The Impact of Virtual Humans on Psychosomatic Medicine.

OBJECTIVE: Virtual humans are likely to enhance the delivery of health care over the next decade. Virtual humans are artificially intelligent computer agents with hyperrealistic, autonomously animated embodiments based on affective computing techniques. Virtual humans could be programmed to screen for health conditions, triage patients, and deliver health interventions, with appropriate facial expressions and body gestures, functioning as a supplement to human care. This article provides a perspective on the implications of virtual humans for behavioral and psychosomatic medicine, and health psychology. METHODS: A narrative review was conducted to integrate observations and findings from research on virtual humans from 91 articles in this multidisciplinary area. RESULTS: Virtual humans can be used for multimodal behavior analysis of patients, individualized tailoring of interventions, and detection of changes of psychological and behavioral measures over time. Virtual humans can also pair the scalability of a website with the interactivity and relational skills of a human tele-therapist. Research is beginning to show the acceptability, feasibility, and preliminary effectiveness of virtual humans in a range of populations. Virtual humans can be easily tailored in terms of their appearance, voice, and language, and may be adapted to fit the characteristics of a patient population or hard-to-reach groups. If co-designed with these communities, virtual humans may help to promote health care engagement and improve outcomes. CONCLUSIONS: Virtual humans can engage and motivate patients, and deliver personalized psychological and behavioral health care. This article provides an overview of the potential impact of virtual humans on psychosomatic medicine and discusses ethical implications.

Development of a Virtual Human for Supporting Tobacco Cessation During the COVID-19 Pandemic.

People who consume tobacco are at greater risk of developing severe COVID-19. Unfortunately, the COVID-19 pandemic reduced the accessibility of tobacco cessation services as a result of necessary social restrictions. Innovations were urgently needed to support tobacco cessation during the pandemic. Virtual humans are artificially intelligent computer agents with a realistic, humanlike appearance. Virtual humans could be a scalable and engaging way to deliver tobacco cessation information and support. Florence, a virtual human health worker, was developed in collaboration with the World Health Organization to remotely support people toward tobacco cessation during the COVID-19 pandemic. Florence delivers evidence-based information, assists with making quit plans, and directs people to World Health Organization-recommended cessation services in their country. In this viewpoint, we describe the process of developing Florence. The development was influenced by a formative evaluation of data from 115 early users of Florence from 49 countries. In general, Florence was positively perceived; however, changes were requested to aspects of her design and content. In addition, areas for new content were identified (eg, for nonsmoker support persons). Virtual health workers could expand the reach of evidence-based tobacco cessation information and personalized support. However, as they are a new innovation in tobacco cessation, their efficacy, feasibility, and acceptability in this application needs to be evaluated, including in diverse populations.

Psychological Predictors of Self-reported COVID-19 Outcomes: Results From a Prospective Cohort Study.

BACKGROUND: Previous research has shown that psychological factors, such as stress and social support, are associated with greater susceptibility to viral respiratory illnesses and more severe symptoms. During the COVID-19 pandemic there has been a well-documented deterioration in psychological well-being and increased social isolation. This raises questions as to whether those experiencing psychological adversity during the pandemic are more at risk of contracting and/or experiencing COVID-19 symptoms. PURPOSE: To examine the relationship between psychological factors and the risk of COVID-19 self-reported infection and the symptomatic experience of SARS-CoV-2 (indicated by the number and severity of symptoms). METHODS: As part of a longitudinal prospective observational cohort study, 1,087 adults completed validated measures of psychological well-being during April 2020 and self-reported incidence of COVID-19 infection and symptom experience across the pandemic through to December 2020. Regression models were used to explore these relationships controlling for demographic and occupational factors. RESULTS: Greater psychological distress during the early phase of the pandemic was significantly associated with subsequent self-reported SARS-CoV-2 infection as well as the experience of a greater number and more severe symptoms. CONCLUSIONS: COVID-19 infection and symptoms may be more common among those experiencing elevated psychological distress. Further research to elucidate the mechanisms underlying these associations is needed.

Longitudinal Associations Between Illness Perceptions and Glycemic Control in Type 2 Diabetes.

BACKGROUND: Cross-sectional research demonstrates associations between illness perceptions and glycemic control in people with type 2 diabetes (T2D). Prospective studies are limited and show mixed findings. This study aimed to investigate (1) whether baseline illness perceptions predicted glycemic control (HbA1c levels) at 6-12-month follow-up and (2) possible differences in baseline illness perceptions between individuals who completed at least one HbA1c blood test during the 12-month follow-up and those who did not. METHODS: A total of 115 individuals with T2D were recruited from an outpatient clinic. Demographic and clinical information and illness perceptions were assessed at baseline. HbA1c was assessed at baseline and 12 months later from clinical records. Hierarchical multiple linear regression examined associations between baseline illness perceptions and HbA1c levels at 6-12-month follow-up, controlling for age, sex, education, types of diabetes medication, and baseline HbA1c. RESULTS: Univariate analysis showed perceived weight management effectiveness at baseline was associated with lower HbA1c at follow-up (rho = -.25, p = .04, n = 67). Adjusted multiple regression showed that HbA1c at baseline was the only significant predictor of HbA1c at 6-12-month follow-up (ß = 0.51, p < .001). There were no significant differences in baseline illness perceptions between individuals who completed HbA1c blood tests during follow-up (n = 78) and those who did not (n = 34), p > .05. CONCLUSION: Illness perceptions at baseline did not predict longitudinal HbA1c in adjusted analyses, nor completion of HbA1c tests. Results may be due to temporal variability in HbA1c and barriers to accessing blood tests.

Cultural Differences in Psychological Distress and Illness Perceptions Amongst People Living With Cardiac Inherited Diseases.

Cardiac Inherited diseases (CID) and minority ethnic status are both associated with anxiety and depression. This study aimed to investigate differences in patient experiences of CID between ethnic groups in New Zealand (NZ) in order to inform psychosocial interventions and promote health equity. A cross-sectional survey was administered to a NZ CID database. One-hundred and fifty-two (152) NZ Europeans, 19 Maori, and two Pasifika participated. Maori and Pasifika peoples reported significantly greater symptom perceptions, shorter timeline perceptions, higher perceived risk of severe symptoms, and were less likely to attribute the cause of their CID to hereditary factors than NZ Europeans. Maori and Pasifika also reported more anxiety and distress, although both groups reported beneficial medication perceptions and high medication adherence. Differences could not be attributed to clinical or other demographic variables. The use of screening tools and development of culturally appropriate interventions may help reduce both distress and health inequities.

A systematic review of illness perception interventions in type 2 diabetes: Effects on glycaemic control and illness perceptions.

AIMS: This systematic review sought to synthesize the evidence regarding the effectiveness of illness perception interventions compared with control conditions at changing illness perceptions and improving glycaemic control in individuals with type 2 diabetes. METHODS: Seven electronic databases were searched between October 2018 and May 2020. Randomized controlled trials that tested interventions informed by the Common-Sense Model in adults with type 2 diabetes, and measured illness perceptions and glycaemic control at pre- and post-intervention were included. The Cochrane risk of bias tool was used to assess risk of bias. RESULTS: A total of 4095 articles were identified, of which nine randomized control trials (2561 participants) across 12 publications were included in this review. Findings showed that all the illness perception domains were modified in at least one trial, with the exception of cyclical timeline perceptions. Coherence, personal control, treatment control and chronic timeline perceptions were the most frequently modified perceptions. Glycaemic control demonstrated an improvement in the intervention group compared to the control group at 3 and 6 months post-intervention in two trials. Risk of bias assessment showed high risk of bias especially for the blinding of participants and the personnel domain. CONCLUSIONS: There is limited evidence that interventions informed by the Common-Sense Model can improve glycaemic control in individuals with type 2 diabetes through changing inaccurate illness perceptions. Recommendations for future research are to tailor intervention content based on baseline perceptions, measure the emotional and causal domains, and involve family members in the intervention. (PROSPERO registration: CRD42019114532).

Effects of Emotional Expressiveness of a Female Digital Human on Loneliness, Stress, Perceived Support, and Closeness Across Genders: Randomized Controlled Trial.

BACKGROUND: Loneliness is a growing public health problem that has been exacerbated in vulnerable groups during the COVID-19 pandemic. Social support interventions have been shown to reduce loneliness, including when delivered through technology. Digital humans are a new type of computer agent that show promise as supportive peers in health care. For digital humans to be effective and engaging support persons, it is important that they develop closeness with people. Closeness can be increased by emotional expressiveness, particularly in female relationships. However, it is unknown whether emotional expressiveness improves relationships with digital humans and affects physiological responses. OBJECTIVE: The aim of this study is to investigate whether emotional expression by a digital human can affect psychological and physiological outcomes and whether the effects are moderated by the user's gender. METHODS: A community sample of 198 adults (101 women, 95 men, and 2 gender-diverse individuals) was block-randomized by gender to complete a 15-minute self-disclosure conversation with a female digital human in 1 of 6 conditions. In these conditions, the digital human varied in modality richness and emotional expression on the face and in the voice (emotional, neutral, or no face; emotional or neutral voice). Perceived loneliness, closeness, social support, caring perceptions, and stress were measured after each interaction. Heart rate, skin temperature, and electrodermal activity were assessed during each interaction. 3-way factorial analyses of variance with post hoc tests were conducted. RESULTS: Emotional expression in the voice was associated with greater perceptions of caring and physiological arousal during the interaction, and unexpectedly, with lower feelings of support. User gender moderated the effect of emotional expressiveness on several outcomes. For women, an emotional voice was associated with increased closeness, social support, and caring perceptions, whereas for men, a neutral voice increased these outcomes. For women, interacting with a neutral face was associated with lower loneliness and subjective stress compared with no face. Interacting with no face (ie, a voice-only black screen) resulted in lower loneliness and subjective stress for men, compared with a neutral or emotional face. No significant results were found for heart rate or skin temperature. However, average electrodermal activity was significantly higher for men while interacting with an emotional voice. CONCLUSIONS: Emotional expressiveness in a female digital human has different effects on loneliness, social, and physiological outcomes for men and women. The results inform the design of digital human support persons and have theoretical implications. Further research is needed to evaluate how more pronounced emotional facial expressions in a digital human might affect the results. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000865819; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381816&isReview.

The Effects of Sensory Enrichment After a Laboratory Stressor on Human Skin Barrier Recovery in a Randomized Trial.

OBJECTIVE: Environmental enrichment (EE) can reduce stress, alter immunity, and speed wound healing in animals. However, it is not known whether these effects translate to humans. This study aimed to investigate whether sensory EE could improve wound healing after a stressor in humans. METHODS: A total of 105 participants underwent a tape-stripping procedure and were then stressed using a laboratory stress paradigm. After this, they were randomized to interact for 30 minutes with one of two possible sensory EE interventions (music as auditory enrichment or a Paro robot as multisensory enrichment) or to a control condition. Skin barrier recovery was measured using transepidermal water loss at baseline, after the stressor, and after the intervention. Stress was measured using self-report, heart rate, blood pressure, and salivary stress-related biological measures. Enjoyment during the intervention was measured by self-report as a possible mediator. RESULTS: The Paro condition had significantly improved skin barrier recovery (mean [M] = 44%, standard error [SE] = 1.92) compared with the control condition (M = 37% SE = 2.01, F(2,88) = 3.25, p = .043), both with and without controlling for covariates. The music condition did not significantly differ from the other conditions (M = 42%, SE = 1.95, p values > .05). Both objective and subjective stress measures did not significantly differ between conditions. Mediational analysis showed that enjoyment levels during the intervention period significantly mediated the relationship between condition and skin barrier recovery (z = 2.00, p = .046). CONCLUSIONS: Paro, or other companion robots, may be an effective form of enrichment to improve skin barrier recovery in humans after a laboratory stressor, and this effect may be due to enjoyment. Further research with patient groups is required to investigate whether Paro can help heal clinical wounds. TRIAL REGISTRATION: ACTRN12618000953235, registered at https://anzctr.org.au.

Correction: The Effect of Robot Attentional Behaviors on User Perceptions and Behaviors in a Simulated Health Care Interaction: Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/13667.].

Young people, mental health and COVID-19 infection: the canaries we put in the coal mine.

OBJECTIVES: The number of people testing positive for Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in the UK, particularly among young adults, is increasing. We report here on the mental health of young adults and related psychological and behavioural responses to the pandemic and consider the role of these factors in fuelling the increase in coronavirus disease 2019 (COVID-19) in this group. METHODS: An online survey was completed during the first six weeks of the first UK-wide lockdown by 3097 respondents, including data for 364 respondents aged 18-24 years. The survey included measures of mental health and indices capturing related psychological and behavioural responses to the pandemic. RESULTS: The mental health of 18- to 24-years-olds in the first 6 weeks of lockdown was significantly poorer than that of older respondents and previously published norms: with 84% reporting symptoms of depression and 72% reporting symptoms of anxiety. Young adults also reported significantly greater loneliness and reduced positive mood, both of which were also associated with greater mental health difficulties. CONCLUSIONS: We contend that the combination of mental health, social and economic considerations may have contributed to the rise of COVID-19 infections in young adults, and ascribing blame to this group will not aid our efforts to regain control of the disease.

Perceptions of Risk of Cardiac Arrest in Individuals Living With a Cardiac Inherited Disease: Are the Doctor and the Patient on the Same Page?

BACKGROUND: Risk perceptions influence patient engagement with treatment recommendations, yet it is unknown whether patients with a cardiac inherited disease (CID) hold accurate risk perceptions. The study aimed to examine whether CID patients' and clinician's risk perceptions correlate and factors associated with patient perceptions. METHODS: 202 CID patients (of 618 [36%]) participated in a postal survey assessing perceived risk of aborted cardiac arrest or sudden cardiac death (ACA/SCD). Median age was 53 (16 to 83 years); 86 had Long QT Syndrome (LQTS), 69 had hypertrophic cardiomyopathy, 12 had dilated cardiomyopathy, and 27 had 'other'. Clinical and genetic characteristics were collected from the CID registry; clinical estimate of 5-year risk was determined for LQTS participants (n = 77) using a combination of cardiac arrest or syncope history, maximal QTc length, age, sex and genotype. RESULTS: Patients' risk perceptions of ACA/SCD ranged from 0 to 100%, (median 20%). Greater risk perceptions were associated with: non-New Zealand (NZ) Europeans (p < 0.01), probands (p < 0.05), reporting more physical symptoms (including those unrelated to CID) (p < 0.01), and more symptoms of anxiety (p < 0.05). Median risk assessment by LQTS patients was 15%, and by the clinician was 4.5%. No association was found between patient and clinician assessments of risk (rs = 0.13, ns), 56% of LQTS patients overestimated their risk, 14% underestimated and 30% were accurate. CONCLUSION: Cardiac inherited disease patients' risk perceptions correlate poorly with those of the clinician. Patients overestimating risk tend to have physical symptoms usually unrelated to their CID, and underlying anxiety. Techniques to better communicate risk are needed.

How Patient Perceptions Shape Responses and Outcomes in Inherited Cardiac Conditions.

At least one-third of adults living with an inherited cardiac condition report clinically-significant levels of psychological distress. Poorer health-related quality of life compared with population norms is also consistently reported. These outcomes are associated with younger patient age, having an implantable cardioverter defibrillator, and receipt of uncertain clinical test results, and can influence self-management behaviours, such as adherence to potentially critical life-preserving medications. According to the Common Sense Model of Illness, people use information from multiple sources to 'make sense' of their health condition, and how they conceptualise the condition can strongly influence adaptation and coping responses. Previous studies with people with inherited cardiac conditions show that illness perceptions, such as greater perceived consequences and a poorer understanding of the condition, are associated with greater psychological distress and poorer adherence to medication. The Common Sense Model provides one potential framework for identifying patients who may be more vulnerable to adverse health outcomes, and for developing early interventions to reduce the physical and psychosocial burden of these conditions. Interventions based on the Common Sense Model have successfully improved physical and psychosocial outcomes associated with other cardiac conditions, and could be tailored for use with patients with an inherited cardiac condition (ICC).

The Effect of Multimodal Emotional Expression on Responses to a Digital Human during a Self-Disclosure Conversation: a Computational Analysis of User Language.

Digital humans show promise for use in healthcare as virtual therapists to deliver psychotherapy or companions for social support. For digital humans to be effective and engaging in these roles, it is important they can build close relationships with people. Emotional expressiveness can improve social closeness in human relationships, especially for females. However, it is unknown whether multimodal emotional expression improves relationships with digital humans. Participants were 185 adults aged 18 years or older with English fluency. Participants were block-randomized by gender to complete the Relationship Closeness Induction Task with one of six versions of a digital human. The digital humans varied in modality richness (face, no face) and emotional expression (emotional voice, neutral voice; emotional face, neutral face). Participants' language was analysed for emotional content using Linguistic Inquiry and Word Count software. A series of three-way ANOVA and ANCOVA were conducted to evaluate the effect of digital human face type, voice type, and participant gender on emotional content in participant language. A digital human with no face was associated with more first-person singular pronoun use than a neutral face and an emotional face digital human. A digital human with no face and a neutral voice received more general negative emotion language than a digital human with no face and an emotional voice. Findings suggest the presence of a face and emotion in the voice may improve emotional responses to digital humans. Results provide evidence for aspects of the theoretical framework of embodied agent-patient communication.

A systematic review of psychological interventions for patients with head and neck cancer.

AIM: The purpose of this systematic review is to identify psychological interventions that have been effective at improving quality of life and reducing psychological distress (depression and anxiety) in patients with head and neck cancer. METHODS: All relevant peer-reviewed articles published between March 1980 and March 2017 were identified through an electronic search of five databases: Medline, Embase, PsycINFO, Scopus, and Academic Search Complete. Risk of bias was independently assessed by two reviewers using the Crowe Critical Appraisal Tool (CCAT). Following this, a narrative synthesis of the findings was completed. RESULTS: Twenty-one unique intervention studies were identified. Interventions tested included cognitive behavioural therapy (CBT), psychoeducation, meditation/mindfulness, group therapy, and telehealth initiatives. Ten studies utilised a randomised controlled design. Five of these investigated CBT and three examined psychoeducation, with the greatest empirical support found for these intervention types. However, the majority of studies were underpowered to detect significant effects and did not examine whether improvements in quality of life and psychological well-being were sustained over time. CONCLUSIONS: Further research is needed to investigate the effects of psychological interventions among patients with head and neck cancer, using randomised controlled designs, adequately powered samples, and long-term follow-up. This would allow evidence-based recommendations to be made regarding the most appropriate interventions to implement in clinical practice. TRIAL REGISTRATION: CRD42017069851.

Reducing Patient Loneliness With Artificial Agents: Design Insights From Evolutionary Neuropsychiatry.

Loneliness is a growing public health issue that substantially increases the risk of morbidity and mortality. Artificial agents, such as robots, embodied conversational agents, and chatbots, present an innovation in care delivery and have been shown to reduce patient loneliness by providing social support. However, similar to doctor and patient relationships, the quality of a patient's relationship with an artificial agent can impact support effectiveness as well as care engagement. Incorporating mammalian attachment-building behavior in neural network processing as part of an agent's capabilities may improve relationship quality and engagement between patients and artificial agents. We encourage developers of artificial agents intended to relieve patient loneliness to incorporate design insights from evolutionary neuropsychiatry.

The Effect of Robot Attentional Behaviors on User Perceptions and Behaviors in a Simulated Health Care Interaction: Randomized Controlled Trial.

BACKGROUND: For robots to be effectively used in health applications, they need to display appropriate social behaviors. A fundamental requirement in all social interactions is the ability to engage, maintain, and demonstrate attention. Attentional behaviors include leaning forward, self-disclosure, and changes in voice pitch. OBJECTIVE: This study aimed to examine the effect of robot attentional behaviors on user perceptions and behaviors in a simulated health care interaction. METHODS: A parallel randomized controlled trial with a 1:1:1:1 allocation ratio was conducted. We randomized participants to 1 of 4 experimental conditions before engaging in a scripted face-to-face interaction with a fully automated medical receptionist robot. Experimental conditions included a self-disclosure condition, voice pitch change condition, forward lean condition, and neutral condition. Participants completed paper-based postinteraction measures relating to engagement, perceived robot attention, and perceived robot empathy. We video recorded interactions and coded for participant attentional behaviors. RESULTS: A total of 181 participants were recruited from the University of Auckland. Participants who interacted with the robot in the forward lean and self-disclosure conditions found the robot to be significantly more stimulating than those who interacted with the robot in the voice pitch or neutral conditions (P=.03). Participants in the forward lean, self-disclosure, and neutral conditions found the robot to be significantly more interesting than those in the voice pitch condition (P<.001). Participants in the forward lean and self-disclosure conditions spent significantly more time looking at the robot than participants in the neutral condition (P<.001). Significantly, more participants in the self-disclosure condition laughed during the interaction (P=.01), whereas significantly more participants in the forward lean condition leant toward the robot during the interaction (P<.001). CONCLUSIONS: The use of self-disclosure and forward lean by a health care robot can increase human engagement and attentional behaviors. Voice pitch changes did not increase attention or engagement. The small effects with regard to participant perceptions are potentially because of the limitations in self-report measures or a lack of comparison for most participants who had never interacted with a robot before. Further research could explore the use of self-disclosure and forward lean using a within-subjects design and in real health care settings.

Open-label Placebos for Wound Healing: A Randomized Controlled Trial.

Background: Open-label placebos are a novel treatment option, in which participants take placebos with full knowledge that they do not contain active medicine. Open-label placebo treatments have been shown to result in patient-reported symptom improvements, but they have not been tested on objectively measurable physiological outcomes such as wound healing. Purpose: The current study aimed to determine whether open-label placebos improved wound healing in punch biopsy wounds compared with no treatment. Methods: In a randomized controlled trial, 70 participants (mean age 27.6 ± 10.1, 58 female) were provided with information about the beneficial effects of placebos and given a 4 mm punch biopsy wound. Participants were then randomized to either an open-label placebo intervention (two placebo tablets twice a day for 10 days) or a no-treatment control group. Wounds were photographed at 7 days and 10 days to determine reepithelialization of the wound surface. Results: No significant differences were observed between the open-label placebo and control conditions in the percentage of wound area healed or for the number of participants with fully reepithelialized wounds at 7 days (placebo 7/32 wounds healed, control 10/33 wounds healed, (χ2[1, N = 65] = 0.60, p = .440, φ = 0.10) and 10 days after wounding (placebo 17/32, control 25/33 wounds healed (χ2[1, N = 65] = 3.64, p = .056, φ = 0.24). Conclusions: Open-label placebo treatment does not improve the healing rate of wounds. Open-label placebos may be beneficial for subjective patient-reported outcomes but do not influence wound healing. Australian New Zealand Clinical Trials Registration: ACTRN12616000411448.

Interactions With Robots: The Truths We Reveal About Ourselves.

In movies, robots are often extremely humanlike. Although these robots are not yet reality, robots are currently being used in healthcare, education, and business. Robots provide benefits such as relieving loneliness and enabling communication. Engineers are trying to build robots that look and behave like humans and thus need comprehensive knowledge not only of technology but also of human cognition, emotion, and behavior. This need is driving engineers to study human behavior toward other humans and toward robots, leading to greater understanding of how humans think, feel, and behave in these contexts, including our tendencies for mindless social behaviors, anthropomorphism, uncanny feelings toward robots, and the formation of emotional attachments. However, in considering the increased use of robots, many people have concerns about deception, privacy, job loss, safety, and the loss of human relationships. Human-robot interaction is a fascinating field and one in which psychologists have much to contribute, both to the development of robots and to the study of human behavior.

Using Robots at Home to Support Patients With Chronic Obstructive Pulmonary Disease: Pilot Randomized Controlled Trial.

BACKGROUND: Socially assistive robots are being developed for patients to help manage chronic health conditions such as chronic obstructive pulmonary disease (COPD). Adherence to medication and availability of rehabilitation are suboptimal in this patient group, which increases the risk of hospitalization. OBJECTIVE: This pilot study aimed to investigate the effectiveness of a robot delivering telehealth care to increase adherence to medication and home rehabilitation, improve quality of life, and reduce hospital readmission compared with a standard care control group. METHODS: At discharge from hospital for a COPD admission, 60 patients were randomized to receive a robot at home for 4 months or to a control group. Number of hospitalization days for respiratory admissions over the 4-month study period was the primary outcome. Medication adherence, frequency of rehabilitation exercise, and quality of life were also assessed. Implementation interviews as well as benefit-cost analysis were conducted. RESULTS: Intention-to-treat and per protocol analyses showed no significant differences in the number of respiratory-related hospitalizations between groups. The intervention group was more adherent to their long-acting inhalers (mean number of prescribed puffs taken per day=48.5%) than the control group (mean 29.5%, P=.03, d=0.68) assessed via electronic recording. Self-reported adherence was also higher in the intervention group after controlling for covariates (P=.04). The intervention group increased their rehabilitation exercise frequency compared with the control group (mean difference -4.53, 95% CI -7.16 to -1.92). There were no significant differences in quality of life. Of the 25 patients who had the robot, 19 had favorable attitudes. CONCLUSIONS: This pilot study suggests that a homecare robot can improve adherence to medication and increase exercise. Further research is needed with a larger sample size to further investigate effects on hospitalizations after improvements are made to the robots. The robots could be especially useful for patients struggling with adherence. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000259549; http://www.anzctr.org.au (Archived by WebCite at  http://www.webcitation.org/6whIjptLS).

The effects of expressive writing before or after punch biopsy on wound healing.

OBJECTIVE: Recent studies have shown that written emotional disclosure (expressive writing) performed in the two weeks prior to wounding improves healing of punch biopsy wounds. In many clinical settings, it would be more practical for patients to perform this intervention after wounding. The aim of this study was to investigate whether expressive writing could speed the healing of punch biopsy wounds if writing was performed after wounds were made. METHODS: One hundred and twenty-two healthy participants aged between 18 and 55years were randomly allocated to one of four groups in a 2 (intervention) by 2 (timing) design. Participants performed either expressive writing or neutral writing, either before or after receiving a 4mm punch biopsy wound. Wounds were photographed on day 10 (primary endpoint) and day 14 after the biopsy to measure epithelisation. Participants also completed questionnaires on stress and affect two weeks prior to the biopsy, on the day of biopsy and two weeks after biopsy. RESULTS: There was a significant difference in healing at day 10 between groups, χ2(3, N=97)=8.84, p=0.032. A significantly greater proportion of participants who performed expressive writing before the biopsy had fully reepithelialised wounds on day 10 compared to participants who performed neutral writing either before or after wounding, with no other significant differences between groups. Amongst people who wrote expressively after wounding, those who finished writing over the first 6days were significantly more likely to be healed at 14days than those who finished writing later. There were significant differences in positive and negative affect over the healing period between the pre and post expressive writing groups. CONCLUSIONS: Expressive writing can improve healing if it is performed prior to wounding. Performing expressive writing after wounding may be able to improve healing depending on the timing of writing and wound assessment. Expressive writing causes affect to worsen followed by subsequent improvement and it is important to consider this in the timing of intervention delivery. Further research with patient groups is required to determine the clinical relevance of these findings.