Acceptance of Telemedicine Compared to In-Person Consultation From the Providers' and Users' Perspectives: Multicenter, Cross-Sectional Study in Dermatology.

BACKGROUND: Teledermatology is currently finding its place in modern health care worldwide as a rapidly evolving field. OBJECTIVE: The aim of this study was to investigate the acceptance of teledermatology compared to in-person consultation from the perspective of patients and professionals. METHODS: This multicenter, cross-sectional pilot study was performed at secondary and tertiary referral centers of dermatology in Switzerland from August 2019 to January 2020. A customized questionnaire addressing demographics and educational data, experience with telemedicine, and presumed willingness to replace in-patient consultations with teledermatology was completed by dermatological patients, dermatologists, and health care workers in dermatology. RESULTS: Among a total of 664 participants, the ones with previous telemedicine experience (171/664, 25.8%) indicated a high level of overall experience with it (patients: 73/106, 68.9%, dermatologists: 6/8, 75.0%, and health care workers: 27/34, 79.4%). Patients, dermatologists, and health care workers were most likely willing to replace in-person consultations with teledermatology for minor health issues (353/512, 68.9%; 37/45, 82.2%; and 89/107, 83.2%, respectively). We observed a higher preference for telemedicine among individuals who have already used telemedicine (patients: P<.001, dermatologists: P=.03, and health care workers, P=.005), as well as among patients with higher educational levels (P=.003). CONCLUSIONS: This study indicates that the preference for teledermatology has a high potential to increase over time since previous experience with telemedicine and a higher level of education were associated with a higher willingness to replace in-patient consultations with telemedicine. We assume that minor skin problems are the most promising issue in teledermatology. Our findings emphasize the need for dermatologists to be actively involved in the transition to teledermatology. TRIAL REGISTRATION: ClinicalTrials.gov NCT04495036; https://classic.clinicaltrials.gov/ct2/show/NCT04495036.

Preliminary findings on long-term effects of fMRI neurofeedback training on functional networks involved in sustained attention.

INTRODUCTION: Neurofeedback based on functional magnetic resonance imaging allows for learning voluntary control over one's own brain activity, aiming to enhance cognition and clinical symptoms. We previously reported improved sustained attention temporarily by training healthy participants to up-regulate the differential activity of the sustained attention network minus the default mode network (DMN). However, the long-term brain and behavioral effects of this training have not yet been studied. In general, despite their relevance, long-term learning effects of neurofeedback training remain under-explored. METHODS: Here, we complement our previously reported results by evaluating the neurofeedback training effects on functional networks involved in sustained attention and by assessing behavioral and brain measures before, after, and 2 months after training. The behavioral measures include task as well as questionnaire scores, and the brain measures include activity and connectivity during self-regulation runs without feedback (i.e., transfer runs) and during resting-state runs from 15 healthy individuals. RESULTS: Neurally, we found that participants maintained their ability to control the differential activity during follow-up sessions. Further, exploratory analyses showed that the training increased the functional connectivity between the DMN and the occipital gyrus, which was maintained during follow-up transfer runs but not during follow-up resting-state runs. Behaviorally, we found that enhanced sustained attention right after training returned to baseline level during follow-up. CONCLUSION: The discrepancy between lasting regulation-related brain changes but transient behavioral and resting-state effects raises the question of how neural changes induced by neurofeedback training translate to potential behavioral improvements. Since neurofeedback directly targets brain measures to indirectly improve behavior in the long term, a better understanding of the brain-behavior associations during and after neurofeedback training is needed to develop its full potential as a promising scientific and clinical tool.

Evaluation of the reliability and validity of computerized tests of attention.

Different aspects of attention can be assessed through psychological tests to identify stable individual or group differences as well as alterations after interventions. Aiming for a wide applicability of attentional assessments, Psychology Experiment Building Language (PEBL) is an open-source software system for designing and running computerized tasks that tax various attentional functions. Here, we evaluated the reliability and validity of computerized attention tasks as provided with the PEBL package: Continuous Performance Task (CPT), Switcher task, Psychomotor Vigilance Task (PVT), Mental Rotation task, and Attentional Network Test. For all tasks, we evaluated test-retest reliability using the intraclass correlation coefficient (ICC), as well as internal consistency through within-test correlations and split-half ICC. Across tasks, response time scores showed adequate reliability, whereas scores of performance accuracy, variability, and deterioration over time did not. Stability across application sites was observed for the CPT and Switcher task, but practice effects were observed for all tasks except the PVT. We substantiate convergent and discriminant validity for several task scores using between-task correlations and provide further evidence for construct validity via associations of task scores with attentional and motivational assessments. Taken together, our results provide necessary information to help design and interpret studies involving attention assessments.

Vision- and touch-dependent brain correlates of body-related mental processing.

In humans, the nature of sensory input influences body-related mental processing. For instance, behavioral differences (e.g., response time) can be found between mental spatial transformations (e.g., mental rotation) of viewed and touched body parts. It can thus be hypothesized that distinct brain activation patterns are associated with such sensory-dependent body-related mental processing. However, direct evidence that the neural correlates of body-related mental processing can be modulated by the nature of the sensory stimuli is still missing. We thus analyzed event-related functional magnetic resonance imaging (fMRI) data from thirty-one healthy participants performing mental rotation of visually- (images) and haptically-presented (plastic) hands. We also dissociated the neural activity related to rotation or task-related performance using models that either regressed out or included the variance associated with response time. Haptically-mediated mental rotation recruited mostly the sensorimotor brain network. Visually-mediated mental rotation led to parieto-occipital activations. In addition, faster mental rotation was associated with sensorimotor activity, while slower mental rotation was associated with parieto-occipital activations. The fMRI results indicated that changing the type of sensory inputs modulates the neural correlates of body-related mental processing. These findings suggest that distinct sensorimotor brain dynamics can be exploited to execute similar tasks depending on the available sensory input. The present study can contribute to a better evaluation of body-related mental processing in experimental and clinical settings.

Abrupt visibility modifications affect specific subjective (not objective) aspects of body ownership.

The sense of body ownership builds on proper multisensory integration mechanisms. The Rubber-Hand Illusion (RHI) paradigm exploits a visuo-tactile multisensory conflict to induce illusory body ownership toward a fake hand, assessed by multidimensional subjective ratings and univocal objective measurements. Considering the controversy as to whether viewing the rubber hand is necessary or not to induce the illusion, we investigated the effects of targeted manipulations of visibility on subjective and objective aspects of the RHI. To this aim, we collected questionnaire and proprioceptive drift data from thirty participants receiving visuo-tactile stimulation in a setup that allowed for increasing and decreasing the visibility (illumination) of the rubber hand. We found that specific subjective ratings (Movement and Loss of Ownership) were sensitive to the interaction between rubber hand's visibility and illusory ownership. The interaction was not significant for the Embodiment subjective component and for the objective one (proprioceptive drift). Since different degrees of visibility did not differentially affect the RHI, these findings highlight that relatively abrupt changes in the visibility of the rubber hand can differentially impact subjective versus objective components of body ownership. This understanding may be critical for neuroscientific theories on the relationship between multisensory integration and body consciousness.

Effects of COVID-19 Lockdown on Melanoma Diagnosis in Switzerland: Increased Tumor Thickness in Elderly Females and Shift towards Stage IV Melanoma during Lockdown.

At the early stages of the COVID-19 outbreak in 2020, Switzerland was among the countries with the highest number of SARS-CoV2-infections per capita in the world. Lockdowns had a remarkable impact on primary care access and resulted in postponed cancer screenings. The aim of this study was to investigate the effects of the COVID-19 lockdown on the diagnosis of melanomas and stage of melanomas at diagnosis. In this retrospective, exploratory cohort study, 1240 patients with a new diagnosis of melanoma were analyzed at five tertiary care hospitals in German-speaking Switzerland over a period of two years and three months. We compared the pre-lockdown (01/FEB/19-15/MAR/20, n = 655) with the lockdown (16/MAR/20-22/JUN/20, n = 148) and post-lockdown period (23/JUN/20-30/APR/21, n = 437) by evaluating patients' demographics and prognostic features using Breslow thickness, ulceration, subtype, and stages. We observed a short-term, two-week rise in melanoma diagnoses after the major lift of social lockdown restrictions. The difference of mean Breslow thicknesses was significantly greater in older females during the lockdown compared to the pre-lockdown (1.9 ± 1.3 mm, p = 0.03) and post-lockdown period (1.9 ± 1.3 mm, p = 0.048). Thickness increase was driven by nodular melanomas (2.9 ± 1.3 mm, p = 0.0021; resp. 2.6 ± 1.3 mm, p = 0.008). A proportional rise of advanced melanomas was observed during lockdown (p = 0.047). The findings provide clinically relevant insights into lockdown-related gender- and age-dependent effects on melanoma diagnosis. Our data highlight a stable course in new melanomas with a lower-than-expected increase in the post-lockdown period. The lockdown period led to a greater thickness in elderly women driven by nodular melanomas and a proportional shift towards stage IV melanoma. We intend to raise awareness for individual cancer care in future pandemic management strategies.

Illusory Body Ownership Affects the Cortical Response to Vicarious Somatosensation.

Fundamental human feelings such as body ownership ("this" body is "my" body) and vicariousness (first-person-like experience of events occurring to others) are based on multisensory integration. Behavioral links between body ownership and vicariousness have been shown, but the neural underpinnings remain largely unexplored. To fill this gap, we investigated the neural effects of altered body ownership on vicarious somatosensation. While recording functional brain imaging data, first, we altered participants' body ownership by robotically delivering tactile stimulations ("tactile" stroking) in synchrony or not with videos of a virtual hand being brushed ("visual" stroking). Then, we manipulated vicarious somatosensation by showing videos of the virtual hand being touched by a syringe's plunger (touch) or needle (pain). Only after the alteration of body ownership (synchronous visuo-tactile stroking) and specifically during late epochs of vicarious somatosensation, vicarious pain was associated with lower activation in premotor and anterior cingulate cortices with respect to vicarious touch. At the methodological level, the present study highlights the importance of the neural response's temporal evolution. At the theoretical level, it shows that the higher-level (cognitive) impact of a lower-level (sensory) body-related processing (visuo-tactile) is not limited to body ownership but also extends to other psychological body-related domains, such as vicarious somatosensation.

Predictors of real-time fMRI neurofeedback performance and improvement - A machine learning mega-analysis.

Real-time fMRI neurofeedback is an increasingly popular neuroimaging technique that allows an individual to gain control over his/her own brain signals, which can lead to improvements in behavior in healthy participants as well as to improvements of clinical symptoms in patient populations. However, a considerably large ratio of participants undergoing neurofeedback training do not learn to control their own brain signals and, consequently, do not benefit from neurofeedback interventions, which limits clinical efficacy of neurofeedback interventions. As neurofeedback success varies between studies and participants, it is important to identify factors that might influence neurofeedback success. Here, for the first time, we employed a big data machine learning approach to investigate the influence of 20 different design-specific (e.g. activity vs. connectivity feedback), region of interest-specific (e.g. cortical vs. subcortical) and subject-specific factors (e.g. age) on neurofeedback performance and improvement in 608 participants from 28 independent experiments. With a classification accuracy of 60% (considerably different from chance level), we identified two factors that significantly influenced neurofeedback performance: Both the inclusion of a pre-training no-feedback run before neurofeedback training and neurofeedback training of patients as compared to healthy participants were associated with better neurofeedback performance. The positive effect of pre-training no-feedback runs on neurofeedback performance might be due to the familiarization of participants with the neurofeedback setup and the mental imagery task before neurofeedback training runs. Better performance of patients as compared to healthy participants might be driven by higher motivation of patients, higher ranges for the regulation of dysfunctional brain signals, or a more extensive piloting of clinical experimental paradigms. Due to the large heterogeneity of our dataset, these findings likely generalize across neurofeedback studies, thus providing guidance for designing more efficient neurofeedback studies specifically for improving clinical neurofeedback-based interventions. To facilitate the development of data-driven recommendations for specific design details and subpopulations the field would benefit from stronger engagement in open science research practices and data sharing.

Can we predict real-time fMRI neurofeedback learning success from pretraining brain activity?

Neurofeedback training has been shown to influence behavior in healthy participants as well as to alleviate clinical symptoms in neurological, psychosomatic, and psychiatric patient populations. However, many real-time fMRI neurofeedback studies report large inter-individual differences in learning success. The factors that cause this vast variability between participants remain unknown and their identification could enhance treatment success. Thus, here we employed a meta-analytic approach including data from 24 different neurofeedback studies with a total of 401 participants, including 140 patients, to determine whether levels of activity in target brain regions during pretraining functional localizer or no-feedback runs (i.e., self-regulation in the absence of neurofeedback) could predict neurofeedback learning success. We observed a slightly positive correlation between pretraining activity levels during a functional localizer run and neurofeedback learning success, but we were not able to identify common brain-based success predictors across our diverse cohort of studies. Therefore, advances need to be made in finding robust models and measures of general neurofeedback learning, and in increasing the current study database to allow for investigating further factors that might influence neurofeedback learning.

Network-based fMRI-neurofeedback training of sustained attention.

The brain regions supporting sustained attention (sustained attention network; SAN) and mind-wandering (default-mode network; DMN) have been extensively studied. Nevertheless, this knowledge has not yet been translated into advanced brain-based attention training protocols. Here, we used network-based real-time functional magnetic resonance imaging (fMRI) to provide healthy individuals with information about current activity levels in SAN and DMN. Specifically, 15 participants trained to control the difference between SAN and DMN hemodynamic activity and completed behavioral attention tests before and after neurofeedback training. Through training, participants improved controlling the differential SAN-DMN feedback signal, which was accomplished mainly through deactivating DMN. After training, participants were able to apply learned self-regulation of the differential feedback signal even when feedback was no longer available (i.e., during transfer runs). The neurofeedback group improved in sustained attention after training, although this improvement was temporally limited and rarely exceeded mere practice effects that were controlled by a test-retest behavioral control group. The learned self-regulation and the behavioral outcomes suggest that neurofeedback training of differential SAN and DMN activity has the potential to become a non-invasive and non-pharmacological tool to enhance attention and mitigate specific attention deficits.

Personode: A Toolbox for ICA Map Classification and Individualized ROI Definition.

Canonical resting state networks (RSNs) can be obtained through independent component analysis (ICA). RSNs are reproducible across subjects but also present inter-individual differences, which can be used to individualize regions-of-interest (ROI) definition, thus making fMRI analyses more accurate. Unfortunately, no automatic tool for defining subject-specific ROIs exists, making the classification of ICAs as representatives of RSN time-consuming and largely dependent on visual inspection. Here, we present Personode, a user-friendly and open source MATLAB-based toolbox that semi-automatically performs the classification of RSN and allows for defining subject- and group-specific ROIs. To validate the applicability of our new approach and to assess potential improvements compared to previous approaches, we applied Personode to both task-related activation and resting-state data. Our analyses show that for task-related activation analyses, subject-specific spherical ROIs defined with Personode produced higher activity contrasts compared to ROIs derived from single-study and meta-analytic coordinates. We also show that subject-specific irregular ROIs defined with Personode improved ROI-to-ROI functional connectivity analyses.Hence, Personode might be a useful toolbox for ICA map classification into RSNs and group- as well as subject-specific ROI definitions, leading to improved analyses of task-related activation and functional connectivity.

Analyzing the association between functional connectivity of the brain and intellectual performance.

Measurements of functional connectivity support the hypothesis that the brain is composed of distinct networks with anatomically separated nodes but common functionality. A few studies have suggested that intellectual performance may be associated with greater functional connectivity in the fronto-parietal network and enhanced global efficiency. In this fMRI study, we performed an exploratory analysis of the relationship between the brain's functional connectivity and intelligence scores derived from the Portuguese language version of the Wechsler Adult Intelligence Scale (WAIS-III) in a sample of 29 people, born and raised in Brazil. We examined functional connectivity between 82 regions, including graph theoretic properties of the overall network. Some previous findings were extended to the Portuguese-speaking population, specifically the presence of small-world organization of the brain and relationships of intelligence with connectivity of frontal, pre-central, parietal, occipital, fusiform and supramarginal gyrus, and caudate nucleus. Verbal comprehension was associated with global network efficiency, a new finding.