49, 95% CI −0.97 to −0.01; working alliance attachment bond: b=−0.65, 95% CI −1.26 to −0.04; working alliance goal agreement: b=−0.59, 95% CI −1.18 to −0.01; interaction between recency of COPD diagnosis and CA type: working alliance goal agreement: b=0.57, 95% CI 0.01 to 1.13). Conclusions: Our results indicate that age and a patient’s personal disease experience inform which CA interaction style the patient should be paired with to achieve increased interaction-related outcomes with the CA. These results allow the design of personalized health care CAs with the goal to increase long-term adherence to health-promoting behavior., Journal of Medical Internet Research, 23 (5), ISSN:1438-8871

Background Emerging evidence indicates the effectiveness of internet-based mobile-supported stress management interventions (iSMIs) in highly stressed employees. It is yet unclear, however, whether iSMIs are also effective without a preselection process in a universal prevention approach, which more closely resembles routine occupational health care. Moreover, evidence for whom iSMIs might be suitable and for whom not is scarce. Objective The aim of this study was to evaluate the iSMI GET.ON Stress in a universal prevention approach without baseline inclusion criteria and to examine the moderators of the intervention effects. Methods A total of 396 employees were randomly assigned to the intervention group or the 6-month waiting list control group. The iSMI consisted of 7 sessions and 1 booster session and offered no therapeutic guidance. Self-report data were assessed at baseline, 7 weeks, and at 6 months following randomization. The primary outcome was perceived stress. Several a priori defined moderators were explored as potential effect modifiers. Results Participants in the intervention group reported significantly lower perceived stress at posttreatment (d=0.71, 95% CI 0.51-0.91) and at 6-month follow-up (d=0.61, 95% CI 0.41-0.81) compared to those in the waiting list control group. Significant differences with medium-to-large effect sizes were found for all mental health and most work-related outcomes. Resilience (at 7 weeks, P=.04; at 6 months, P=.01), agreeableness (at 7 weeks, P=.01), psychological strain (at 6 months, P=.04), and self-regulation (at 6 months, P=.04) moderated the intervention effects. Conclusions This study indicates that iSMIs can be effective in a broad range of employees with no need for preselection to achieve substantial effects. The subgroups that might not profit had extreme values on the respective measures and represented only a very small proportion of the investigated sample, thereby indicating the broad applicability of GET.ON Stress. Trial Registration German Clinical Trials Register DRKS00005699; https://www.drks.de/DRKS00005699

Objective:To examine the adherence to the Mediterranean diet in the adult general population of Cyprus and assess its relationship with multi-morbidity.Design:A representative sample of the adult population of Cyprus was selected in 2018–2019 using stratified sampling. Demographics, Mediterranean diet, smoking and physical activity, as well as the presence of chronic, clinical and mental conditions, were collected using a validated questionnaire. Diseases were classified according to the International Classification of Diseases, 10th Revision.Setting:The five government-controlled municipalities of the Republic of Cyprus.Participants:A total of 1140 Cypriot men and women over 18 years.Results:The average Mediterranean diet score was 15·5 ± 4·0 with males and residents of rural regions being more adherent to the Mediterranean diet compared with females and residents of urban regions (P < 0·05). Being in the higher tertile of adherence to the Mediterranean diet was associated with lower odds of multi-morbidity compared with the lower tertile, and this result was statistically significant even after adjusting for age, gender, smoking habits and physical activity (OR = 0·68, 95 % CI 0·46, 0·99).Conclusions:The study provides evidence of the adherence to the Mediterranean diet in Cypriot population and its association with multi-morbidity. Adherence to the Mediterranean diet was associated with lower risk of multi-morbidity. Future research would attempt to replicate such results that could add solid pieces of evidence towards meeting some criteria of causality and severity tests; hence, prevention programmes and practice guidelines in Cyprus and elsewhere should take into account those beneficial effects.

Children are entitled to safe, efficacious, and age-appropriate medicines. However, the provision of optimal medicines for children is limited by the lack of commercial incentives, a dearth of clinical trials on paediatric medicines, delays in licensing medicines for children, and the absence of suitable formulations for children. Children are not small adults, but rather a vulnerable population with specific needs resulting from their changing physiology, who make up a heterogeneous patient group with a scope of diseases different than those of adults, and for whom there is a scarcity of data on appropriate medicines delivery and use. Therefore, these needs are discussed in detail in this background paper; the challenges and opportunities for improvement and further research are also identified.

Background: The incidence of chronic diseases such as type 2 diabetes is increasing in countries worldwide, including Singapore. Health professional–delivered healthy lifestyle interventions have been shown to prevent type 2 diabetes. However, ongoing personalized guidance from health professionals is not feasible or affordable at the population level. Novel digital interventions delivered using mobile technology, such as conversational agents, are a potential alternative for the delivery of healthy lifestyle change behavioral interventions to the public. Objective: We explored perceptions and experiences of Singaporeans on healthy living, diabetes, and mobile health (mHealth) interventions (apps and conversational agents). This study was conducted to help inform the design and development of a conversational agent focusing on healthy lifestyle changes. Methods: This qualitative study was conducted in August and September 2019. A total of 20 participants were recruited from relevant healthy living Facebook pages and groups. Semistructured interviews were conducted in person or over the telephone using an interview guide. Interviews were transcribed and analyzed in parallel by 2 researchers using Burnard’s method, a structured approach for thematic content analysis. Results: The collected data were organized into 4 main themes: use of conversational agents, ubiquity of smartphone apps, understanding of diabetes, and barriers and facilitators to a healthy living in Singapore. Most participants used health-related mobile apps as well as conversational agents unrelated to health care. They provided diverse suggestions for future conversational agent-delivered interventions. Participants also highlighted several knowledge gaps in relation to diabetes and healthy living. Regarding barriers to healthy living, participants mentioned frequent dining out, high stress levels, lack of work-life balance, and lack of free time to engage in physical activity. In contrast, discipline, preplanning, and sticking to a routine were important for enabling a healthy lifestyle. Conclusions: Participants in this study commonly used mHealth interventions and provided important insights into their knowledge gaps and needs in relation to changes in healthy lifestyle behaviors. Future digital interventions such as conversational agents focusing on healthy lifestyle and diabetes prevention should aim to address the barriers highlighted in our study and motivate individuals to adopt healthy lifestyle behavior., JMIR Formative Research, 5 (11), ISSN:2561-326X

Background: The number of smartphone apps that focus on the prevention, diagnosis, and treatment of depression is increasing. A promising approach to increase the effectiveness of the apps while reducing the individual’s burden is the use of just-in-time adaptive intervention (JITAI) mechanisms. JITAIs are designed to improve the effectiveness of the intervention and reduce the burden on the person using the intervention by providing the right type of support at the right time. The right type of support and the right time are determined by measuring the state of vulnerability and the state of receptivity, respectively. Objective: The aim of this study is to systematically assess the use of JITAI mechanisms in popular apps for individuals with depression. Methods: We systematically searched for apps addressing depression in the Apple App Store and Google Play Store, as well as in curated lists from the Anxiety and Depression Association of America, the United Kingdom National Health Service, and the American Psychological Association in August 2020. The relevant apps were ranked according to the number of reviews (Apple App Store) or downloads (Google Play Store). For each app, 2 authors separately reviewed all publications concerning the app found within scientific databases (PubMed, Cochrane Register of Controlled Trials, PsycINFO, Google Scholar, IEEE Xplore, Web of Science, ACM Portal, and Science Direct), publications cited on the app’s website, information on the app’s website, and the app itself. All types of measurements (eg, open questions, closed questions, and device analytics) found in the apps were recorded and reviewed. Results: None of the 28 reviewed apps used JITAI mechanisms to tailor content to situations, states, or individuals. Of the 28 apps, 3 (11%) did not use any measurements, 20 (71%) exclusively used self-reports that were insufficient to leverage the full potential of the JITAIs, and the 5 (18%) apps using self-reports and passive measurements used them as progress or task indicators only. Although 34% (23/68) of the reviewed publications investigated the effectiveness of the apps and 21% (14/68) investigated their efficacy, no publication mentioned or evaluated JITAI mechanisms. Conclusions: Promising JITAI mechanisms have not yet been translated into mainstream depression apps. Although the wide range of passive measurements available from smartphones were rarely used, self-reported outcomes were used by 71% (20/28) of the apps. However, in both cases, the measured outcomes were not used to tailor content and timing along a state of vulnerability or receptivity. Owing to this lack of tailoring to individual, state, or situation, we argue that the apps cannot be considered JITAIs. The lack of publications investigating whether JITAI mechanisms lead to an increase in the effectiveness or efficacy of the apps highlights the need for further research, especially in real-world apps., Journal of Medical Internet Research, 23 (9), ISSN:1438-8871

Background: In recent years, the number of people suffering from chronic conditions that require ongoing medical support reaching into the everyday lives of patients is constantly increasing. Global health systems are, however, not adequately equipped for this extraordinarily time-consuming and cost-intensive development. Here, conversational agents (CAs) can offer easily scalable and ubiquitous support. However, different aspects have not yet been sufficiently investigated to fully exploit their potential. One such trait is the interaction style between patients and CAs. In human-to-human settings, the interaction style is an imperative part of the relationship between patients and physicians. The patient-physician interaction is recognized as critical success factor for patient's satisfaction, treatment adherence, and subsequent treatment outcome. However, it remains so far effectively unknown how different interaction styles can be implemented into CA relationships and if these are recognizable by users. Objective: The objective of this paper is to develop an operationalization scheme to induce two specific interaction styles into CA-patient dialogues and subsequently test and validate them in a chronic healthcare context. Methods: Based on the Roter Interaction Analysis System (RIAS) and iterative evaluations by scientific experts and medical healthcare professionals, we identified 15 communication components that characterize the two operationalized interaction styles, i.e., the deliberative and paternalistic interaction style. These communication components were used to develop two CA variations, each representing one of the two interaction styles. We assessed them in an online between-subject experiment. Here, participants were asked to put themselves in the position of a patient suffering from chronic obstructive pulmonary disease (COPD). Participants were randomly assigned to interact with one of the two CAs and subsequently asked to identify the respective interaction style. A chi-square test was used to assess the correct identification of the CA-patient interaction style. Results: 88 individuals (48% female, mean age= 31.5 years) fulfilled the inclusion criteria and participated in the online experiment. Participants in both the paternalistic and deliberative condition correctly identified the underlying interaction style of the CAs in more than 80% of the assessments (X2 (1, 88) = 38.23, P = .000; rφ = .68). The validation of the operationalization scheme was hence successful. Conclusions: We developed an operationalization scheme tailored for a medical context to induce a paternalistic, respectively, deliberative interaction style into a written interaction between a patient and a CA. We successfully tested and validated the operationalization scheme in an online experiment with 88 participants. Future research should implement and test the operationalization scheme with actual chronic patients and compare results between medical conditions. The operationalization scheme can further be used as a starting point to develop dynamic CAs that adapt their interaction style to their users., Journal of Medical Internet Research, 23 (1), ISSN:1438-8871

Background: Simulation study results suggest that COVID-19 contact tracing apps have the potential to achieve pandemic control. Concordantly, high app adoption rates were a stipulated prerequisite for success. Early studies on potential adoption were encouraging. Several factors predicting adoption rates were investigated, especially pertaining to user characteristics. Since then, several countries have released COVID-19 contact tracing apps.Objective: This study’s primary aim is to investigate the quality characteristics of national European COVID-19 contact tracing apps, thereby shifting attention from user to app characteristics. The secondary aim is to investigate associations between app quality and adoption. Finally, app features contributing to higher app quality were identified.Methods: Eligible COVID-19 contact tracing apps were those released by national health authorities of European Union member states, former member states, and countries of the European Free Trade Association, all countries with comparable legal standards concerning personal data protection and app use voluntariness. The Mobile App Rating Scale was used to assess app quality. An interdisciplinary team, consisting of two health and two human–computer interaction scientists, independently conducted Mobile App Rating Scale ratings. To investigate associations between app quality and adoption rates and infection rates, Bayesian linear regression analyses were conducted.Results: We discovered 21 national COVID-19 contact tracing apps, all demonstrating high quality overall and high-level functionality, aesthetics, and information quality. However, the average app adoption rate of 22.9% (SD 12.5%) was below the level recommended by simulation studies. Lower levels of engagement-oriented app design were detected, with substantial variations between apps. By regression analyses, the best-case adoption rate was calculated by assuming apps achieve the highest ratings. The mean best-case adoption rates for engagement and overall app quality were 39.5% and 43.6%, respectively. Higher adoption rates were associated with lower cumulative infection rates. Overall, we identified 5 feature categories (symptom assessment and monitoring, regularly updated information, individualization, tracing, and communication) and 14 individual features that contributed to higher app quality. These 14 features were a symptom checker, a symptom diary, statistics on COVID-19, app use, public health instructions and restrictions, information of burden on health care system, assigning personal data, regional updates, control over tracing activity, contact diary, venue check-in, chats, helplines, and app-sharing capacity.Conclusions: European national health authorities have generally released high quality COVID-19 contact tracing apps, with regard to functionality, aesthetics, and information quality. However, the app’s engagement-oriented design generally was of lower quality, even though regression analyses results identify engagement as a promising optimization target to increase adoption rates. Associations between higher app adoption and lower infection rates are consistent with simulation study results, albeit acknowledging that app use might be part of a broader set of protective attitudes and behaviors for self and others. Various features were identified that could guide further engagement-enhancing app development. Background: Simulation study results suggest that COVID-19 contact tracing apps have the potential to achieve pandemic control. Concordantly, high app adoption rates were a stipulated prerequisite for success. Early studies on potential adoption were encouraging. Several factors predicting adoption rates were investigated, especially pertaining to user characteristics. Since then, several countries have released COVID-19 contact tracing apps.Objective: This study’s primary aim is to investigate the quality characteristics of national European COVID-19 contact tracing apps, thereby shifting attention from user to app characteristics. The secondary aim is to investigate associations between app quality and adoption. Finally, app features contributing to higher app quality were identified.Methods: Eligible COVID-19 contact tracing apps were those released by national health authorities of European Union member states, former member states, and countries of the European Free Trade Association, all countries with comparable legal standards concerning personal data protection and app use voluntariness. The Mobile App Rating Scale was used to assess app quality. An interdisciplinary team, consisting of two health and two human–computer interaction scientists, independently conducted Mobile App Rating Scale ratings. To investigate associations between app quality and adoption rates and infection rates, Bayesian linear regression analyses were conducted.Results: We discovered 21 national COVID-19 contact tracing apps, all demonstrating high quality overall and high-level functionality, aesthetics, and information quality. However, the average app adoption rate of 22.9% (SD 12.5%) was below the level recommended by simulation studies. Lower levels of engagement-oriented app design were detected, with substantial variations between apps. By regression analyses, the best-case adoption rate was calculated by assuming apps achieve the highest ratings. The mean best-case adoption rates for engagement and overall app quality were 39.5% and 43.6%, respectively. Higher adoption rates were associated with lower cumulative infection rates. Overall, we identified 5 feature categories (symptom assessment and monitoring, regularly updated information, individualization, tracing, and communication) and 14 individual features that contributed to higher app quality. These 14 features were a symptom checker, a symptom diary, statistics on COVID-19, app use, public health instructions and restrictions, information of burden on health care system, assigning personal data, regional updates, control over tracing activity, contact diary, venue check-in, chats, helplines, and app-sharing capacity.Conclusions: European national health authorities have generally released high quality COVID-19 contact tracing apps, with regard to functionality, aesthetics, and information quality. However, the app’s engagement-oriented design generally was of lower quality, even though regression analyses results identify engagement as a promising optimization target to increase adoption rates. Associations between higher app adoption and lower infection rates are consistent with simulation study results, albeit acknowledging that app use might be part of a broader set of protective attitudes and behaviors for self and others. Various features were identified that could guide further engagement-enhancing app development.

Background University teaching methods are changing, and in response to a classical teacher-centered approach, new methods continue to strengthen knowledge acquisition by involving students more actively in their learning, thus achieving greater motivation and commitment. Objective This study aimed to analyze the degree of satisfaction of physiotherapy students who used a board game–based approach, as well as to compare the difference between traditional and gamification teaching methods and their influence on the final evaluation of these students. Methods A comparative study was conducted. Participants were physiotherapy students who were enrolled in the subject of “physiotherapy in geriatric and adult psychomotricity” (n=59). They were divided into two groups (experimental [n=29] and control [n=30] groups) through convenience sampling. The experimental group received gamification lessons, where the students performed different tests adapted from Party&Co, and the control group received traditional lessons. A total of 16 theoretical lessons were received in both groups. Results The scores in the final examination of the subject were higher in the experimental group (mean 7.53, SD 0.95) than in the control group (mean 6.24, SD 1.34), showing a statistically significant difference between the two groups (P=.001). Conclusions Overall, the “Physiotherapy Party” game not only stimulated learning and motivated students, but also improved learning outcomes among participants, and the improvements were greater than those among students who received traditional teaching.

Background University students with depression and anxiety do not easily receive or seek treatment; therefore, internet-based interventions have been suggested to be a promising way to improve treatment accessibility and availability. However, it has not been examined whether a guided, culturally adapted, transdiagnostic, internet-based intervention is effective for treating symptoms of depression, anxiety, or both among university students in Indonesia. Objective This study aims to investigate the feasibility (acceptability and satisfaction, usability, and uptake) of a guided, culturally adapted, transdiagnostic, internet-based intervention among university students with symptoms of depression, anxiety, or both in Indonesia. Methods Students from Universitas Gadjah Mada, Yogyakarta, Indonesia, were screened for symptoms of depression, anxiety, or both, and filled online informed consent, demographic questionnaires, and a quality of life measure at pretreatment assessment (T0). Subsequently, the participants started the intervention. Seven weeks after T0, the primary outcomes of this feasibility study were analyzed at posttreatment assessment (T1) using the 8-item Client Satisfaction Questionnaire (CSQ-8) and the System Usability Scale (SUS). Mean and SDs for the CSQ-8 and SUS were calculated to examine feasibility. Within-group secondary outcomes (depression, anxiety, and quality of life) were inspected for outliers and normal distribution. Paired-sample t tests were used to investigate differences between time points of secondary outcomes. A mixed-method approach of quantitative and qualitative analyses was adopted. Both the primary and secondary outcomes were additionally explored with an individual semistructured interview and synthesized descriptively. Results A total of 50 participants completed the intervention. We found a moderate to high level of satisfaction and acceptability, a slightly below-average level of desirable usability (≥70), and an adherence rate of 52% which was higher than expected given the novelty of the intervention. Results for the secondary outcomes indicated a decrease in depression and anxiety. For depression, the overall mean difference between the 2 time points for depression was 3.92 (95% CI 2.75-5.1; Hedges g 1.15; P Conclusions A culturally adapted, transdiagnostic, internet-based intervention appears to be acceptable and feasible for reducing symptoms of depression, anxiety, or both, and increasing quality of life in university students in Indonesia. Future studies should include a randomized controlled trial to assess the effectiveness of such interventions as they may supplement existing counseling services in universities, reduce the treatment costs, and maximize treatment accessibility in low-resourced settings. International Registered Report Identifier (IRRID) RR2-10.1016/j.invent.2018.11.002

Background: Effective treatments for various conditions such as obesity, cardiac heart diseases, or low back pain require not only personal on-site coaching sessions by health care experts but also a significant amount of home exercises. However, nonadherence to home exercises is still a serious problem as it leads to increased costs due to prolonged treatments. Objective: To improve adherence to home exercises, we propose, implement, and assess the novel coaching concept of hybrid ubiquitous coaching (HUC). In HUC, health care experts are complemented by a conversational agent (CA) that delivers psychoeducation and personalized motivational messages via a smartphone, as well as real-time exercise support, monitoring, and feedback in a hands-free augmented reality environment. Methods: We applied HUC to the field of physiotherapy and conducted 4 design-and-evaluate loops with an interdisciplinary team to assess how HUC is perceived by patients and physiotherapists and whether HUC leads to treatment adherence. A first version of HUC was evaluated by 35 physiotherapy patients in a lab setting to identify patients’ perceptions of HUC. In addition, 11 physiotherapists were interviewed about HUC and assessed whether the CA could help them build up a working alliance with their patients. A second version was then tested by 15 patients in a within-subject experiment to identify the ability of HUC to address adherence and to build a working alliance between the patient and the CA. Finally, a 4-week n-of-1 trial was conducted with 1 patient to show one experience with HUC in depth and thereby potentially reveal real-world benefits and challenges. Results: Patients perceived HUC to be useful, easy to use, and enjoyable, preferred it to state-of-the-art approaches, and expressed their intentions to use it. Moreover, patients built a working alliance with the CA. Physiotherapists saw a relative advantage of HUC compared to current approaches but initially did not see the potential in terms of a working alliance, which changed after seeing the results of HUC in the field. Qualitative feedback from patients indicated that they enjoyed doing the exercise with an augmented reality–based CA and understood better how to do the exercise correctly with HUC. Moreover, physiotherapists highlighted that HUC would be helpful to use in the therapy process. The longitudinal field study resulted in an adherence rate of 92% (11/12 sessions; 330/360 repetitions; 33/36 sets) and a substantial increase in exercise accuracy during the 4 weeks. Conclusions: The overall positive assessments from both patients and health care experts suggest that HUC is a promising tool to be applied in various disorders with a relevant set of home exercises. Future research, however, must implement a variety of exercises and test HUC with patients suffering from different disorders., Journal of Medical Internet Research, 23 (2), ISSN:1438-8871

Khechechuri is an endemic species of a pear spread over one region of Western Georgia, called Adjara. Pears are a dietary source of bioactive components such as polyphenols and triterpenic acid. In addition to highlighting its gastronomic value, the aim of the article was to examine and compare phenolic compounds, flavonoids, catechins, phenolic acids, and antioxidant activities in Khechechuri collected from various villages in the Adjara region, namely Adjaristskali, Merisi, Dandalo, Shuakhevi, and Khulo. Five parts of the fruit, the skin, edible pulp, whole pear (skin + pulp), juice, and pomace, were analyzed and the results compared. Our study indicated that the highest total phenolic content was found in the skin of West Georgian pear types (4650 mg/kg.) Moreover, the pomace showed significant amounts of total phenolic content in each of the Khechechuri samples analyzed. Flavonoids were found in each part of the Khechechuri pears, with the notable exception of the fruit juice. A positive correlation between the total phenolic content and the geographical altitude of where the fruits were collected was observed.

Background Digital communication technologies are playing an important role in the health communication strategies of governments and public health authorities during the COVID-19 pandemic. The internet and social media have become important sources of health-related information on COVID-19 and on protective behaviors. In addition, the COVID-19 infodemic is spreading faster than the coronavirus itself, which interferes with governmental health-related communication efforts. This jeopardizes national public health containment strategies. Therefore, digital health literacy is a key competence to navigate web-based COVID-19–related information and service environments. Objective This study aimed to investigate university students’ digital health literacy and web-based information-seeking behaviors during the early stages of the COVID-19 pandemic in Germany. Methods A cross-sectional study among 14,916 university students aged ≥18 years from 130 universities across all 16 federal states of Germany was conducted using a web-based survey. Along with sociodemographic characteristics (sex, age, subjective social status), the measures included five subscales from the Digital Health Literacy Instrument (DHLI), which was adapted to the specific context of the COVID-19 pandemic. Web-based information-seeking behavior was investigated by examining the web-based sources used by university students and the topics that the students searched for in connection with COVID-19. Data were analyzed using univariate and bivariate analyses. Results Across digital health literacy dimensions, the greatest difficulties could be found for assessing the reliability of health-related information (5964/14,103, 42.3%) and the ability to determine whether the information was written with a commercial interest (5489/14,097, 38.9%). Moreover, the respondents indicated that they most frequently have problems finding the information they are looking for (4282/14,098, 30.4%). When stratified according to sociodemographic characteristics, significant differences were found, with female university students reporting a lower DHLI for the dimensions of “information searching” and “evaluating reliability.” Search engines, news portals, and websites of public bodies were most often used by the respondents as sources to search for information on COVID-19 and related issues. Female students were found to use social media and health portals more frequently, while male students used Wikipedia and other web-based encyclopedias as well as YouTube more often. The use of social media was associated with a low ability to critically evaluate information, while the opposite was observed for the use of public websites. Conclusions Although digital health literacy is well developed in university students, a significant proportion of students still face difficulties with certain abilities to evaluate information. There is a need to strengthen the digital health literacy capacities of university students using tailored interventions. Improving the quality of health-related information on the internet is also key.

Background Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients. Aims We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns. Method This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded. Results Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included. Conclusions A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

Background: Noncommunicable diseases (NCDs) constitute a burden on public health. These are best controlled through self-management practices, such as self-information. Fostering patients’ access to health-related information through efficient and accessible channels, such as commercial voice assistants (VAs), may support the patients’ ability to make health-related decisions and manage their chronic conditions. Objective: This study aims to evaluate the reliability of the most common VAs (ie, Amazon Alexa, Apple Siri, and Google Assistant) in responding to questions about management of the main NCD. Methods: We generated health-related questions based on frequently asked questions from health organization, government, medical nonprofit, and other recognized health-related websites about conditions associated with Alzheimer’s disease (AD), lung cancer (LCA), chronic obstructive pulmonary disease, diabetes mellitus (DM), cardiovascular disease, chronic kidney disease (CKD), and cerebrovascular accident (CVA). We then validated them with practicing medical specialists, selecting the 10 most frequent ones. Given the low average frequency of the AD-related questions, we excluded such questions. This resulted in a pool of 60 questions. We submitted the selected questions to VAs in a 3×3×6 fractional factorial design experiment with 3 developers (ie, Amazon, Apple, and Google), 3 modalities (ie, voice only, voice and display, display only), and 6 diseases. We assessed the rate of error-free voice responses and classified the web sources based on previous research (ie, expert, commercial, crowdsourced, or not stated). Results: Google showed the highest total response rate, followed by Amazon and Apple. Moreover, although Amazon and Apple showed a comparable response rate in both voice-and-display and voice-only modalities, Google showed a slightly higher response rate in voice only. The same pattern was observed for the rate of expert sources. When considering the response and expert source rate across diseases, we observed that although Google remained comparable, with a slight advantage for LCA and CKD, both Amazon and Apple showed the highest response rate for LCA. However, both Google and Apple showed most often expert sources for CVA, while Amazon did so for DM. Conclusions: Google showed the highest response rate and the highest rate of expert sources, leading to the conclusion that Google Assistant would be the most reliable tool in responding to questions about NCD management. However, the rate of expert sources differed across diseases. We urge health organizations to collaborate with Google, Amazon, and Apple to allow their VAs to consistently provide reliable answers to health-related questions on NCD management across the different diseases., Journal of Medical Internet Research, 23 (12), ISSN:1438-8871

Automatic segmentation of bones in computed tomography (CT) images is used for instance in beam hardening correction algorithms where it improves the accuracy of resulting CT numbers. Of special interest are pelvic bones, which—because of their strong attenuation—affect the accuracy of brachytherapy in this region. This work evaluated the performance of the JJ2016 algorithm with the performance of MK2014v2 and JS2018 algorithms; all these algorithms were developed by authors. Visual comparison, and, in the latter case, also Dice similarity coefficients derived from the ground truth were used. It was found that the 3D-based JJ2016 performed better than the 2D-based MK2014v2, mainly because of the more accurate hole filling that benefitted from information in adjacent slices. The neural network-based JS2018 outperformed both traditional algorithms. It was, however, limited to the resolution of 1283 owing to the limited amount of memory in the graphical processing unit (GPU). Funding: VetenskapsradetSwedish Research Council [VR-NT 2016-05033]

SummaryBackgroundSchool closures were part of a series of non-pharmacological intervention (NPI) measures addressing the COVID-19 pandemic in Cyprus. We aimed to study changes in the environment, diet, behavior, personal hygiene, contacts, lifestyle choices and the degree of compliance to NPI measures by primary school children in Cyprus at school and at home for two periods, i.e., before lockdown and during the school re-opening using the methodological context of the human exposome.MethodsDuring June 2020, an online survey questionnaire was forwarded to parents of primary school children through schools’ administrations, with questions about the children’s lifestyle/behaviours for two periods; school re-opening, following the population-wide lockdown (May 21-June 26, 2020), and the school period before lockdown (before March 2020). Descriptive statistics and exposome wide association analysis were implemented to agnostically assess associations of demographic, lifestyle and behavioral parameters with the degree of compliance to NPI measures.FindingsA total of 1509 children from more than 180 primary schools (out of 330 schools) in Cyprus were included. Median number of contacts per day at home, school and other places during weekdays was lower (pInterpretationIn this national survey, children showed a high degree of compliance to most NPI measures for the community and primary school settings in Cyprus. The initial NPI measures may have affected the children’s exposome profile in the following months, by altering their diet, physical activity, sedentary lifestyle and hand hygiene habits.FundingThe study was partially funded by the EXPOSOGAS project, H2020 under grant agreement #810995Panel: Research in contextEvidence before this studyWe searched PubMed for studies published until September 30, 2020 using the search terms: COVID-19, children and lifestyle. Only six peer-reviewed, English-language studies were retrieved on the effect of COVID-19 measures on children’s lifestyle. The impact of non-pharmacological intervention (NPI) measures on children’s health during the pandemic period has been sporadically studied by focusing on a few risk factors at a time without using the exposome’s methodological framework, which is defined as the comprehensive characterization of all environmental exposures during one’s lifetime.Added value of this studyA survey targeted all primary schools of Cyprus to comprehensively study the impact of the initial population-wide NPI measures (lockdown) (March 13-May 4) on the children’s exposome during the school re-opening period (May 21 – June 26). To the best of our knowledge, this is the first study looking at the post-confinement (lockdown) exposome profile changes of children during schools’ re-opening, after the initial population-wide NPI measures of COVID-19 response. The comprehensive and agnostic description of the children’s exposome profile may help to comprehensively account for both known and possibly unknown effects of NPI measures on children’s health and for delineating the children’s degree of compliance to infection prevention and control protocols at school and at home.Implications of all the available evidenceThis dataset could inform COVID-19 risk-based public health response strategies targeted for school settings. Future response strategies to epidemic waves shall consider elements of promoting a healthy lifestyle for children at school and at home. Public health policy could ultimately benefit from the inclusion of the human exposome methodological framework and its tools towards the improved identification of susceptible sub-population groups and to facilitate the deployment of site-tailored public health measures; this may be particularly relevant for children and their potential to spread the disease to vulnerable groups.

Background: Work stress affects individual health and well-being. These negative effects could be mitigated through regular monitoring of employees’ stress. Such monitoring becomes even more important as the digital transformation of the economy implies profound changes in working conditions. Objective: The goal of this study was to investigate the association between computer mouse movements and work stress in the field. Methods: We hypothesized that stress is associated with a speed-accuracy trade-off in computer mouse movements. To test this hypothesis, we conducted a longitudinal field study at a large business organization, where computer mouse movements from regular work activities were monitored over 7 weeks; the study included 70 subjects and 1829 observations. A Bayesian regression model was used to estimate whether self-reported acute work stress was associated with a speed-accuracy trade-off in computer mouse movements. Results: There was a negative association between stress and the two-way interaction term of mouse speed and accuracy (mean −0.32, 95% highest posterior density interval −0.58 to −0.08), which means that stress was associated with a speed-accuracy trade-off. The estimated association was not sensitive to different processing of the data and remained negative after controlling for the demographics, health, and personality traits of subjects. Conclusions: Self-reported acute stress is associated with computer mouse movements, specifically in the form of a speed-accuracy trade-off. This finding suggests that the regular analysis of computer mouse movements could indicate work stress., Journal of Medical Internet Research, 23 (4), ISSN:1438-8871

Cerium oxide nanoparticles with integrated gadolinium have been proved to be useful as contrast agents in magnetic resonance imaging. Of question is their performance in dual-energy computed tomography. The aims of this work are to determine (1) the relation between the computed tomography number and the concentration of the I, Gd or Ce contrast agent and (2) under what conditions it is possible to resolve the type of contrast agent. Hounsfield values of iodoacetic acid, gadolinium acetate and cerium acetate dissolved in water at molar concentrations of 10, 50 and 100 mM were measured in a water phantom using the Siemens SOMATOM Definition Force scanner; gadolinium- and cerium acetate were used as substitutes for the gadolinium-integrated cerium oxide nanoparticles. The relation between the molar concentration of the I, Gd or Ce contrast agent and the Hounsfield value was linear. Concentrations had to be sufficiently high to resolve the contrast agents. Funding: VetenskapsradetSwedish Research Council [VR-NT 2016-05033]

Background: Slow-paced breathing training (6 breaths per minute [BPM]) improves physiological and psychological well-being by inducing relaxation characterized by increased heart rate variability (HRV). However, classic breathing training has a limited target group, and retention rates are very low. Although a gameful approach may help overcome these challenges, it is crucial to enable breathing training in a scalable context (eg, smartphone only) and ensure that they remain effective. However, despite the health benefits, no validated mobile gameful breathing training featuring a biofeedback component based on breathing seems to exist. Objective: This study aims to describe the design choices and their implementation in a concrete mobile gameful breathing training app. Furthermore, it aims to deliver an initial validation of the efficacy of the resulting app. Methods: Previous work was used to derive informed design choices, which, in turn, were applied to build the gameful breathing training app Breeze. In a pretest (n=3), design weaknesses in Breeze were identified, and Breeze was adjusted accordingly. The app was then evaluated in a pilot study (n=16). To ascertain that the effectiveness was maintained, recordings of breathing rates and HRV-derived measures (eg, root mean square of the successive differences [RMSSDs]) were collected. We compared 3 stages: baseline, standard breathing training deployed on a smartphone, and Breeze. Results: Overall, 5 design choices were made: use of cool colors, natural settings, tightly incorporated game elements, game mechanics reflecting physiological measures, and a light narrative and progression model. Breeze was effective, as it resulted in a slow-paced breathing rate of 6 BPM, which, in turn, resulted in significantly increased HRV measures compared with baseline (P, JMIR Serious Games, 9 (1), ISSN:2291-9279

Health data bear great promises for a healthier and happier life, but they also make us vulnerable. Making use of millions or billions of data points, Machine Learning (ML) and Artificial Intelligence (AI) are now creating new benefits. For sure, harvesting Big Data can have great potentials for the health system, too. It can support accurate diagnoses, better treatments and greater cost effectiveness. However, it can also have undesirable implications, often in the sense of undesired side effects, which may in fact be terrible. Examples for this, as discussed in this article, are discrimination, the mechanisation of death, and genetic, social, behavioural or technological selection, which may imply eugenic effects or social Darwinism. As many unintended effects become visible only after years, we still lack sufficient criteria, long-term experience and advanced methods to reliably exclude that things may go terribly wrong. Handing over decision-making, responsibility or control to machines, could be dangerous and irresponsible. It would also be in serious conflict with human rights and our constitution., Journal of European CME, 10 (1), ISSN:2161-4083

Risk assessment and risk prediction have become essential in the prevention of cardiovascular disease. Even though risk prediction tools are recommended in the European guidelines, they are not adequately implemented in clinical practice. Risk prediction tools are meant to estimate prognosis in an unbiased and reliable way and to provide objective information on outcome probabilities. They support informed treatment decisions about the initiation or adjustment of preventive medication. Risk prediction tools facilitate risk communication to the patient and their family, and this may increase commitment and motivation to improve their health. Over the years many risk algorithms have been developed to predict 10-year cardiovascular mortality or lifetime risk in different populations, such as in healthy individuals, patients with established cardiovascular disease and patients with diabetes mellitus. Each risk algorithm has its own limitations, so different algorithms should be used in different patient populations. Risk algorithms are made available for use in clinical practice by means of - usually interactive and online available - tools. To help the clinician to choose the right tool for the right patient, a summary of available tools is provided. When choosing a tool, physicians should consider medical history, geographical region, clinical guidelines and additional risk measures among other things. Currently, the website is the only risk prediction tool providing prediction algorithms for all patient categories, and its implementation in clinical practice is suggested/advised by the European Association of Preventive Cardiology. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this paper was produced within the framework of the ESC Prevention of Cardiovascular Disease Programme which is led by the European Association of Preventive Cardiology (EAPC) in collaboration with the Acute Cardiovascular Care Association (ACCA) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP). The ESC Prevention of Cardiovascular Disease Programme is supported by unrestricted educational grants. The authors received no financial support for the research, authorship, and/or publication of this article. Rossello, X (corresponding author), Ctr Nacl Invest Cardiovasc CNIC Carlos III, Melchor Fernandez Almagro 3, Madrid 28029, Spain. fjrossello@cnic.es

Introduction The incidences and types of missed nursing care in the acute care and community sectors are both ubiquitous and quantifiable, however, there are few research studies relating to the type and frequency of missed maternity-based care for mothers and families. The aim of this study is to estimate the incidences and types of Australian missed midwifery care and to identify those factors that have causal links to it. Methods A non-experimental, descriptive method using a Likert developed MISSCARE scale was used to ascertain consensus estimates made by Australian midwives. Electronic invitations were extended to their membership using an inclusive link to the MISSCARE survey. Inclusion criteria were all ANMF members who were midwives and currently employed within the Australian public and private healthcare systems. Data analysis was undertaken using both Rasch analysis and Structural Equation Modelling. Results The type and frequency of missed Australian midwifery care can be quantified and several demographic factors are significant predictor variables for overall missed midwifery care. The most prevalent aspects of missed care in the Australian midwifery setting are midwives’ hand hygiene, supportive care, perinatal education, and surveillance type midwifery practices. Conclusions As the frequencies and types of missed midwifery care in Australia have been identified, it is possible for midwives to be mindful of minimising care omissions related to hand hygiene, providing supportive care and education to mothers as well as surveillance-type midwifery practices.

BackgroundChronic back pain (CBP) is linked to a higher prevalence and higher occurrence of major depressive disorder (MDD) and can lead to reduced quality of life. Unfortunately, individuals with both CBP and recurrent MDD are underidentified. Utilizing health care insurance data may provide a possibility to better identify this complex population. In addition, internet- and mobile-based interventions might enhance the availability of existing treatments and provide help to those highly burdened individuals. ObjectiveThis pilot randomized controlled trial investigated the feasibility of recruitment via the health records of a German health insurance company. The study also examined user satisfaction and effectiveness of a 9-week cognitive behavioral therapy and Web- and mobile-based guided self-help intervention Get.Back in CBP patients with recurrent MDD on sick leave compared with a waitlist control condition. MethodsHealth records from a German health insurance company were used to identify and recruit participants (N=76) via invitation letters. Study outcomes were measured using Web-based self-report assessments at baseline, posttreatment (9 weeks), and a 6-month follow-up. The primary outcome was depressive symptom severity (Center for Epidemiological Studies–Depression); secondary outcomes included anxiety (Hamilton Anxiety and Depression Scale), quality of life (Assessment of Quality of Life), pain-related variables (Oswestry Disability Index, Pain Self-Efficacy Questionnaire, and pain intensity), and negative effects (Inventory for the Assessment of Negative Effects of Psychotherapy). ResultsThe total enrollment rate with the recruitment strategy used was 1.26% (76/6000). Participants completed 4.8 modules (SD 2.6, range 0-7) of Get.Back. The overall user satisfaction was favorable (mean Client Satisfaction Questionnaire score=24.5, SD 5.2). Covariance analyses showed a small but statistically significant reduction in depressive symptom severity in the intervention group (n=40) at posttreatment compared with the waitlist control group (n=36; F1,76=3.62, P=.03; d=0.28, 95% CI −0.17 to 0.74). Similar findings were noted for the reduction of anxiety symptoms (F1,76=10.45; P=.001; d=0.14, 95% CI −0.31 to 0.60) at posttreatment. Other secondary outcomes were nonsignificant (.06≤P≤.44). At the 6-month follow-up, the difference between the groups with regard to reduction in depressive symptom severity was no longer statistically significant (F1,76=1.50, P=.11; d=0.10, 95% CI −0.34 to 0.46). The between-group difference in anxiety at posttreatment was maintained to follow-up (F1,76=2.94, P=.04; d=0.38, 95% CI −0.07 to 0.83). There were no statistically significant differences across groups regarding other secondary outcomes at the 6-month follow-up (.08≤P≤.42). ConclusionsThese results suggest that participants with comorbid depression and CBP on sick leave may benefit from internet- and mobile-based interventions, as exemplified with the positive user satisfaction ratings. The recruitment strategy via health insurance letter invitations appeared feasible, but more research is needed to understand how response rates in untreated individuals with CBP and comorbid depression can be increased. Trial RegistrationGerman Clinical Trials Register DRKS00010820; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00010820.