Christine M. Schubert

Mindfulness-Based Stress Reduction for the Treatment of Adolescent Psychiatric Outpatients: A Randomized Clinical Trial

Research has shown that mindfulness-based treatment interventions may be effective for a range of mental and physical health disorders in adult populations, but little is known about the effectiveness of such interventions for treating adolescent conditions. The present randomized clinical trial was designed to assess the effect of the mindfulness-based stress reduction (MBSR) program for adolescents age 14 to 18 years with heterogeneous diagnoses in an outpatient psychiatric facility (intent-to-treat N = 102). Relative to treatment-as-usual control participants, those receiving MBSR self-reported reduced symptoms of anxiety, depression, and somatic distress, and increased self-esteem and sleep quality. Of clinical significance, the MBSR group showed a higher percentage of diagnostic improvement over the 5-month study period and significant increases in global assessment of functioning scores relative to controls, as rated by condition-naïve clinicians. These results were found in both completer and intent-to-treat samples. The findings provide evidence that MBSR may be a beneficial adjunct to outpatient mental health treatment for adolescents.

Puberty and Body Composition

Body composition during puberty is a marker of metabolic changes that occur during this period of growth and maturation, and, thus, holds key information regarding current and future health. During puberty, the main components of body composition (total body fat, lean body mass, bone mineral content) all increase, but considerable sexual dimorphism exists. Methods for measuring body composition (e.g. densitometry and dual-energy X-ray absorptiometry) and degree of maturity will be discussed in this review. Components of body composition show age-to-age correlations (i.e. ‘tracking’), especially from adolescence onwards. Furthermore, adipose tissue is endocrinologically active and is centrally involved in the interaction between adipocytokines, insulin and sex-steroid hormones, and thus influences cardiovascular and metabolic disease processes. In conclusion, pubertal body composition is important, not only for the assessment of contemporaneous nutritional status, but also for being linked directly to the possible onset of chronic disease later in life and is, therefore, useful for disease risk assessment and intervention early in life.

Do Changes in Body Mass Index Percentile Reflect Changes in Body Composition in Children? Data From the Fels Longitudinal Study

OBJECTIVE. Our aim was to examine the degree to which changes in BMI percentile reflect changes in body fat and lean body mass during childhood and how age and gender affect these relationships. METHODS. This analysis used serial data on 494 white boys and girls who were aged 8 to 18 years and participating in the Fels Longitudinal Study (total 2319 observations). Total body fat (TBF), total body fat-free mass (FFM), and percentage of body fat (%BF) were determined by hydrodensitometry, and then BMI was partitioned into its fat and fat-free components: fat mass index (FMI) and FFM index (FFMI). We calculated predicted changes (Δ) in FMI, FFMI, and %BF for each 10-unit increase in BMI percentile using mixed-effects models. RESULTS. FFMI had a linear relationship with BMI percentile, whereas FMI and %BF tended to increase dramatically only at higher BMI percentiles. Gender and age had significant effects on the relationship between BMI percentile and FFMI, FMI, and %BF. Predicted Δ%BF for boys 13 to 18 years of age was negative, suggesting loss of relative fatness for each 10-unit increase in BMI percentile. CONCLUSIONS. In this longitudinal study of white children, FFMI consistently increased with BMI percentile, whereas FMI and %BF had more complicated relationships with BMI percentile depending on gender, age, and whether BMI percentile was high or low. Our results suggest that BMI percentile changes may not accurately reflect changes in adiposity in children over time, particularly among male adolescents and children of lower BMI.

Minimal hepatic encephalopathy is associated with motor vehicle crashes: the reality beyond the driving test.

Patients with minimal hepatic encephalopathy (MHE) have impaired driving skills, but association of MHE with motor vehicle crashes is unclear. Standard psychometric tests (SPT) or inhibitory control test (ICT) can be used to diagnose MHE. The aim was to determine the association of MHE with crashes and traffic violations over the preceding year and on 1‐year follow‐up. Patients with cirrhosis were diagnosed with MHE by ICT (MHEICT) and SPT (MHESPT). Self and department‐of‐transportation (DOT)‐reports were used to determine crashes and violations over the preceding year. Agreement between self and DOT‐reports was analyzed. Patients then underwent 1‐year follow‐up for crash/violation occurrence. Crashes in those with/without MHEICT and MHESPT were compared. 167 patients with cirrhosis had DOT‐reports, of which 120 also had self‐reports. A significantly higher proportion of MHEICT patients with cirrhosis experienced crashes in the preceding year compared to those without MHE by self‐report (17% vs 0.0%, P = 0.0004) and DOT‐reports (17% vs 3%, P = 0.004, relative risk: 5.77). SPT did not differentiate between those with/without crashes. A significantly higher proportion of patients with crashes had MHEICT compared to MHESPT, both self‐reported (100% vs 50%, P = 0.03) and DOT‐reported (89% vs 44%, P = 0.01). There was excellent agreement between self and DOT‐reports for crashes and violations (Kappa 0.90 and 0.80). 109 patients were followed prospectively. MHEICT patients had a significantly higher future crashes/violations compared to those without (22% vs 7%, P = 0.03) but MHESPT did not. MHEICT (Odds ratio: 4.51) and prior year crash/violation (Odds ratio: 2.96) were significantly associated with future crash/violation occurrence. Conclusion: Patients with cirrhosis and MHEICT have a significantly higher crash rate over the preceding year and on prospective follow‐up compared to patients without MHE. ICT, but not SPT performance is significantly associated with prior and future crashes and violations. There was an excellent agreement between self‐ and DOT‐reports. (HEPATOLOGY 2009.)

Persistence of Cognitive Impairment After Resolution of Overt Hepatic Encephalopathy

BACKGROUND & AIMS In patients with cirrhosis, hepatic encephalopathy (HE) has acute but reversible as well as chronic components. We investigated the extent of residual cognitive impairment following clinical resolution of overt HE (OHE). METHODS Cognitive function of cirrhotic patients was evaluated using psychometric tests (digit symbol, block design, and number connection [NCT-A and B]) and the inhibitory control test (ICT). Improvement (reduction) in ICT lures and first minus second halves (DeltaL(1-2)) were used to determine learning of response inhibition. Two cross-sectional studies (A and B) compared data from stable cirrhotic patients with or without prior OHE. We then prospectively assessed cognitive performance, before and after the first episode of OHE. RESULTS In study A (226 cirrhotic patients), 54 had experienced OHE, 120 had minimal HE, and 52 with no minimal HE. Despite normal mental status on lactulose after OHE, cirrhotic patients were cognitively impaired, based on results from all tests. Learning of response inhibition (DeltaL(1-2) > or =1) was evident in patients with minimal HE and no minimal HE but was lost after OHE. In study B (50 additional patients who developed > or =1 documented OHE episode during follow-up), the number of OHE hospitalizations correlated with severity of residual impairment, indicated by ICT lures (r = 0.5, P = .0001), digit symbol test (r = -0.39, P = .002), and number connection test-B (r = 0.33, P = .04). In the prospective study (59 cirrhotic patients without OHE), 15 developed OHE; ICT lure response worsened significantly after OHE (12 before vs 18 after, P = .0003), and learning of response inhibition was lost. The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing. CONCLUSIONS In cirrhosis, episodes of OHE are associated with persistent and cumulative deficits in working memory, response inhibition, and learning.

Long-Term Outcomes After Catheter Ablation of Cavo-Tricuspid Isthmus Dependent Atrial Flutter: A Meta-Analysis

Background—Despite the success of catheter ablation of cavotricuspid isthmus–dependent atrial flutter (AFL), important postablation outcomes are ill-defined. The purpose of our study was to analyze long-term outcomes after catheter ablation of cavotricuspid isthmus–dependent AFL. Methods and Results—A meta-analysis was performed of articles reporting clinical outcomes after catheter ablation of AFL published between January 1988 and July 2008. The analysis included 158 studies comprising 10 719 patients (79% men, 59.8±0.5 years old, 46% left atrial enlargement, 46% heart disease, 42% with history of atrial fibrillation, 14.3±0.4 months of follow-up). The overall acute success rate adjusted for reporting bias was 91.1% (95% CI, 89.5 to 92.4), 92.7% (95% CI, 90.0 to 94.8) for 8- to 10-mm tip/or irrigated radiofrequency catheters, and 87.9% (95% CI, 84.2 to 90.9) for 4- to 6-mm tip catheters (P>0.05). Atrial flutter recurrence rates were significantly reduced by use of 8- to 10-mm tip or irrigated radiofrequency catheters (6.7% versus 13.8%, P<0.05) and by use of bidirectional cavotricuspid isthmus block as a procedural end point (9.3% versus 23.6%, P<0.05). The AFL recurrence rate did not increase over time. The overall occurrence rate of atrial fibrillation after AFL ablation was 33.6% (95% CI, 29.7 to 37.3) but was 52.7% (95% CI, 47.8 to 57.6) in patients with a history of atrial fibrillation before ablation and 23.1% (95% CI, 17.5 to 29.9) in those without atrial fibrillation before ablation (P<0.05). The incidence of atrial fibrillation increased over time in both groups; however, 5 years after ablation, the incidence of atrial fibrillation was similar in those with and without atrial fibrillation before ablation. The acute complication rate was 2.6% (95% CI, 2 to 3). The mortality rate during follow-up was 3.3% (95% CI, 2.4 to 4.5). Antiarrhythmic drug use after ablation was 31.6% (95% CI, 25.6 to 37.8). The long-term use of coumadin was 65.9%, (95% CI, 43.8 to 82.8). Quality of life data were very limited. Conclusions—AFL ablation is safe and effective. Ablation technology and procedural end points have greater influences on AFL recurrences than on acute ablation success rates. Atrial fibrillation is common after AFL ablation. Almost one third of patients take antiarrhythmic drugs after AFL ablation. Atrial fibrillation before AFL ablation may indicate a more advanced state of electric disease.

Pediatric obstructive sleep apnea and quality of life: A meta-analysis

OBJECTIVE: 1) To assess the quality of life (QOL) in children with obstructive sleep apnea (OSA) compared with QOL of children with chronic medical conditions, and 2) To determine QOL in children with OSA after adenotonsillectomy in short- and long-term follow-up. DATA SOURCES/REVIEW METHODS: A literature review on QOL in pediatric OSA using the PubMed database. RESULTS: The literature search yielded 10 articles that satisfied inclusion and exclusion criteria. In three studies, the Child Health Questionnaire (CHQ) survey was used to compare 193 patients who had OSA with 93 children who had juvenile rheumatoid arthritis (JRA) and with 815 healthy children. Of 12 CHQ subscale scores for children with OSA, 8 scores were significantly lower (indicating a poorer QOL) than controls. Children with OSA scored 19.23 points lower than healthy children in the subscale of parental impact-emotional. Children with OSA had QOL scores that were similar to those of children with JRA. In seven publications, 369 children with OSA undergoing adenotonsillectomy were studied by using the OSA-18 QOL instrument. The total OSA-18 score and each of the domain scores showed significant improvement (P < 0.0001) after adenotonsillectomy. At long-term follow-up, QOL scores remained significantly improved. CONCLUSIONS: Pediatric OSA has a significant impact on QOL. QOL in pediatric OSA is similar to that of children with JRA. Large improvements in QOL occur after adenotonsillectomy, and these findings are maintained in the long-term. The literature lacks control studies on QOL in pediatric OSA.

Lipids, lipoproteins, lifestyle, adiposity and fat-free mass during middle age: the Fels Longitudinal Study.

Introduction:Although lipid profiles tend to worsen with age, it is not fully known if such age-related changes are influenced primarily by body composition and lifestyle or by other aspects of aging.Objective:We investigated the extent to which the fat and fat-free components of body mass index (BMI) and lifestyle factors influence patterns of change in lipids independent of age.Design:Serial data were analyzed using sex-specific longitudinal models. These models use serial data from individuals to assume a general pattern of change over time, while allowing baseline age and the rate of change to vary among individuals.Subjects:Serial data were obtained from 940 examinations of 269 healthy white participants (126 men, 143 women), aged 40–60 years, in the Fels Longitudinal Study.Measurements:Measurements included age, the fat (FMI) and fat-free mass (FFMI) components of BMI, high-density lipoprotein (HDL-C), low-density lipoprotein (LDL-C), triglycerides (TG), total cholesterol (TC), fasting glucose and insulin, physical activity, alcohol use and smoking, and womens menopausal status and estrogen use.Results:In both sexes, increased FMI was significantly associated with increased LDL-C, TG and TC, and decreased HDL-C. Increased FFMI was significantly related to decreased HDL-C and increased TG. Independent age effects remained significant only for LDL-C and TC in men and TC in women. Increased insulin was significantly related to increased TG in women. Moderate alcohol consumption was associated with higher HDL-C in men. Physical activity lowered male LDL-C and TC levels, and increased female HDL-C levels. Menopause was associated with increases in LDL-C. Premenopausal women not using estrogen had significantly lower HDL-C, TG, and TC than postmenopausal women taking estrogen.Conclusions:(1) Age is an important independent predictor for LDL-C and TC in men, and TC in women, but it is not as influential as body composition and lifestyle on HDL-C and TG in men and women, and LDL-C in women. (2) Increasing FMI is the major contributor to elevated TC, LDL-C and TG levels, and decreased HDL-C levels in men and women. (3) FFMI significantly influences HDL and TG levels in both sexes. (4) Maintaining a lower BMI via a reduced fat component may be more beneficial in lowering CVD risks than other factors.

Cytokine Comparisons Between Women With Breast Cancer and Women With a Negative Breast Biopsy

Background: Understanding the biological milieu associated with disease states has important implications for biobehavioral research. Cytokines, signaling molecules that mediate and regulate immunity, inflammation, and hematopoiesis, are an important component of the biological milieu associated with breast cancer. Cytokines have been used as biomarkers in research for prognosis and have been associated with symptoms and adverse outcomes in multiple conditions, including breast cancer. To date, however, the examination of cytokine patterns has been limited by traditional laboratory methods. Advances in proteomic technology now permit the characterization of a broader array of cytokines in a single specimen. Because cytokines operate in integrated networks, a more complete understanding will be gained as multiple cytokines can be examined for patterns of response that may be associated with symptoms and prognosis. Objectives: To use proteomic technology (a) to examine whether there was a difference in cytokine levels and patterns in women with breast cancer compared with controls, (b) to define and compare the receiver operator characteristic curves for standard cytokine classifications, and (c) to identify the best-fitting empirical model of cytokines to distinguish groups of women found to have breast cancer from those with negative biopsies. Methods: The cytokine levels of 35 women who had been diagnosed recently with breast cancer were compared with 24 women with a suspicious breast mass who were found subsequently to have a negative breast biopsy. Multiplex bead array assays permitted the simultaneous measure of multiple markers in a small volume of serum. Nonparametric procedures were used to determine differences in the median values and the distributions for each cytokine. The receiver operator characteristic curves were defined to identify patterns of cytokines. Results: There were significantly higher systemic cytokine values in women with cancer in comparison with those in women without cancer for all cytokines measured, with the exception of granulocyte colony-stimulating factor and interferon-gamma. The only significant associations found between cytokines and age or race were increased levels of interleukin-8 (r = .53) and macrophage inflammatory protein-1&bgr; (r = .45) with increased age in women with a negative biopsy. Three cytokines (granulocyte colony-stimulating factor, interleukin-6, and interleukin-17) distinguished between the breast cancer and no-cancer groups with an exceptionally high areas under the curve (0.981; SE = 0.017). Discussion: Levels of cytokines and their patterns were markedly different in women with breast cancer as compared with those in women who did not have breast cancer. Results from this study highlight the need for further research to examine the levels and patterns of cytokines that may serve as biomarkers in clinical research. Innovations in proteomic technology have implications for expanding biobehavioral research.

Exploratory study of stress-buffering response patterns from interaction with a therapy dog.

ABSTRACT This exploratory study builds on existing research on the physiological stress response to human–animal interactions in a non-clinical sample of adult dog-owners interacting with their own or an unfamiliar therapy dog under similar conditions. Participants were therapy-dog owners (TDO group; n = 5) interacting with their own dogs and dog owners interacting with an unfamiliar therapy dog (AAA group; n = 5). Following a 30minute baseline period, participants completed a stress task followed by a 30-minute dog interaction and then watched a neutral video for 60 minutes. The outcome variable of interest was the bio-behavioral stress response, measured by systolic and diastolic blood pressure (SBP, DBP), heart rate (HR), salivary cortisol, salivary alpha-amylase, and self-report. Trait anxiety and attitudes toward pets were assessed as moderating variables. Results revealed consistent physiological patterns, showing modest increases with the stressor and decreases from baseline following the intervention, for salivary cortisol, SBP, DBP, HR, and self reported anxiety and stress for both groups. In general, although the TDO group tended to perceive less stress and anxiety during the intervention than the AAA group, greater reductions in physiological measures were observed in the AAA group. Positive attitudes toward pets in the total sample of dog owners were associated with decreased levels of self-reported stress (p < 0.05), salivary cortisol, and SBP, while higher levels of trait anxiety were associated with higher levels of salivary cortisol (p < 0.05). In addition, higher levels of trait anxiety were associated with lower levels of autonomic nervous system indicators of stress (HR; SBP, p < 0.05; DBP, p < 0.05). Results support a buffering effect on the stress response associated with owners interacting with their dogs that may extend to interactions with unfamiliar therapy dogs in AAA, and supports the need for replication studies with larger sample sizes.