Enhancing Therapeutic Processes in Videoconferencing Psychotherapy: Interview Study of Psychologists' Technological Perspective.

BACKGROUND: The COVID-19 pandemic caused a surge in the use of telehealth platforms. Psychologists have shifted from face-to-face sessions to videoconference sessions. Therefore, essential information that is easily obtainable via in-person sessions may be missing. Consequently, therapeutic work could be compromised. OBJECTIVE: This study aimed to explore the videoconference psychotherapy (VCP) experiences of psychologists around the world. Furthermore, we aimed to identify technological features that may enhance psychologists' therapeutic work through augmented VCP. METHODS: In total, 17 psychologists across the world (n=7, 41% from Australia; n=1, 6% from England; n=5, 29% from Italy; n=1, 6% from Mexico; n=1, 6% from Spain; and n=2, 12% from the United States) were interviewed. We used thematic analysis to examine the data collected from a sample of 17 psychologists. We applied the Chaos Theory to interpret the system dynamics and collected details about the challenges posed by VCP. For collecting further information about the technology and processes involved, we relied on the Input-Process-Output (IPO) model. RESULTS: The analysis resulted in the generation of 9 themes (input themes: psychologists' attitude, trust-reinforcing features, reducing cognitive load, enhancing emotional communication, and engaging features between psychologists and patients; process themes: building and reinforcing trust, decreasing cognitive load, enhancing emotional communication, and increasing psychologist-patient engagement) and 19 subthemes. Psychologists found new strategies to deal with VCP limitations but also reported the need for more technical control to facilitate therapeutic processes. The suggested technologies (eye contact functionality, emergency call functionality, screen control functionality, interactive interface with other apps and software, and zooming in and out functionality) could enhance the presence and dynamic nature of the therapeutic relationship. CONCLUSIONS: Psychologists expressed a desire for enhanced control of VCP sessions. Psychologists reported a decreased sense of control within the therapeutic relationship owing to the influence of the VCP system. Great control of the VCP system could better approximate the critical elements of in-person psychotherapy (eg, observation of body language). To facilitate improved control, psychologists would like technology to implement features such as improved eye contact, better screen control, emergency call functionality, ability to zoom in and out, and an interactive interface to communicate with other apps. These results contribute to the general perception of the computer as an actual part of the VCP process. Thus, the computer plays a key role in the communication, rather than remaining as a technical medium. By adopting the IPO model in the VCP environment (VCP-IPO model), the relationship experience may help psychologists have more control in their VCP sessions.

A Perspective on Client-Psychologist Relationships in Videoconferencing Psychotherapy: Literature Review.

BACKGROUND: During the COVID-19 pandemic, people have been encouraged to maintain social distance. Technology helps people schedule meetings as remote videoconferencing sessions rather than face-to-face interactions. Psychologists are in high demand because of an increase in stress as a result of COVID-19, and videoconferencing provides an opportunity for mental health clinicians to treat current and new referrals. However, shifting treatment from face-to-face to videoconferencing is not simple: both psychologists and clients miss in-person information cues, including body language. OBJECTIVE: This review proposes a new theoretical framework to guide the design of future studies examining the impact of a computer as a mediator of psychologist-client relationships and the influence of videoconferencing on the relationship process. METHODS: We conducted a literature review including studies focused on communication and key concepts of the therapeutic relationship and therapeutic alliance. RESULTS: Studies have reported that clients are generally satisfied with videoconference therapy in terms of the relationship with their therapists and the establishment of the therapeutic alliance. Conversely, studies indicate that psychologists continue to highlight difficulties in establishing the same quality of therapeutic relationship and therapeutic alliance. The contrasting experiences might underlie the differences in the type of emotional and cognitive work required by both actors in any therapy session; furthermore, the computer seems to take part in their interaction not only as a vehicle to transmit messages but also as an active part of the communication. A new model of interaction and relationship is proposed, taking into account the presence of the computer, along with further hypotheses. CONCLUSIONS: It is important to consider the computer as having an active role in the client-psychologist relationship; thus, it is a third party to the communication that either assists or interferes with the interaction between psychologists and clients.

Sunny holidays before and after melanoma diagnosis are respectively associated with lower Breslow thickness and lower relapse rates in Italy.

BACKGROUND: Previous studies have reported an association between sun exposure and improved cutaneous melanoma (CM) survival. We analysed the association of UV exposure with prognostic factors and outcome in a large melanoma cohort. METHODS: A questionnaire was given to 289 (42%) CM patients at diagnosis (Group 1) and to 402 CM patients (58%) during follow-up (Group 2). Analyses were carried out to investigate the associations between sun exposure and melanoma prognostic factors and survival. RESULTS: Holidays in the sun two years before CM diagnosis were significantly associated with lower Breslow thickness (p=0.003), after multiple adjustment. Number of weeks of sunny holidays was also significantly and inversely associated with thickness in a dose-dependent manner (p=0.007). However when stratifying by gender this association was found only among women (p=0.0004) the risk of CM recurrence in both sexes was significantly lower in patients (n=271) who had holidays in the sun after diagnosis, after multiple adjustment including education: HR=0.30 (95%CI:0.10-0.87; p=0.03) conclusions: Holidays in the sun were associated with thinner melanomas in women and reduced rates of relapse in both sexes. However, these results do not prove a direct causal effect of sun exposure on survival since other confounding factors, such as vitamin D serum levels and socio-economic status, may play a role. Other factors in sun seeking individuals may also possibly affect these results.

Immigration and changes in the epidemiology of hemoglobin disorders in Italy : an emerging public health burden.

BACKGROUND: In the last years Italy is confronting with massive migratory movements from developing countries where hemoglobinopathies are widespread. This is causing a large diffusion and a changing spectrum in the epidemiology of hemoglobin disorders in Italy. METHODS: Investigations recently published in Italy on hemoglobinopathies among immigrants were revised in order to appreciate the impact of immigration from developing countries on epidemiology of these pathologies and to outline adequate guidelines of prevention. RESULTS: Although in Italy there is a limited number of investigations regarding the relation between immigration and hemoglobin disorders, published data show that in our Nation there is a changing and increasing spectrum of hemoglobinopathies linked to immigration. CONCLUSIONS: Prospective and retrospective actions of public healthy preventive policy are requested, based upon information (health educational programs for immigrants and caregivers), screenings among immigrants (school screening, pre-marital, preconception and early pregnancy screening, newborn screening), counseling for foreign at-risk couples and healthy carriers.

Prognosis in patients with sentinel node-positive melanoma is accurately defined by the combined Rotterdam tumor load and Dewar topography criteria.

PURPOSE: Prognosis in patients with sentinel node (SN)-positive melanoma correlates with several characteristics of the metastases in the SN such as size and site. These factors reflect biologic behavior and may separate out patients who may or may not need additional locoregional and/or systemic therapy. PATIENTS AND METHODS: Between 1993 and 2008, 1,080 patients (509 women and 571 men) were diagnosed with tumor burden in the SN in nine European Organisation for Research and Treatment of Cancer (EORTC) melanoma group centers. In total, 1,009 patients (93%) underwent completion lymph node dissection (CLND). Median Breslow thickness was 3.00 mm. The median follow-up time was 37 months. Tumor load and tumor site were reclassified in all nodes by the Rotterdam criteria for size and in 88% by the Dewar criteria for topography. RESULTS: Patients with submicrometastases (< 0.1 mm in diameter) were shown to have an estimated 5-year overall survival rate of 91% and a low nonsentinel node (NSN) positivity rate of 9%. This is comparable to the rate in SN-negative patients. The strongest predictive parameter for NSN positivity and prognostic parameter for survival was the Rotterdam-Dewar Combined (RDC) criteria. Patients with submicrometastases that were present in the subcapsular area only, had an NSN positivity rate of 2% and an estimated 5- and 10-year melanoma-specific survival (MSS) of 95%. CONCLUSION: Patients with metastases < 0.1 mm, especially when present in the subcapsular area only, may be overtreated by a routine CLND and have an MSS that is indistinguishable from that of SN-negative patients. Thus the RDC criteria provide a rational basis for decision making in the absence of conclusions provided by randomized controlled trials.

Electrochemotherapy for cutaneous and subcutaneous tumor lesions: a novel therapeutic approach.

Electroporation uses pulsed, high-intensity electric fields to temporarily increase cell membrane permeability by creation of pores, through which small molecules, such as chemotherapeutic agents, can diffuse inside cells before they reseal. The combination of electroporation with the administration of otherwise low-permeant cytotoxic drugs is known as electrochemotherapy (ECT). The two most commonly used drugs are bleomycin and cisplatin. ECT has already been proven to be effective in diverse tumor histotypes, including melanoma and basal and squamous cell carcinoma, Kaposi sarcoma, and breast cancer, also in those cases nonresponding to classical chemotherapies or other loco-regional treatment modalities, with a good safety profile. ECT can be proposed as loco-regional therapy for disseminated cutaneous and subcutaneous tumor lesions as alternative treatment modality to conventional therapies or as palliative care, in order to improve patients' quality of life.

Human herpesvirus 8 seroprevalence among internationally adopted children coming from Eastern Europe.

The seroprevalence of Human Herpes Virus 8 (HHV8) and its transmission pattern were assessed testing serum samples of 120 internationally adopted children (aged 1-15 years) coming from Eastern Europe. Determinations of IgG antibodies against both latent and lytic HHV-8 antigens were performed by indirect immunofluorescence assay. Antibodies were detected only for lytic antigen of the virus in 12.5% of children with a seroprevalence significatively higher (19.6%) in young children (age 1-6). No correlation was observed between HHV8 seropositivity and serological markers for hepatitis A, B and C viruses and Human Immunodeficiency virus. In conclusion, our findings suggest that HHV8 infection is widespread in some populations from the East Europe, and that person to person contacts among children could be considered the predominant mode of HHV8 transmission in younger age.

Celiac disease in the developing countries: a new and challenging public health problem.

In the past, celiac disease was believed to be a chronic enteropathy, almost exclusively affecting people of European origin. The availability of new, simple, very sensitive and specific serological tests (anti-gliadin, anti-endomysium and anti-transglutaminase antibody assays) have shown that celiac disease is common not only in Europe and in people of European ancestry but also in the developing countries where the major staple diet is wheat (Southern Asia, the Middle East, North West and East Africa, South America), both in the general population and in the groups at risk. Gluten intolerance thus appears to be a widespread public health problem and an increased level of awareness and clinical suspicion are needed in the New World where physicians must learn to recognize the variable clinical presentations (classical, atypical and silent forms) of celiac disease. In the developing countries, both serological screening in the general population and serological testing in groups at risk are necessary for an early identification of celiac patients. The gluten-free diet poses a challenging public health problem in the developing countries, especially since commercial gluten-free products are not available.

Are food intolerances and allergies increasing in immigrant children coming from developing countries ?

There are not available data concerning the occurrence, the clinical features and the environmental risk factors for food intolerances and allergies in immigrant children. The aim of the study was to evaluate rates, distribution, clinical features and environmental risk factors for food intolerances and allergies in immigrant children. Hospital records of 4,130 patients with celiac disease (CD), cow milk protein intolerance (CMPI) and food allergies (FA) diagnosed in 24 Italian Centres from 1999 to 2001 were retrospectively reviewed, comparing immigrant patients with Italian ones. 78/4,130 (1.9%) patients were immigrant: 36/1,917 (1.9%) had CD, 24/1,370 (1.75%) CMPI and 18/843 (2.1%) FA. They were evenly distributed across Italy and their native areas were: East Europe (23/78), Northern Africa (23/78), Southern Asia (14/78), Saharan and Sub-Saharan Africa (9/78), Southern America (4/78), Far East (3/7), Middle East (2/78). Despite differences in their origin, the clinical features of immigrant children were similar to the ones of Italian patients and among each ethnic group. The majority of them were born in Italy (57/78) or have been residing in Italy since several years (19/78). All of them had lost dietary habits of the native countries and had acquired those of the Italian childhood population. Food intolerances and allergies are present also in children coming from developing countries, and paediatricians will need to have a full awareness of them because the number of immigrant children in Italy is quickly increasing. The clinical features of food intolerances and allergies appear the same in each ethnic group, despite differences in races. Sharing of dietary habits with the Italian childhood population seems to be an important environmental risk factor.

Analysis of candidate genes in celiac disease: a tool to identify life-threatening associated genes?

The authors have recently reported that celiac patients show a proinflammatory cytokine genetic profile characterized by the contemporaneous presence of both the tumour necrosis factor-alpha-308A and the interferon-gamma +874T allele-positive genotypes. The same alleles are considered risk factors for aging associated disease, whereas an anti-inflammatory cytokine genotype profile might be associated with an extended life expectancy. This paper reports data on the 1249-1250InsACAA/Non-Ins transforming growth factor (TGF)-beta2, a multifunctional anti-inflammatory cytokine, polymorphism distribution in 88 celiac disease (CD) patients, 99 age- and sex-matched controls, and 28 >95-year-old healthy subjects living in western Sicily. These data demonstrate that genotype frequencies of CD patients are not different from that of age-matched and >95-year-old healthy control subjects. These data might suggest that TGF-beta2 polymorphism is not involved in the complex genotypes associated with successful or unsuccessful aging. In addition, one can speculate that the genotype profile associated with CD susceptibility might be detrimental for longevity, and studies of this CD genetic asset might point to a candidate gene for antiaging strategies.

Immunization status of internationally adopted children in Italy.

An increasing number of internationally adopted children is coming to Italy, and their immunization status is unknown. We evaluated the immunization status of such children in Palermo, Italy. We searched for the presence of a BCG scar in 88 children, 49 boys and 39 girls (mean age 76+/-32 months), most of whom (98%) came from Eastern Europe. Presence of BCG scar was observed in 59 (67.1%) of them, included five children without any pre-adoptive medical records. Twenty-three out of 29 children without any evidence of BCG scar were tested by Mantoux. Seven (30.4%) of 23 were tuberculin positive and diagnosed as having latent tuberculosis infection. We also examined immunization status against poliovirus 1-3, tetanus, diphtheria, pertussis, measles, mumps, rubella and hepatitis B of 70 internationally adopted children and we compared it with the pre-adoptive immunization records of their birth country. Protective titers (>1:8) against poliovirus 1-3, were found respectively in 67.1%, 91.4%, 42.8% of 70 immunized children, and only 38.5% of them had at the same time full protection against all three types of poliovirus. Protective titers against tetanus and diphtheria were found in 91.4% and 95.7% of 70 vaccinated children. Presence of antibodies against pertussis, measles, mumps and rubella was observed respectively in 16 (32.6%) of 49, 40 (62.5%) of 64, 28 (56%) of 50 and 24 (85.7%) of 28 children who had received the vaccine. As regards hepatitis B, only 20 of 29 vaccinated children had detectable hepatitis B surface antibodies, while four of 29 vaccinated and two of 41 not vaccinated children were positive for both hepatitis B surface antibodies and hepatitis B core antibodies. Finally three of 41 not vaccinated children were both hepatitis B surface antigen and hepatitis B core antibodies positive. No relation was found between health status and immunization and between age and antibody positiveness of vaccinated children except for hepatitis B, therefore the youngest immunized children were more likely to be hepatitis B surface antibodies positive. Our data suggest that internationally adopted children should be tested for their immunization status on arrival in the adopting country, because they are not protected in a sufficient way against vaccine-preventable diseases and their pre-adoptive immunization records sometimes are lacking and frequently are scarcely reliable.

Treatment of acquired factor VIII inhibitor with recombinant activated factor VIIa: data from the Italian registry of acquired hemophilia.

We report on the data collected in the Italian Registry of acquired haemophilia (AH) in 2001. Recombinant activated factor VII (rFVIIa) was selected as first-line therapy in 19 bleeding episodes because of their severity and as salvage in one case. Bleeding was controlled in 90% of the episodes, indicating the efficacy of rFVIIa in HA.

Plasma cytokine profiles in patients with celiac disease and selective IgA deficiency.

Celiac disease (CD) and selective IgA deficiency (IgAD) are frequently associated, and share the same genetic background. The aim of the present study was to evaluate both Type 1 and 2 plasma cytokine levels in CD and in CD-IgAD. IL-2, TNF-alpha, IL-10, IL-4 and IL-13 plasma levels were measured both at diagnosis and after a gluten-free diet (GFD) in 32 CD patients, in 27 CD-IgAD patients and in 30 healthy controls. IFN-gamma levels were significantly higher in CD and CD-IgAD than in controls, TNF-alpha displayed significantly higher levels in CD-IgAD when compared both with controls and with CD, and IL-2 was in CD-IgAD significantly increased respect to controls. Kinetics of the Type 1 cytokine plasma levels did not show a clear relationship with the GFD in both groups of CD patients, and particularly in those with IgAD. IL-4 and IL-13, both at diagnosis and after a GFD, were not significantly different in controls and in celiac patients (with and without IgAD). IL-10, whose production is stimulated by the TNF-alpha, had significantly higher plasma levels in CD-IgAD, but not in CD patients, with a significant decrease after a GFD. CD and especially CD-IgAD patients display persistently higher pro-inflammatory cytokine levels, suggesting a persistent state of activation of pro-phlogistic signals in CD, particularly when IgAD coexists. Serial measurement of serum IL-10 may be an adjunctive evaluating criterion in the follow-up of CD-IgAD patients.

Increased prevalence of autoimmune diseases in first-degree relatives of patients with celiac disease.

BACKGROUND: The prevalence of autoimmune disorders is increased in patients with celiac disease (CD), and it is unknown whether their first-degree relatives also have a high risk of autoimmune disorders. METHODS: To assess the prevalence of autoimmune diseases in first-degree relatives of CD patients, the authors looked for autoimmune disorders in 225 first-degree relatives of 66 children with CD (group A) and in 232 first-degree relatives of 68 healthy children (group B). For both groups, serologic screening for CD was performed through antiendomysium (EMA) and tissue transglutaminase autoantibodies (tTGAA). EMA- and tTGAA-positive subjects were offered an intestinal biopsy. The age at onset of autoimmune diseases was also recorded in group A. RESULTS: The prevalence of autoimmune disorders was significantly (P = 0.028) higher in group A (11 of 225, 4.8%) than in group B (2 of 232, 0.86%). In relatives of CD patients, the prevalence increased with age (chi2 for trend, 43.5; P < 0.0001). Serologic screening for CD was only positive in group A (15 of 225 subjects). An intestinal biopsy was performed in 13 of these 15 relatives (2 refused biopsy). Eleven of 13 had flat mucosa, with subclinical or silent forms of CD. The prevalence of autoimmune diseases in the EMA- and tTGAA-positive relatives of CD patients was significantly higher (3 of 15, 20%; P = 0.028; odds ratio, 6.3; 95% CI, 1/0.21-1/0.11, 4.9-7.6) than in those who were EMA and tTGAA negative (8/210, 3.8%). CONCLUSIONS: The first-degree relatives of CD patients have an increased risk of autoimmune diseases, most likely connected with unrecognized subclinical or silent forms of CD.

Acquired factor VIII inhibitors in pregnancy: data from the Italian Haemophilia Register relevant to clinical practice.

OBJECTIVE: To review the clinical problems related to the inhibitor of factor VIII (FVIII) in pregnancy. DESIGN: Retrospective analysis. SETTING: Haemophilia and haemotology centres. POPULATION: Patients registered and followed up at the centres. METHODS: Data were collected from the Italian Haemophilia Register of acquired FVIII inhibitor. RESULTS: Twenty of 96 cases with FVIII inhibitor were identified postpartum. The time of appearance was 3-150 days postpartum. All but one of the cases were idiopathic; 11/20 patients required blood transfusions. In six patients, the inhibitor was identified because of surgical bleeding, four after hysterectomies carried out because of postpartum haemorrhage. A prolonged activated partial thromboplastin time was present in all women in whom the test was carried out. Nine women did not require treatment because the bleeding was mild; in 11 patients bleeding was promptly controlled by different therapeutic modalities. Immunosuppressive therapy was used to suppress the inhibitor. The majority of the patients who achieved complete remission received steroids; in 6/6 patients who relapsed, a second remission was obtained with combined therapy. CONCLUSIONS: In a review of 20 pregnancies with FVIII inhibitor, over a 15 year period, bleeding was controlled in all cases with no fatalities. Correct evaluation of coagulation screening tests, in particular, activated partial thromboplastin time, is essential.