Relationship between anxiety and internet searches before percutaneous ultrasound-guided diagnostic procedures: A prospective cohort study.

Invasive procedures guided by ultrasound (US) are part of routine medical diagnostic investigation. The lack of knowledge surrounding the technical aspects of such procedures can lead patients to seek complementary information on the Internet, which may in turn trigger anxiety. However, the intersection between the fields of Radiology and Psychology is poorly studied. Here, we identify the profile of an anxious patient before an US-guided intervention. We prospectively studied 133 patients undergoing image-guided procedures. The State-Trait Anxiety Inventory (STAI) was applied for psychometry. Significantly higher anxiety scores were observed in female patients (p = .001), those who believed they had received inadequate information from their referring physician (p = .006), and in patients who considered online information unreliable or difficult to access (p = .007 and p = .001, respectively). Participants who defined themselves as proactive online reported lower anxiety levels (p = .003).

Introduction

Ultrasound (US)-guided invasive procedures are essential modalities in clinical oncology. Advantages of US techniques include real-time imaging, rapid results, low costs, portability, safety and radiation exposure avoidance [1]. Technological advances in medical imaging devices have given rise to an expanding set of interventional procedures designed to benefit the increasing patient population [2]. In parallel, the Internet is increasingly utilized to retrieve information related to medical procedures prior to communication with a healthcare professional [3]. However, online information can be misleading and may amplify misperceptions rather than provide clarification [4]. Given the large amount of inaccurate information online, people can easily become misinformed [5]. While there is a greater awareness of the need to minimize anxiety levels before image-guided procedures [6], very few studies correlate these interventions with the use of the Internet as a consultation tool.

Studies that evaluate Internet usage by patients in search of health information show conflicting data. Similarly, results from studies that assess Internet usage by health professionals are divergent. Several researchers characterize the Internet as both a therapeutic tool [7] and a device to improve doctor-patient relationships. A study conducted by Google® found an increasing rate of health-related searches amongst its users, with a higher number of respondents having sought the platform as their first source of information (35%) than those who immediately consulted a physician (26%) [3]. Another survey conducted by the same platform [8] revealed the primary topic participants searched for online was medical treatment (60%), followed by general information about diseases (52%) and symptoms (48%). However, uncertainties and difficulties in comprehending medical language are often reported due to the multiplicity of information available online [9].

The intersection between the fields of Radiology and Psychology is poorly studied. Considering radiology tests are conducted in the initial approach for diagnosing and monitoring of cancer treatment, it is extremely important that this intersection be further studied. Therefore, the objective of the present study was to investigate the demographic and psychological profiles of patients undergoing US-guided invasive procedures, the patients’ online searches about their proposed interventions, and the impact these variables had on their anxiety levels before the procedure.

Methods

Study design

We conducted a prospective study of patients undergoing US-guided invasive procedures at a cancer center. This study was approved by our Institutional Review Board and performed in accordance with the ethical standards outlined in the Declaration of Helsinki (certificate number approval by the ethics committee 66022517.8.0000.5432, appraisal 2.063.731). Between July 2018 and July 2019, patients were recruited for participation while in the waiting room for their image-guided invasive procedure. All patients that were approached agreed to participate in the study and provided informed consent before inclusion.

Fig 1 depicts the criteria used in patient selection. Hospitalized patients were excluded from the study due to time restrictions before medical interventions.

Fig 1

Inclusion criteria.

STAI, State -Trait Anxiety Inventory; US, ultrasound.

Patients were evaluated at two separate time points. First, prior to the procedure patients completed the State-Trait Anxiety Inventory (STAI). This self-administered questionnaire has been used since 1970 [10] and has the most robust validation in medical literature. It measures state and trait components of anxiety with questions relating to the present moment. After the procedure, patients completed another self-administered questionnaire that addressed multiple variables including education, socio-demographics, and pain levels during the procedure, as well as subjective questions concerning the reliability of information available on the Internet. Notably, participants were informed that there were no ‘correct’ answers in either of the questionnaires. Fig 2 outlines the steps taken from the patients’ arrival at the hospital to the application of the questionnaires and the performance of the procedures.

Fig 2

Flowchart representing the steps taken from the patients’ arrival at the hospital to the presentation of the questionnaires and the performance of the procedures.

STAI, State -Trait Anxiety Inventory; US, ultrasound.

Pre-procedure questionnaire

STAI consists of two subdivisions, each with unique characteristics. The first is the Anxiety-State scale (STAI-State), which assesses states of anxiety in the present moment by asking respondents how they feel “now,” using items that measure subjective feelings of apprehension, tension, nervousness, and concern. The second is the Anxiety-Trait scale (STAI-Trait), which assesses personality characteristics related to anxiety propensity, including general states of calmness, confidence, and security. This psychometric tool is self-administered and consists of 40 items, with 20 allocated to each subscale. The scores range from 20 to 80 in both subsets, with higher scores indicating greater anxiety levels. Generally, a cutoff value of 39–40 points is used to detect symptoms of clinically significant anxiety [10-13]. Most adults require approximately 10 minutes to complete the questionnaire.

Post-procedure questionnaire (supplementary material)

The following clinical and sociodemographic data were collected: age, gender, education level and patient referral source (public or private health care). Patients were asked to provide their medical history and gave responses to subjective questions regarding regular medical follow-ups and overall health (whether they considered themselves “healthy” or “unhealthy”).

Closed questions were used for respondents to evaluate the amount of information provided to them by the referring physician before their procedure, as well as their proactivity in searching for medical information online. The subjective concept of proactivity was assessed by asking, "A proactive person is one who seeks to anticipate problems; to foresee situations… Do you consider yourself to be proactive when searching for information about your health?” Patients were also asked to appraise the reliability and accessibility of online information.

Statistical methods

The STAI-State and STAI-Trait anxiety scores were compared with other variables. Normality distribution was tested using the Kolmogorov-Smirnov test, with p-values of .021 for State and .004 for Trait obtained. The non-parametric Mann-Whitney test was used to compare two subgroups, and the Kruskal-Wallis test was used when three subgroups were analyzed. In the 3-group comparison, whenever statistically significant differences were detected, the Kruskal-Wallis multiple comparison test was used. Scores of p < .05 were considered statistically significant. SPSS software was used (version 20.0).

Results

133 patients underwent US-guided invasive procedures. The mean age of respondents was 49.7 years. Procedures comprised fine needle aspiration (FNA) and core needle biopsy (CNB). 77 patients (57.8%) underwent FNAs at anatomic sites, distributed as follows: 50 thyroid, 10 breast, nine axillary lymph nodes, four cervical lymph nodes, three parotid, and one soft tissue lesion. 56 patients (42.2%) patients underwent core biopsies: 50 breast, three prostate, and three cervical lymph nodes. Baseline characteristics are shown in Table 1.

Table 1

Baseline characteristics of patients undergoing US-guided invasive procedures.

Parameter	US
Sex	n	%
Female	109	82%
Male	24	18%
Education
Incomplete Fundamental	6	4.5%
Complete Fundamental (9 years)	6	4.5%
Incomplete High School	5	3.8%
Complete High School (12 years)	22	16.5%
Incomplete University education	25	18.0%
Complete University education (≥ 14 years)	69	51.9%
Origin
Public Health System	29	21.8%
Private Health System	104	78.2%
Regular medical attention 1
Yes	120	90.8%
No	13	9.2%
Procedure previously performed
Yes	55	41.4%
No	78	58.6%
Previous cancer treatment
Yes	45	33.8%
No	88	66.2%
Individual subjective aspect of health status 2
Healthy	127	95.5%
Unhealthy	6	4.5%

US, ultrasonography.

1 Patients asked if they considered themselves to have regular medical follow-up.

2 Patients asked about their perception of their general health.

Female respondents reported higher mean levels of anxiety than male respondents in the STAI-State scale (p = 0.001) (Table 2). There was a statistically significant inverse relationship between patient assessment of the amount of information received from the referring physician and STAI-State anxiety scores (p = 0.006) (Table 3). As this parameter had three possible responses, the Mann-Whitney test was used to compare responses two by two. Statistical significance was found in the comparisons between the responses “limited information” and “all necessary information,” and between “almost all necessary information” and “all necessary information” (p < 0.05). The relationship between the patients’ self-assessed proactivity and STAI scores are shown in Table 4.

Table 2

Comparison of anxiety (assessed by STAI) between genders.

STAI	Sex	Mean	Median	SD	n	IC	P
State	Female	44.0	45.0	9.1	109.0	1.7	0.001
	Male	36.6	37.0	8.4	24.0	3.4
Trait	Female	39.7	39.0	8.2	109.0	1.5	0.063
	Male	36.2	34.5	9.8	24.0	3.9

STAI, State -Trait Anxiety Inventory; US, ultrasound.

Table 3

Comparison between anxiety levels (assessed by STAI) and information previously provided by the referring physician.

Respondents were asked the following question: "Do you believe that the referring doctor provided all the necessary information to you prior to your procedure?".

STAI	Answer	Mean	Median	SD	N	IC	p
State	Limited information	49.2	48	6.6	5	5.8	0.006
	Almost all necessary information	47.3	46	8.7	22	3.6
	All necessary information	41.2	42	9.2	105	1.8
Trait	Limited information	49.4	55	12.6	5	11.0	0.075
	Almost all necessary information	41.0	40,5	8.4	22	3.5
	All necessary information	38.1	38	8.1	105	1.5

STAI, State -Trait Anxiety Inventory.

Table 4

Comparison between anxiety levels (assessed by STAI) proactivity.

STAI	Answer	Mean	Median	SD	n	IC	p
State	Yes	41,8	42	9.6	108	1.8	0.003
	No	47,4	48	5.8	23	2.4
Trait	Yes	38,6	38	9.0	108	1.7	0.129
	No	41,0	40	6.4	23	2.6

STAI, State -Trait Anxiety Inventory.

There was a significant correlation between STAI-State scores and how reliable patients found information on the internet concerning their procedure, with higher scores associated with “unreliable” responses (p = 0.007). STAI-State scores were also directly related to assessments of the accessibility of online information (mean of 39.3 points for those who considered accessibility “easy”, compared to 45.4 points for those who reported it to be “difficult” (p = 0.001), Table 5. There were no significant associations between STAI anxiety scores and age, education level, past experiences of undergoing the proposed procedure or cancer treatment, subjective assessments of health status, or the regularity of medical care (p > 0.05).

Table 5

Comparison between anxiety levels (assessed by STAI) and patients’ subjective appraisals of the reliability and accessibility of online information regarding US-guided invasive procedures.

The available data refers to both those who did and did not search online. Anxiety scores were measured using the STAI scale.

STAI	Answer	Mean	Median	SD	N	IC	p
State	Reliable	40.2	40.5	10.6	60	2.7	0.007
	Unreliable	45.0	45.0	7.3	58	1.9
Trait	Reliable	38.1	36.5	9.1	60	2.3	0.119
	Unreliable	40.2	39.5	8.3	58	2.1
State	Easy	39.3	40	10.2	55	2.7	0.001
	Difficult	45.4	45	7.5	65	1.8
Trait	Easy	37.5	37	8.2	55	2.2	0.060
	Difficult	40.5	39	8.9	65	2.2

STAI, State -Trait Anxiety Inventory.

Discussion

The profile of a patient who undergoes an US-guided percutaneous interventional procedure is likely a female who reports regular medical care and has higher education and private health insurance. This patient undergoes the procedure for the first time, does not receive cancer treatment, and believes they are healthy. We observed significantly higher anxiety scores among female patients, respondents who reported to have had received insufficient information from their referring physician, those who considered information available on the Internet unreliable, and participants who found it difficult to access information online. On the other hand, patients who defined themselves as proactive in their online searches demonstrated lower anxiety levels before invasive interventions. These results are relevant in clinical practice because there are few studies that associate Internet use, information communicated by referring physicians, and anxiety levels prior to US-guided invasive procedures.

Our results show that females presented higher levels of anxiety than males, which is consistent with the findings of several published studies. Yu et al. [11] conducted a study on cancer patients before diagnostic imaging exams. Of the 328 participants, 152 (46.3%) reported having anxiety and females were found to have higher levels of anxiety than males (p = 0.021). Surgical studies are more prevalent in medical literature. Despite inherent differences between populations, such studies can be instructive when examining the difference in anxiety levels between genders. Domar et al. [12] evaluated 523 patients undergoing elective surgery. Preoperatively, multiple parameters were evaluated including patients’ age, gender, occupation, education level, type of surgery, and whether they had previously undergone a similar procedure. Respondents completed the STAI questionnaire for anxiety psychometry in the waiting room right before their intervention. Of all the parameters examined, only gender was found to be positively correlated with anxiety levels, with females presenting as more anxious. This finding has also been reported in other parts of the world [13]. Jafar et al. used STAI to evaluate 300 pre-surgical patients in Pakistan and found higher levels of anxiety in female respondents. However, considering anxiety questionnaires are self-administered, female patients may be more inclined to admit to having anxiety than their male counterparts. It is therefore necessary to exercise caution before stating that these data represent an innate difference in anxiety levels between genders [14].

Patients who claimed to have received insufficient information from referring physicians were found to be more anxious before US-guided interventions. The lack of knowledge amongst patients prior to undergoing medical interventions has been the subject of previous studies. Kiyohara et al. [15] evaluated 140 patients before undergoing elective surgical procedures. STAI scores were correlated to the patients’ understanding of their diagnoses, surgical procedures, and types of anesthesia. Knowledge about the diagnosis or the prescribed anesthesia did not significantly influence anxiety levels amongst participants. However, patients who had doubts about their surgical procedure reported higher STAI-State anxiety psychometry scores. Our results indicate patients with limited prior medical information have higher STAI-State scores, which supports previous studies that highlight the importance of patients receiving adequate information before medical procedures.

Various studies have been conducted to elucidate patient behavior after medical appointments. Bell et al. [16] used an online questionnaire to evaluate 274 members of an online community who had undergone a medical consultation within the 30 days prior to the study. Most respondents reported having searched for information online after their appointments (68%). Those who reported that they received insufficient information in their consultation were more likely to search online. Li et al. [17] evaluated 311 patients who had medical consultations in 2019. Participants listed curiosity and the perception that physicians gave incomplete information as the primary reasons for searching for complementary data on the Internet. There are, however, some limitations in these studies that are important to note. Firstly, they were limited to members of small online communities, raising questions regarding the generalization of their findings. In addition, as participants were connected to the Internet, it is possible that they were more familiar with this technology than the general population. On the other hand, the present study brings new information to medical literature, as it included patients in the waiting room right before their procedures. Further, the questionnaires were applied regardless of whether participants had searched for complementary information online. Despite these methodological differences, we believe that our results are complementary and indicate that misinformation may lead patients to search for supplementary information online.

Patient appraisal of online information was also assessed. Both participants who assessed online information as “unreliable” and those who reported difficulty with accessibility were found to have higher anxiety levels. Previous studies have attempted to identify which criteria are credible quality indicators of online information. Johnson et al. [18] concluded that the formation of trust is influenced both by central parameters such as website content, as well as peripheral factors such as style and ease of access. On the contrary, Kelton et al. inferred that reliability assessments are linked to users’ personal concepts and their identification with the available content. They proposed that a sense of concurrence between the user and the website results from the commonality between the information presented and “the user’s own sense of identity, goals and values.” [19]. Consequently, personal identification is seen to play a central role in creating a perception of “reliable” information. Therefore, we have identified a clinical interaction amenable to intervention, in which a more transparent communication interface between online information and the patient could decrease anxiety before an US-guided invasive procedure. A potential example would be the recommendation of trusted sites by physicians during consultations, preferably in the institution where the procedure takes place.

Proactivity in initiating online searches for information relating to health has also been studied. Murray et al. [20] conducted a telephone survey that covered all regions of the United States and consisted of 3209 participants. “Proactive” individuals were defined as those who instigated an online search for health topics of their own accord. The author concluded that proactive participants were more likely to consider themselves as “excellent” or “particularly good” at assessing the reliability of online information, as well as in their ability to find relevant information. The present study demonstrated that patients who were more proactive were less anxious at the time of their US-guided interventions. Mc Mullan et al. [21] published a literature review on the use of the Internet to obtain health information and its impact on doctor-patient relationships. Three potential responses to patients who utilize online searches prior to consultation were discussed: 1) the healthcare professional feels threatened by the information and responds by defensively stating his "expert opinion"; 2) the healthcare professional and the patient cooperate in the analysis of online information; 3) the healthcare professional guides patients to reliable sites on the Internet. Previous studies suggest positive results when information found on the Internet by the patient is discussed with the doctor [22]. On the other hand, it is precisely this third response that leads us to formulate a question yet to be answered: can proactivity be encouraged during consultations? If so, could it result in reduced anxiety levels before US-guided procedures?

We verified the absence of significant associations between STAI-Trait scores, the studied demographic parameters, and Internet use. This finding was expected since the STAI-Trait scale reflects a more chronic predisposition to anxiety. A meta-analysis published by Schneider et al. [23] reviewed all published articles and unpublished dissertations between 1980 and 2005 that utilized STAI to address psychosocial interventions for cancer patients. The results for changes in STAI-Trait scores were equivocal, suggesting that pre-intervention stress is more accurately characterized by STAI-State. Thus, considering that the focus of our study was anxiety levels experienced moments before an invasive procedure, the STAI-State was expected to reflect the patients’ anxiety levels more accurately.

It should also be noted that there is a high prevalence of psychiatric disorders such as depression and anxiety amongst cancer patients [24]. Despite the large knowledge gap in the medical literature and the absence of specific guidelines on the subject [25], health professionals involved in care are required to understand how to approach said conditions. While our study advances understanding of image-guided diagnostic procedures, it is important to note cancer patients are individuals with a significant anxiety burden that requires further investigation on the subject.

There are several other limitations in the present study that must be considered. Firstly, regarding the quality of communication by the referring physician, we draw attention to the lack of a structured diagnostic clinical interview. Additionally, we must consider the heterogeneity between the comparison groups, namely the different types of procedures in different organs and tissues. Finally, study participants were not directly asked whether they suffered from a psychiatric illness. While the authors found no evidence of consultations with clinical psychologists or psychiatrists in any of the patients’ electronic medical records, participants were not directly asked about symptoms or previous traumatic events.

Conclusion

Despite limitations, this study shows that higher anxiety scores before invasive US-guided procedures were found in female patients, in those who reported having had received insufficient information from their referring physician, and in those who considered online information to be unreliable or difficult to access. The recognition of this profile can guide measures to reduce anxiety in patients who will undergo an US-guided invasive procedure, by improving communication between patient and physician and providing accurate and easily accessible information online.

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Reviewer #1: I am glad to review and assess this exciting article, entitled, “Anxiety and internet research before percutaneous ultrasound-guided diagnostic procedures”. Invasive procedures guided by ultrasound (US) are part of the routine medical diagnostic investigation. The lack of knowledge related to technical aspects about them can lead the patient to seek complementary information on the internet, which can trigger anxiety. However, the intersection between the areas of Radiology and Psychology is poorly studied. Here we show the profile of an anxious patient before an US-guided intervention.

The organization of this article is good and partly satisfactory. The Introduction section, methodology portions are adequate. I suggest the authors improve these parts overall to enhance the work quality. As suggested, I recommend that authors do a little more work and add the latest literature to support the study. I accept this manuscript after minor revision, as I have recommended.

Some valuable comments are given below;

• The manuscript needs language, grammar, and syntactic editing. The English language usage should be checked by a fluent English speaker (Writing quality is inferior. Numerous grammatical mistakes and meaningless sentences)

• The primary defect of this study is the debate or argument is not clearly stated in the introduction session. Hence, the contribution is weak in this manuscript. I would suggest the author enhance your theoretical discussion and your debate or argument.

• The research gap is not evident and appropriate.

• Must add much more explanations and interpretations for the results, which are not enough

• It is suggested to compare the results of the present research with some similar studies which is done before (more justification is needed)

• Should add a flowchart to the article to show the research methodology

Reviewer #2: This paper is well written and enriches the existing literature. The methodology is sound and has been applied before. The results are presented well and discussed. Therefore, I will recommend the acceptance of the paper.

Reviewer #3: I have evaluated this interesting study entitled, "Anxiety and internet research before percutaneous ultrasound-guided diagnostic procedures."

is an informative research study. I suggest some minor corrections to check the typo errors in writing to enhance the English quality to reach the scientific merit for the publication of this study.

This article describes that invasive procedures guided by ultrasound (US) are part of the routine medical diagnostic investigation. The lack of knowledge related to technical aspects about them can lead the patient to seek complementary information on the internet, which can trigger anxiety. However, the intersection between the areas of Radiology and Psychology is poorly studied. Here we show the profile of an anxious patient before an US-guided intervention.

I am in favor of this study and will recommend for publication. However, the authors need to revise the manuscript and work according to my suggestions to enhance the quality. I will accept this paper for publication after these minor changes as suggested below.

Introduction and literation sections

I recommend the authors add suggested articles in the introduction and literature sections. These research articles have identified health-related topics I believe it will improve the quality of your work. I strongly suggested them to improve this section a bit more. I advise authors to revisit their introduction and literature sections of the recommended studies and cite these studies to enhance your research study's quality to reach scientific merit for publication.

Wang, C., Wang, D., Duan, K., & Mubeen, R. (2021). Global financial crisis, smart lockdown strategies, and the COVID-19 spillover impacts: A global perspective implications from Southeast Asia. Front Psychiatry, 12, 1-14. doi:10.3389/fpsyt.2021.643783

Abbas, J., Raza, S., Nurunnabi, M., Minai, M. S., & Bano, S. (2019). The Impact of Entrepreneurial Business Networks on Firms’ Performance Through a Mediating Role of Dynamic Capabilities. Sustainability, 11(11), 3006. doi:10.3390/su11113006

NeJhaddadgar, N., Ziapour, A., Zakkipour, G., Abolfathi, M., & Shabani, M. (2020, Nov 13). Effectiveness of telephone-based screening and triage during COVID-19 outbreak in the promoted primary healthcare system: a case study in Ardabil province, Iran. Z Gesundh Wiss, 1-6. https://doi.org/10.1007/s10389-020-01407-8

Abbas, J., Aqeel, M., Abbas, J., Shaher, B., A, J., Sundas, J., & Zhang, W. (2019, Feb 1). The moderating role of social support for marital adjustment, depression, anxiety, and stress: Evidence from Pakistani working and nonworking women. J Affect Disord, 244, 231-238. https://doi.org/10.1016/j.jad.2018.07.071

Literature

I want to see publish this creative study after some corrections. I have endorsed this study as; it deserves the merit for publication. However, I suggest the authors make minor corrections according to my advice. Please read the suggested studies and cite them in the introduction, literature, and method sections. How corporate social responsibility, innovation and social media and internet use is helpful. Add few lines in the introduction and literature sections. How companies are practicing CSR, business, entrepreneurial networks with innovation and knowledge sharing to improve the business performance and provide better healthcare medicines?

Azizi, M. R., Atlasi, R., Ziapour, & Naemi, R. (2021). Innovative human resource management strategies during the COVID-19 pandemic: A systematic narrative review approach. Heliyon, 7(6), e07233. doi:10.1016/j.heliyon.2021.e07233

Abbas, J., Zhang, Q., Hussain, I., Akram, S., Afaq, A., & Shad, M. A. (2020). Sustainable Innovation in Small Medium Enterprises: The Impact of Knowledge Management on Organizational Innovation through a Mediation Analysis by Using SEM Approach. Sustainability, 12(6), 2407. doi:https://doi.org/10.3390/su12062407

Azadi, N. A., Ziapour, A., Lebni, J. Y., Irandoost, S. F., & Chaboksavar, F. (2021). The effect of education based on health belief model on promoting preventive behaviors of hypertensive disease in staff of the Iran University of Medical Sciences. Archives of Public Health, 79(1), 69. doi:10.1186/s13690-021-00594-4

Abbas, J., Hussain, I., Hussain, S., Akram, S., Shaheen, I., & Niu, B. (2019). The Impact of Knowledge Sharing and Innovation upon Sustainable Performance in Islamic Banks: A Mediation Analysis through an SEM Approach. Sustainability, 11(15), 4049. doi:10.3390/su11154049

Materials and Methods

The results section of the paper presents a good view of the study. This work presents a notable investigation on a selected topic. I suggest the authors to present high quality graphs. By including some graphical presentations will improve the quality of this study. Please see the proposed studies and see the graphical representation. Improve your work like these studies and cite them in this section.

Paulson, K. R., Kamath, A. M., Alam, T., Bienhoff, K., Abady, G. G., . . . Kassebaum, N. J. (2021). Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019. The Lancet, 1-36. doi:10.1016/s0140-6736(21)01207-1

Abbas, J., Aqeel, M., Ling, J., Ziapour, A., Raza, M. A., & Rehna, T. (2020). Exploring the relationship between intimate partner abuses, resilience, psychological, and physical health problems in Pakistani married couples: a perspective from the collectivistic culture. Sexual and Relationship Therapy, 35, 1-30. https://doi.org/10.1080/14681994.2020.1851673

Abbas, J., Aman, J., Nurunnabi, M., & Bano, S. (2019). The Impact of Social Media on Learning Behavior for Sustainable Education: Evidence of Students from Selected Universities in Pakistan. Sustainability, 11(6). https://doi.org/10.3390/su11061683

Abbas, J., Aqeel, M., Jaffar, A., Nurunnabi, M., & Bano, S. (2019, 2019/07/01). Tinnitus perception mediates the relationship between physiological and psychological problems among patients. Journal of Experimental Psychopathology, 10(3), 2043808719858559. https://doi.org/10.1177/2043808719858559

Discussion

I suggest the authors to discuss the effects of the COVID-19. I suggest you to cite these studies. Read the proposed studies to improve your results and discussion section. See the recommended studies and improve your sections.

Su, Z., McDonnell, D., Wen, J., Kozak, M., Šegalo, S., . . . Xiang, Y.-T. (2021). Mental health consequences of COVID-19 media coverage: the need for effective crisis communication practices. Globalization and Health, 17(1), 4. doi:10.1186/s12992-020-00654-4

Aqeel, M., Shuja, K. H., Rehna, T., Ziapour, A., Yousaf, I., & Karamat, T. (2021). The Influence of Illness Perception, Anxiety and Depression Disorders on Students Mental Health during COVID-19 Outbreak in Pakistan: A Web-Based Cross-Sectional Survey. International Journal of Human Rights in Healthcare, 14, 1-14.

Abbas, J. (2020). The Impact of Coronavirus (SARS-CoV2) Epidemic on Individuals Mental Health: The Protective Measures of Pakistan in Managing and Sustaining Transmissible Disease. Psychiatr Danub, 32(3-4), 472-477. https://doi.org/10.24869/psyd.2020.472

Conclusion

I suggest you make a separate heading of the conclusion and do not mix it with implications.

Policy Recommendations

I again recommend you to make a separate heading of the Policy Recommendations.

The conclusion section is acceptable. Overall, this presents a good piece of research work. I recommend that authors do a little more work and revise this article accordingly. I suggest the authors check English quality and fix some weak sentences. If you have already taken English editing service, ask them to recheck the quality to meet scientific merit for publication. I endorse this manuscript for publication after minor corrections, as suggested.

Reviewer #4: Thank you for submitting the manuscript. I have read your manuscript very carefully. The theme you are addressing is an important one that investigates the doctor-patient relationship. I am convinced that small adjustments can increase the quality and readability of the paper.First of all I would like you to enter the protocol number of the approval by the Ethics Committee of the study.I would also like to have more information about the patient's medical history. I'll explain. The paper does not talk about the psychological history of patients, but only about their self-definition as pro-active or not.This definition is too reductive to understand the psychological situation of the patients involved. The psychological history of the subjects would provide us with important information to better understand the possible origin of anxiety and possible confounding factors.Have any traumatic factors been investigated in the history of the subjects (war veterans, child abuse, road accidents ...)? Have you asked about the possible use of anxiolytic drugs? Have you asked if the subjects have ever been in psychotherapy?If you have this information, in my opinion, it must be explained in the paper and it must be correlated with the results. If, on the other hand, you do not have one, it is necessary to insert this gap among the limitations of the study.I am sure that with these small suggestions the paper can be improved. I hope these comments are helpful to you.

Kind Regards

**********

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Reviewer #1: Yes: KASHIF ABBASS

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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4 Dec 2021

Reviewer #1

1. The manuscript needs language, grammar, and syntactic editing. The English language usage should be checked by a fluent English speaker (Writing quality is inferior. Numerous grammatical mistakes and meaningless sentences)

�  The authors agree with the statements. The entire article was submitted for review by a native English speaker.

2. The primary defect of this study is the debate or argument is not clearly stated in the introduction session. Hence, the contribution is weak in this manuscript. I would suggest the author enhance your theoretical discussion and your debate or argument. The research gap is not evident and appropriate.

�  The authors agree. To clarify the central theme of the study, the following excerpt was added to the first paragraph of the introduction: “Although image-guided procedures and the use of the Internet as a resource are ingrained in the modern world, few studies have correlated the two with the presence of anxiety before invasive procedures.”

3. Must add much more explanations and interpretations for the results, which are not enough. It is suggested to compare the results of the present research with some similar studies which is done before (more justification is needed)

�  The authors agree. More time was spent on improving the discussion section to bring more clarity when connecting our study with previous publications.

• Should add a flowchart to the article to show the research methodology

�  The authors agree and the text was edited to include the flowchart represented in Figure 2.

Reviewer #2

This paper is well written and enriches the existing literature. The methodology is sound and has been applied before. The results are presented well and discussed. Therefore, I will recommend the acceptance of the paper.

�  The authors are grateful for the comments.

Reviewer #3:

I have evaluated this interesting study entitled, "Anxiety and internet research before percutaneous ultrasound-guided diagnostic procedures." is an informative research study. I suggest some minor corrections to check the typo errors in writing to enhance the English quality to reach the scientific merit for the publication of this study.

This article describes that invasive procedures guided by ultrasound (US) are part of the routine medical diagnostic investigation. The lack of knowledge related to technical aspects about them can lead the patient to seek complementary information on the internet, which can trigger anxiety. However, the intersection between the areas of Radiology and Psychology is poorly studied. Here we show the profile of an anxious patient before an US-guided intervention.

I am in favor of this study and will recommend for publication. However, the authors need to revise the manuscript and work according to my suggestions to enhance the quality. I will accept this paper for publication after these minor changes as suggested below.

Introduction and literation sections

I recommend the authors add suggested articles in the introduction and literature sections. These research articles have identified health-related topics I believe it will improve the quality of your work. I strongly suggested them to improve this section a bit more. I advise authors to revisit their introduction and literature sections of the recommended studies and cite these studies to enhance your research study's quality to reach scientific merit for publication.

Wang, C., Wang, D., Duan, K., & Mubeen, R. (2021). Global financial crisis, smart lockdown strategies, and the COVID-19 spillover impacts: A global perspective implications from Southeast Asia. Front Psychiatry, 12, 1-14. doi:10.3389/fpsyt.2021.643783

Abbas, J., Raza, S., Nurunnabi, M., Minai, M. S., & Bano, S. (2019). The Impact of Entrepreneurial Business Networks on Firms’ Performance Through a Mediating Role of Dynamic Capabilities. Sustainability, 11(11), 3006. doi:10.3390/su11113006

NeJhaddadgar, N., Ziapour, A., Zakkipour, G., Abolfathi, M., & Shabani, M. (2020, Nov 13). Effectiveness of telephone-based screening and triage during COVID-19 outbreak in the promoted primary healthcare system: a case study in Ardabil province, Iran. Z Gesundh Wiss, 1-6. https://doi.org/10.1007/s10389-020-01407-8

Abbas, J., Aqeel, M., Abbas, J., Shaher, B., A, J., Sundas, J., & Zhang, W. (2019, Feb 1). The moderating role of social support for marital adjustment, depression, anxiety, and stress: Evidence from Pakistani working and nonworking women. J Affect Disord, 244, 231-238. https://doi.org/10.1016/j.jad.2018.07.071

Literature

I want to see publish this creative study after some corrections. I have endorsed this study as; it deserves the merit for publication. However, I suggest the authors make minor corrections according to my advice. Please read the suggested studies and cite them in the introduction, literature, and method sections. How corporate social responsibility, innovation and social media and internet use is helpful. Add few lines in the introduction and literature sections. How companies are practicing CSR, business, entrepreneurial networks with innovation and knowledge sharing to improve the business performance and provide better healthcare medicines?

Azizi, M. R., Atlasi, R., Ziapour, & Naemi, R. (2021). Innovative human resource management strategies during the COVID-19 pandemic: A systematic narrative review approach. Heliyon, 7(6), e07233. doi:10.1016/j.heliyon.2021.e07233

Abbas, J., Zhang, Q., Hussain, I., Akram, S., Afaq, A., & Shad, M. A. (2020). Sustainable Innovation in Small Medium Enterprises: The Impact of Knowledge Management on Organizational Innovation through a Mediation Analysis by Using SEM Approach. Sustainability, 12(6), 2407. doi:https://doi.org/10.3390/su12062407

Azadi, N. A., Ziapour, A., Lebni, J. Y., Irandoost, S. F., & Chaboksavar, F. (2021). The effect of education based on health belief model on promoting preventive behaviors of hypertensive disease in staff of the Iran University of Medical Sciences. Archives of Public Health, 79(1), 69. doi:10.1186/s13690-021-00594-4

Abbas, J., Hussain, I., Hussain, S., Akram, S., Shaheen, I., & Niu, B. (2019). The Impact of Knowledge Sharing and Innovation upon Sustainable Performance in Islamic Banks: A Mediation Analysis through an SEM Approach. Sustainability, 11(15), 4049. doi:10.3390/su11154049

Materials and Methods

The results section of the paper presents a good view of the study. This work presents a notable investigation on a selected topic. I suggest the authors to present high quality graphs. By including some graphical presentations will improve the quality of this study. Please see the proposed studies and see the graphical representation. Improve your work like these studies and cite them in this section.

Paulson, K. R., Kamath, A. M., Alam, T., Bienhoff, K., Abady, G. G., . . . Kassebaum, N. J. (2021). Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019. The Lancet, 1-36. doi:10.1016/s0140-6736(21)01207-1

Abbas, J., Aqeel, M., Ling, J., Ziapour, A., Raza, M. A., & Rehna, T. (2020). Exploring the relationship between intimate partner abuses, resilience, psychological, and physical health problems in Pakistani married couples: a perspective from the collectivistic culture. Sexual and Relationship Therapy, 35, 1-30. https://doi.org/10.1080/14681994.2020.1851673

Abbas, J., Aman, J., Nurunnabi, M., & Bano, S. (2019). The Impact of Social Media on Learning Behavior for Sustainable Education: Evidence of Students from Selected Universities in Pakistan. Sustainability, 11(6). https://doi.org/10.3390/su11061683

Abbas, J., Aqeel, M., Jaffar, A., Nurunnabi, M., & Bano, S. (2019, 2019/07/01). Tinnitus perception mediates the relationship between physiological and psychological problems among patients. Journal of Experimental Psychopathology, 10(3), 2043808719858559. https://doi.org/10.1177/2043808719858559

�  The authors agree and the text was edited to include the flowchart represented in Figure 2.

Discussion

I suggest the authors to discuss the effects of the COVID-19. I suggest you to cite these studies. Read the proposed studies to improve your results and discussion section. See the recommended studies and improve your sections.

Su, Z., McDonnell, D., Wen, J., Kozak, M., Šegalo, S., . . . Xiang, Y.-T. (2021). Mental health consequences of COVID-19 media coverage: the need for effective crisis communication practices. Globalization and Health, 17(1), 4. doi:10.1186/s12992-020-00654-4

Aqeel, M., Shuja, K. H., Rehna, T., Ziapour, A., Yousaf, I., & Karamat, T. (2021). The Influence of Illness Perception, Anxiety and Depression Disorders on Students Mental Health during COVID-19 Outbreak in Pakistan: A Web-Based Cross-Sectional Survey. International Journal of Human Rights in Healthcare, 14, 1-14.

Abbas, J. (2020). The Impact of Coronavirus (SARS-CoV2) Epidemic on Individuals Mental Health: The Protective Measures of Pakistan in Managing and Sustaining Transmissible Disease. Psychiatr Danub, 32(3-4), 472-477. https://doi.org/10.24869/psyd.2020.472

�  The authors are grateful for the constructive feedback and have read all the above studies. After careful consideration we selected the following articles to include in our study. The first one was entitled “Abbas, J., Aqeel, M., Abbas, J., Shaher, B., A, J., Sundas, J., & Zhang, W. (2019, Feb 1). The moderating role of social support for marital adjustment, depression, anxiety, and stress: Evidence from Pakistani working and nonworking women. J Affect Disord, 244, 231-238. https://doi.org/10.1016/j.jad.2018.07.071”. It fits perfectly with our argument that correlates higher anxiety in the female gender, as it follows: “Preoperatively, multiple parameters were evaluated including: patients’ age, sex gender, occupation, education level, type of surgery, and whether they patient had previously undergone a similar procedure. Respondents completed the STAI questionnaire for anxiety psychometry in the waiting room right before their intervention. Of all the parameters examined, only the female gender was found to be positively correlated with anxiety levels. This finding has also been reported in other parts of the world [10]. Jafar et al. used STAI to evaluate 300 pre-surgical patients in Pakistan and found higher levels of anxiety in females. However, considering anxiety questionnaires are self-administered, female patients may be more inclined to admit to having anxiety than males patients. It is therefore necessary to exercise caution before stating that these data represent an innate difference in anxiety levels between genders [11].”

Conclusion

I suggest you make a separate heading of the conclusion and do not mix it with implications.

Policy Recommendations

I again recommend you to make a separate heading of the Policy Recommendations.

�  Although the author agrees with the comment and think it would be more coherent to separate the policy recommendations and implications from the conclusion, this paper follows the recommendations and structure set out in PLOSONE guideline.

The conclusion section is acceptable. Overall, this presents a good piece of research work. I recommend that authors do a little more work and revise this article accordingly. I suggest the authors check English quality and fix some weak sentences. If you have already taken English editing service, ask them to recheck the quality to meet scientific merit for publication. I endorse this manuscript for publication after minor corrections, as suggested.

�  The authors agree. To clarify the central theme of the study, the following excerpt was added to the first paragraph of the introduction: “Although image-guided procedures and the use of the Internet as a resource are ingrained in the modern world, few studies have correlated the two with the presence of anxiety before invasive procedures.”. Additionally, the entire article was submitted for review by a native English speaker.

Reviewer #4

Thank you for submitting the manuscript. I have read your manuscript very carefully. The theme you are addressing is an important one that investigates the doctor-patient relationship. I am convinced that small adjustments can increase the quality and readability of the paper.

1. First of all I would like you to enter the protocol number of the approval by the Ethics Committee of the study.

�  The authors agree and added the following text: “(certificate number approval by the ethics committee 66022517.8.0000.5432, appraisal 2.063.731).” - Study Design.

2. I would also like to have more information about the patient's medical history. I'll explain. The paper does not talk about the psychological history of patients, but only about their self-definition as pro-active or not. This definition is too reductive to understand the psychological situation of the patients involved. The psychological history of the subjects would provide us with important information to better understand the possible origin of anxiety and possible confounding factors. Have any traumatic factors been investigated in the history of the subjects (war veterans, child abuse, road accidents ...)? Have you asked about the possible use of anxiolytic drugs? Have you asked if the subjects have ever been in psychotherapy? If you have this information, in my opinion, it must be explained in the paper and it must be correlated with the results. If, on the other hand, you do not have one, it is necessary to insert this gap among the limitations of the study. I am sure that with these small suggestions the paper can be improved. I hope these comments are helpful to you.

�  This observation is very important and the authors are grateful. During the study, we were careful to look for appointments with psychologists or psychiatrists by the participants. Despite not being an inclusion/exclusion criterion, we found that no patient had had an appointment with these professionals at the hospital where the invasive procedure was performed. This does not prevent an important limitation of our study since aspects of psychiatric illnesses were not directly addressed or questioned. These points have been added to the Discussion session, in limitations, as follows: “Finally, there were no direct questions included regarding the presence of psychiatric illness among study participants. While the authors found no evidence of consultations with clinical psychologists or psychiatrists in the patients’ electronic medical records, participants were not directly asked about symptoms or previous traumatic events.”

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

7 Jan 2022

12 Feb 2022

Editor Comments

I suggest further changes

1. TITLE. Include the type of the study and setting.. For example: "A prospective cohort study ..."

�  The study title has been changed to: “Relationship Between Anxiety and Internet Searches Before Percutaneous Ultrasound-guided Diagnostic Procedures: A Prospective Cohort Study”

2. ABSTRACT. Include p-values

�  P-values were included.

3. LIMITATIONS (It deserves a dedicated paragraph). Emphasizes that cancer patients are individuals with a significant anxiety burden.

�  Prior to specific limitations session, the following was added: “It should also be noted that there is a high prevalence of psychiatric disorders such as depression and anxiety amongst cancer patients [22]. This universe requires understanding from health professionals involved in care, despite the large knowledge gap in the medical literature and the absence of specific guidelines on the subject [23]. While our study advances understanding of image-guided diagnostic procedures, it is important to note cancer patients are individuals with a significant anxiety burden that requires further investigations on the subject.

3. CONCLUSION. Add "Despite limitations, this study shows that ..."

�  Added phrase as follows: “Despite limitations, this study shows that higher anxiety scores before invasive US-guided procedures were found in female patients, in those who reported having had received insufficient information from their referring physician, and in those who considered online information to be unreliable or difficult to access. The recognition of this profile can guide measures to reduce anxiety in patients who will undergo an US-guided invasive procedure, by improving patient-physician communication and providing accurate and easily accessible information online.”

4. REFERENCES. Many references are more than 20 years old. This is a gap for the article. Add, other more recent references:

a. about anxiety: doi: 10.1097/RMR.0000000000000238; doi 10.18632/oncotarget.17238; doi: 10.1002/da.23115 b. about internet-based patients' searching: doi: 10.1176/appi.ps.201800495; doi: 10.1371/journal.pone.0261471.

�  The authors agree with this observation. The reference “Bull Med Libr Assoc. 2001 Oct;89(4):397-9. PMID: 11837263; PMCID: PMC57970” has been replaced by “Top Magn Reson Imaging. 2020 Aug;29(4):197-201. doi: 10.1097/RMR.0000000000000238. PMID: 32472820”. Another updated reference was added (Psychiatr Serv. 2019 Apr 1;70(4):324-328.”).

�  We are especially grateful for the suggested article " PLoS One. 2021 Dec 31;16(12):e0261471" as it fits properly into the following manuscript excerpt: “Three potential responses to patients who utilize online searches prior to consultation were discussed: 1) the healthcare professional feels threatened by the information and responds by defensively stating his "expert opinion"; 2) the healthcare professional and the patient cooperate in the analysis of online information; 3) the healthcare professional guides patients to reliable sites on the Internet. Previous studies suggest positive results when the information brought from the Internet by the patient is discussed together with the doctor [21]. On the other hand, it is precisely in this third response that our study supports and leads us to formulate a question yet to be answered: can proactivity be encouraged during consultations? If so, could it result in reduced anxiety before US-guided procedures?”

Finally, I suggest another round of lexical correction. The style still doesn't sound.

�  A new spelling and writing style review was requested from a professional who is native and fluent in the English language.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

7 Jun 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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Guest Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear authors,

After being sent to three independent reviewers, they considered the paper would need a major revision in order to potentially be published.

Thus, please, read carefully the comments of the reviewers and try to give response to them.

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Francisco Sampaio

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #5: All comments have been addressed

Reviewer #6: (No Response)

Reviewer #7: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #5: Yes

Reviewer #6: Partly

Reviewer #7: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #5: No

Reviewer #6: I Don't Know

Reviewer #7: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #5: Yes

Reviewer #6: No

Reviewer #7: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #5: * It is a very interesting and very current topic. Health systems must find strategies to increase the well-being of their patients. This work can help to find these strategies, after identifying the causes.

* Despite not being native to the English language, it seems to me that English should be revised.

* On page 12, section "Statistical Methods", authors should add, right after the phrase "The non-parametric Mann-Whitney

test was used to compare two subgroups, and the Kruskal-Wallis test was used when three subgroups were analyzed.", the following:

"In the 3 group comparison, whenever statistically significant differences were detected, the Kruskal-Wallis multiple comparison test was used."

Authors should not use the Mann-Whitney test to compare groups 2 to 2, as this increases the probability of type I error from 0.05 to 0.143 (as it is related to the number of comparisons to be performed). They should use the Kruskal-Wallis multiple comparison tests, already available in SPSS version 20.0.

* The titles of tables 2, 3, 4 and 5 are not correct. In any of the tables, what the authors are doing is comparing anxiety levels (STAI-State and STAI-Trait) between groups. They are not studying the correlation.

Reviewer #6: It seems, the manuscript do not follow scientific writing for an article such as topic presentations and study design and figure 1, raw presentation.

Reviewer #7: It is a current exciting topic and manuscript. While not the most original work, it adds exciting data concerning patient-centered care during diagnostic procedures. It provides essential information to oncology specialty professionals and general practice. However, the manuscript presents some relevant weaknesses.

A linguistic revision is suggested to make the reading more accessible and precise.

Abstract: Reduce background (the last two sentences are not needed) and improve methods, results, and conclusion

Introduction: The introduction should be improved with more references related to diagnostic medical procedures and online search anxiety. There are scientific papers available.

Methods: Please organize better methods section regarding Sample or participants, measures (information regarding STAI is repetitive), proceedings (including dates for data collecting), ethical considerations, and Statistical analyses.

Results: Did the authors considered performed Hierarchical linear regression analyses to explore potential predictors of patients’ anxiety before US-guided invasive procedures?

Considering STAI_T, authors could also use descriptive data of patients with clinically relevant anxiety and without clinically relevant anxiety.

Discussion: The discussion tries to be exhaustive, with references to other studies. However, the complete information related to cancer is not clear since the current sample did not have a cancer diagnosis. This need to be clarified perhaps in the methods section

making it very long and with some unnecessary indications (for example, values of the statistics of the studies with which it compares its results). The discussion should also include limitations and indications for future studies.

A linguistic revision is suggested to make the reading more accessible and precise.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #5: No

Reviewer #6: Yes: Ali Bikmoradi

Reviewer #7: No

**********

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

22 Jul 2022

Reviewer #5

* It is a very interesting and very current topic. Health systems must find strategies to increase the well-being of their patients. This work can help to find these strategies, after identifying the causes.

1. *Despite not being native to the English language, it seems to me that English should be revised.

�  The authors agree with the statements. The entire article was submitted for review by a native English speaker.

2. *On page 12, section "Statistical Methods", authors should add, right after the phrase "The non-parametric Mann-Whitney test was used to compare two subgroups, and the Kruskal-Wallis test was used when three subgroups were analyzed.", the following:

"In the 3 group comparison, whenever statistically significant differences were detected, the Kruskal-Wallis multiple comparison test was used."

Authors should not use the Mann-Whitney test to compare groups 2 to 2, as this increases the probability of type I error from 0.05 to 0.143 (as it is related to the number of comparisons to be performed). They should use the Kruskal-Wallis multiple comparison tests, already available in SPSS version 20.0.

�  The authors agree with the statements. The suggested sentence was included in its entirety in the manuscript.

3. * The titles of tables 2, 3, 4 and 5 are not correct. In any of the tables, what the authors are doing is comparing anxiety levels (STAI-State and STAI-Trait) between groups. They are not studying the correlation.

�  The authors agree with the indicated inadequacy. The term relationship has been changed to correlation.

Reviewer #6

It seems, the manuscript do not follow scientific writing for an article such as topic presentations and study design and figure 1, raw presentation.

�  The authors appreciate the reviewer's comment. However, we did our best to follow scientific methodology, especially in writing. After going through corrections from 7 different reviewers and 2 editors, we believe we have done a good job. Thanks again for the comment.

Reviewer #7

It is a current exciting topic and manuscript. While not the most original work, it adds exciting data concerning patient-centered care during diagnostic procedures. It provides essential information to oncology specialty professionals and general practice. However, the manuscript presents some relevant weaknesses.

1. A linguistic revision is suggested to make the reading more accessible and precise.

�  The authors agree with the statements. The entire article was submitted for review by a native English speaker.

2. Abstract: Reduce background (the last two sentences are not needed) and improve methods, results, and conclusion

�  The authors are grateful for the observations made by the reviewer. The abstract was reduced, and the other sections were revised to clarify the ideas presented.

3. Introduction: The introduction should be improved with more references related to diagnostic medical procedures and online search anxiety. There are scientific papers available.

�  The authors agree with the observed fact and chose to add the following article to the manuscript: "Swire-Thompson B, Lazer D. Public Health and Online Misinformation: Challenges and Recommendations. Annu Rev Public Health. 2020 Apr 2;41:433-451 doi: 10.1146/annurev-publhealth-040119-094127. Epub 2019 Dec 24. PMID: 31874069". It is an excellent source that supports the misinterpretations that online information can lead to.

4. Methods: Please organize better methods section regarding Sample or participants, measures (information regarding STAI is repetitive), proceedings (including dates for data collecting), ethical considerations, and Statistical analyses.

�  The authors eliminated some repetitive information about the STAI questionnaire and also added the study data collection date to the manuscript in the Methods / Study Design section.

5. Results: Did the authors considered performed Hierarchical linear regression analyses to explore potential predictors of patients’ anxiety before US-guided invasive procedures?

Considering STAI_T, authors could also use descriptive data of patients with clinically relevant anxiety and without clinically relevant anxiety.

�  The authors are grateful for the questions raised. Hierarchical linear regression analysis was considered, however, as it is a topic such as anxiety, with countless variables, the authors opted for a statistical method rather than a model comparison. The STAI_T was used in our study basically because it was attached to the STAI_S in its original questionnaire. However, as the image-guided invasive procedure is a one-off event, its use could have been dispensed with. There were no significant correlations with this questionnaire. We chose to keep it in the manuscript precisely to raise this discussion.

6. Discussion: The discussion tries to be exhaustive, with references to other studies. However, the complete information related to cancer is not clear since the current sample did not have a cancer diagnosis. This need to be clarified perhaps in the methods section

making it very long and with some unnecessary indications (for example, values of the statistics of the studies with which it compares its results). The discussion should also include limitations and indications for future studies.

�  The authors are grateful for the comments raised by the reviewer. The sample of participants included cancer patients (45 patients, about 34% of the total), as shown in Table 1. There was no correlation with anxiety levels , as shown in the Results section: "There were no significant associations between STAI anxiety scores and age, education level, age, past experiences of health treatment of the medical status, or proposed procedure or subjective assessments of the regularity of care (P > 005)." As the reviewer correctly pointed out, this issue needs clarification, this point being addressed in the Discussion, in limitations, in the following excerpt: "It should also be noted that there is a high prevalence of psychiatric disorders such as depression and anxiety amongst cancer patients [23 ]. Despite the large knowledge gap in the medical literature and the absence of specific guidelines on the subject [24], health professionals in care are required to understand how to approach said conditions."

A linguistic revision is suggested to make the reading more accessible and precise.

�  The authors agree with the statements. The entire article was submitted for review by a native English speaker.

Submitted filename: Response to Reviewers.docx

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9 Aug 2022

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Comments to the Author

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Reviewer #5: (No Response)

Reviewer #6: All comments have been addressed

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Reviewer #5: Yes

Reviewer #6: Partly

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Reviewer #5: Yes

Reviewer #6: I Don't Know

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Reviewer #5: Yes

Reviewer #6: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #5: Yes

Reviewer #6: No

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Reviewer #5: The article has improved substantially. However, there are still some details that must be corrected, namely:

* Whenever authors refer to the p-value, it must be in lower case, p instead of P. Authors should review the entire text.

* The titles of tables 2, 3, 4 and 5 are not correct, as they are not evaluating the form and intensity of the relationship between two variables, but the comparison of the values of a variable (which is quantitative) between the categories of a qualitative variable. Therefore, instead of correlation, there should be a comparison, for example comparison of the state of anxiety (assessed by STAI) between ...

Reviewer #6: It seems, the manuscript needs to rewrite or revise by an scientific writer for scientific article in order to be condense, clear methodology even the name of method " One hundred and thirty-three patients were

evaluated prospectively". Repeatable of the research work is important. Sampling and research community, response rate are important as well.

**********

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Reviewer #5: No

Reviewer #6: No

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29 Aug 2022

Reviewer #5

* The article has improved substantially. However, there are still some details that must be corrected, namely:

1. * Whenever authors refer to the p-value, it must be in lower case, p instead of P. Authors should review the entire text.

�  The authors are grateful for the observation made. The entire manuscript was revised and the p-values corrected.

2. * The titles of tables 2, 3, 4 and 5 are not correct, as they are not evaluating the form and intensity of the relationship between two variables, but the comparison of the values of a variable (which is quantitative) between the categories of a qualitative variable. Therefore, instead of correlation, there should be a comparison, for example comparison of the state of anxiety (assessed by STAI) between ...

�  The authors agree with the observations made. Conceptual changes were made to the table titles.

Reviewer #6

1. It seems, the manuscript needs to rewrite or revise by an scientific writer for scientific article in order to be condense, clear methodology even the name of method " One hundred and thirty-three patients were evaluated prospectively". Repeatable of the research work is important. Sampling and research community, response rate are important as well.

�  The authors are again grateful for the reviewer's notes. The entire article was reviewed and the necessary changes were made to clarify the scientific language.

Submitted filename: Response to Reviewers.docx

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12 Sep 2022

Relationship Between Anxiety and Internet Searches Before Percutaneous Ultrasound-guided Diagnostic Procedures: A Prospective Cohort Study

PONE-D-21-27163R4

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Reviewer #5: All comments have been addressed

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #5: Yes

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Reviewer #5: Yes

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Reviewer #5: Yes

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26 Sep 2022

PONE-D-21-27163R4

Relationship Between Anxiety and Internet Searches Before Percutaneous Ultrasound-guided Diagnostic Procedures: A Prospective Cohort Study

Dear Dr. Meira:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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