Melinda Higgins

Combined exercise and cognitive behavioral therapy improves outcomes in patients with heart failure

OBJECTIVE The purpose of this study is to compare the effectiveness of a combined 12-week home-based exercise (EX)/cognitive behavioral therapy (CBT) program (n=18) with CBT alone (n=19), EX alone (n=20), and with usual care (UC, n=17) in stable New York Heart Association Class II to III heart failure (HF) patients diagnosed with depression. METHODS Depressive symptom severity [Hamilton Rating Scale for Depression (HAM-D)], physical function [6-min walk test (6MWT)], and health-related quality of life (HRQOL) (Minnesota Living with Heart Failure Questionnaire) were evaluated at baseline (T1), after the 12-week intervention/control (T2), and following a 3-month telephone follow-up (T3). A repeated measures analysis of variance was used to determine group differences. Depression severity was dichotomized as minor (HAM-D, 11-14) and moderate-to-major depression (HAM-D, >/=15), and group intervention and control responses were also evaluated on that basis. RESULTS The greatest reduction in HAM-D scores over time occurred in the EX/CBT group (-10.4) followed by CBT (-9.6), EX (-7.3), and UC (-6.2), but none were statistically significant. The combined group showed a significant increase in 6-min walk distance at 24 weeks (F=13.5, P<.001). Among all groups with moderate-to-major depression, only those in CBT/EX had sustained lower HAM-D scores at 12 and 24 weeks, 6MWT distances were significantly greater at 12 (P=.018) and 24 (P=.013) weeks, and the greatest improvement in HRQOL also occurred. CONCLUSIONS Interventions designed to improve both physical and psychological symptoms may provide the best method for optimizing functioning and enhancing HRQOL in patients with HF.

The molecular phenotype of severe asthma in children.

BACKGROUND Although the clinical attributes of severe asthma in children have been well described, the differentiating features of the lower airway inflammatory response are less understood. OBJECTIVES We sought to discriminate severe from moderate asthma in children by applying linear discriminant analysis, a supervised method of high-dimensional data reduction, to cytokines and chemokines measured in the bronchoalveolar lavage (BAL) fluid and alveolar macrophage (AM) lysate. METHODS Bronchoalveolar lavage fluid was available from 53 children with asthma (severe asthma, n = 31) undergoing bronchoscopy for clinical indications and 30 nonsmoking adults. Twenty-three cytokines and chemokines were measured by using bead-based multiplex assays. Linear discriminant analyses of the BAL fluid and AM analytes were performed to develop predictive models of severe asthma in children. RESULTS Although univariate analysis of single analytes did not differentiate severe from moderate asthma in children, linear discriminant analyses allowed for near complete separation of the moderate and severe asthmatic groups. Significant correlations were also noted between several of the AM and BAL analytes measured. In the BAL fluid, IL-13 and IL-6 differentiated subjects with asthma from controls, whereas growth-related oncogene (CXCL1), RANTES (CCL5), IL-12, IFN-gamma, and IL-10 best characterized severe versus moderate asthma in children. In the AM lysate, IL-6 was the strongest discriminator of all the groups. CONCLUSION Severe asthma in children is characterized by a distinct airway molecular phenotype that does not have a clear T(H)1 or T(H)2 pattern. Improved classification of children with severe asthma may assist with the development of targeted therapeutics for this group of children who are difficult to treat.

Social subordination produces distinct stress-related phenotypes in female rhesus monkeys

Social subordination in female macaques is imposed by harassment and the threat of aggression and produces reduced control over ones social and physical environment and a dysregulation of the limbic-hypothalamic-pituitary-adrenal axis resembling that observed in people suffering from psychopathologies. These effects support the contention that this particular animal model is an ethologically relevant paradigm in which to investigate the etiology of stress-induced psychological illness related to women. Here, we sought to expand this model by performing a discriminate analysis (DA) on 33 variables within three domains; behavioral, metabolic/anthropomorphic, and neuroendocrine, collected from socially housed female rhesus monkeys in order to assess whether exposure to social subordination produces a distinct phenotype. A receiver operating characteristic (ROC) curve was also calculated to determine each domains classification accuracy. DA found significant markers within each domain that differentiated dominant and subordinate females. Subordinate females received more aggression, showed more submissive behavior, and received less of affiliation from others than did dominant females. Metabolic differences included increased leptin, and reduced adiponectin in dominant compared to subordinate females. Dominant females exhibited increased sensitivity to hormonal stimulation with higher serum LH in response to estradiol, cortisol in response to ACTH, and increased glucocorticoid negative feedback. Serum oxytocin, CSF DOPAC and serum PACAP were all significantly higher in dominant females. ROC curve analysis accurately predicted social status in all three domains. Results suggest that socially house rhesus monkeys represent a cogent animal model in which to study the physiology and behavioral consequences of chronic psychosocial stress in humans.

A Trial of Family Partnership and Education Interventions in Heart Failure

BACKGROUND Lowering dietary sodium and adhering to medication regimens are difficult for persons with heart failure (HF). Because these behaviors often occur within the family context, this study evaluated the effects of family education and partnership interventions on dietary sodium (Na) intake and medication adherence (MA). METHODS AND RESULTS HF patient and family member (FM) dyads (n = 117) were randomized to: usual care (UC), patient-FM education (PFE), or family partnership intervention (FPI). Dietary Na (3-day food record), urinary Na (24-hour urine), and MA (Medication Events Monitoring System) were measured at baseline (BL) before randomization, and at 4 and 8 months. FPI and PFE reduced urinary Na at 4 months, and FPI differed from UC at 8 months (P = .016). Dietary Na decreased from BL to 4 months, with both PFE (P = .04) and FPI (P = .018) lower than UC. The proportion of subjects adherent to Na intake (≤2,500 mg/d) was higher at 8 months in PFE and FPI than in UC (χ(2)(2) = 7.076; P = .029). MA did not differ among groups across time. Both FPI and PFE groups increased HF knowledge immediately after intervention. CONCLUSIONS Dietary Na intake, but not MA, was improved by PFE and FPI compared with UC. The UC group was less likely to be adherent with dietary Na. Greater efforts to study and incorporate family-focused education and support interventions into HF care are warranted.

Development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test.

Background and Research Objective:Several heart failure (HF) knowledge tools have been developed and tested over the past decade; however, they vary in content, format, psychometric properties, and availability. This article details the development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test (A-HFKT) as a standardized instrument for both the research and clinical settings. Participants and Methods:Development and psychometric testing of the A-HFKT were undertaken with 116 New York Heart Association (NYHA) class II and III community-dwelling HF patients and their family members (FMs) participating in a family intervention study. Internal consistency, reliability, and content validity were examined. Construct validity was assessed by correlating education level, literacy, dietary sodium ingestion, medication adherence, and healthcare utilization with knowledge. Results:Content validity ratings on relevance and clarity ranged from 0.55 to 1.0, with 81% of the items rated from 0.88 to 1.0. Cronbach α values were .84 for patients, .75 for FMs, and .73 for combined results. Construct validity testing revealed a small but significant correlation between higher patient and FM knowledge on sodium restriction questions and lower ingested sodium, r = −0.17, P = .05 and r = −0.19, P = .04, respectively, and between patient knowledge and number of days that medications were taken correctly (diuretics: r = 0.173, P < .05, and angiotensin-converting enzyme: r = 0.223, P = .01). Finally, patients seeking emergency care or requiring hospitalization in the 4 months before study entry were found to have significantly lower FM knowledge using both t test and logistic regression modeling. Conclusions:The A-HFKT was revised using the content and construct validity data and is available for use with HF patients and FMs. The construct validity testing indicates that patient knowledge has a significant relationship to aspects of self-care. Furthermore, family knowledge may influence patient adherence with sodium restriction and healthcare utilization behavior.

Combined Aerobic and Resistance Exercise Program Improves Task Performance in Patients With Heart Failure

OBJECTIVES To assess the effects of a home-based aerobic and resistance training program on the physical function of adults with New York Heart Association (NYHA) class II and III patients and systolic heart failure (HF). DESIGN Randomized controlled trial. SETTING Home based. PARTICIPANTS Stable patients (N=24; mean age, 60 ± 10 y; left ventricular ejection fraction, 25% ± 9%; 50% white; 50% women) with New York Heart Association (NYHA) classes II and III (NYHA class III, 58%) systolic heart failure (HF). INTERVENTION A 12-week progressive home-based program of moderate-intensity aerobic and resistance exercise. Attention control wait list participants performed light stretching and flexibility exercises. MAIN OUTCOME MEASURES A 10-item performance-based physical function measure, the Continuous Scale Physical Functional Performance test (CS-PFP10), was the major outcome variable and included specific physical activities measured in time to complete a task, weight carried during a task, and distance walked. Other measures included muscle strength, HRQOL (Minnesota Living With Heart Failure Questionnaire, Epworth Sleepiness Scale), functional capacity (Duke Activity Status Index), and disease severity (brain natriuretic peptide) levels. RESULTS After the exercise intervention, 9 of 10 specific task activities were performed more rapidly, with increased weight carried by exercise participants compared with the attention control wait list group. Exercise participants also showed significant improvements in CS-PFP10 total score (P<.025), upper and lower muscle strength, and HRQOL (P<.001) compared with the attention control wait list group. Adherence rates were 83% and 99% for the aerobic and resistance training, respectively. CONCLUSIONS Patients with stable HF who participate in a moderate-intensity combined aerobic and resistance exercise program may improve performance of routine physical activities of daily living by using a home-based exercise approach. Performance-based measures such as the CS-PFP10 may provide additional insights into physical function in patients with HF that more commonly used exercise tests may not identify. Early detection of subtle changes that may signal declining physical function that are amenable to intervention potentially may slow further loss of function in this patient population.

Red blood cell transfusion-related necrotizing enterocolitis in very-low-birthweight infants: A near-infrared spectroscopy investigation

Recent evidence suggests that antecedent red blood cell (RBC) transfusions increase the risk for necrotizing enterocolitis (NEC), the most common gastrointestinal emergency encountered by very‐low‐birthweight (VLBW) infants. The underlying mechanism for this association is unknown. Altered oxygenation of the mesenteric vasculature during RBC transfusion has been hypothesized to contribute to NEC development and was investigated in this study.

PSYCHOLOGICAL FACTORS ARE IMPORTANT CORRELATES OF DIETARY PATTERN IN OVERWEIGHT ADULTS

Introduction and Purpose:Abdominal obesity, the central distribution of adipose tissue, is a well-established cardiometabolic disease risk factor. The prevalence has steadily increased since 1988, and now more than 50% of adults have abdominal obesity. Psychological distress coupled with increased dietary energy density (ED) may contribute to abdominal obesity. Guided by the stress and coping model, this study examined the relationship between psychological factors (perceived stress and depressive symptoms) and dietary ED in overweight, working adults. The first hypothesis tested if psychological factors explained a significant amount of food and beverage ED variance above that accounted for by demographic factors. The second hypothesis tested if psychological factors explained a significant amount of food and nonalcoholic beverage ED variance above that accounted for by demographic factors. Post hoc analyses compared macronutrient composition and food group pattern between overweight, working adults with and without depressive symptoms. Methods:This descriptive, cross-sectional, correlation study was composed of 87 overweight, working adults (mean age, 41.3 [SD, 10.2] years; mean body mass index, 32.1 [SD, 6.1] kg/m2; 73.6% women; 50.6% African American). Participants completed the Beck Depression Inventory II and Perceived Stress Scale and weighed-3-day-food record analyzed for caloric intake (kilocalories) and weight (in grams) of consumed foods and beverages that were used to calculate ED (in kilocalories/gram). Height and weight were measured to calculate body mass index. Descriptive statistics, Mann-Whitney U test, and sequential regression modeling were used for data analysis. Results:Depressive symptoms were reported by 21.9% of participants and explained variance in food and beverage ED above that accounted for by African American race and reporting adequate caloric intake. Depressive symptoms explained variance in food and nonalcoholic beverage ED above that accounted for male sex, African American race, and reporting adequate caloric intake. Perceived stress and depressive symptoms were positively correlated; however, perceived stress was not a significant predictor of food and beverage ED. Conclusions:Depressive symptoms, potentially modifiable, were 4 times that found in the general population and independently predicted increased food and beverage ED. Further research is needed to determine if improvements in depressive symptoms alter dietary ED, potentially reducing cardiometabolic disease risk.

A combined aerobic and resistance exercise program improves physical functional performance in patients with heart failure: a pilot study.

Background: Recent guidelines for exercise in patients with heart failure (HF) recommended aerobic and resistance exercise as being safe and effective; however, the clinical and functional significance of these combined training modalities has not been established. In this pilot study, combined aerobic and resistance training was hypothesized to improve physical function, muscle strength, and health-related quality of life (HRQOL) compared with an attention control wait list (ACWL). Methods: The 10-item Continuous Scale Physical Functional Performance Test (CS-PFP10), which simulates common household chores; muscle strength (handgrip and knee extension); and HRQOL (Kansas City Cardiomyopathy Questionnaire) were evaluated at baseline (T1) and at 12 weeks (T2). The home-based moderate-intensity walking and resistance training program was performed 5 days a week. Results: Twenty-four New York Heart Association class II to III HF patients (mean [SD] age, 60 [10] years; mean [SD] left ventricular ejection fraction, 25% [9%]) were randomized to a combined aerobic and resistance exercise program or to an ACWL group. Of the total group, 58% were New York Heart Association class III HF patients, 50% were white, and 50% were female. The CS-PFP10 total scores were significantly increased in the exercise group, from 45 (18) to 56 (16). The Kansas City Cardiomyopathy Questionnaire overall summary score was significantly improved (P < .001) at T2 in the exercise intervention group compared with the ACWL group. Conclusions: Participants provided the home-based, combined aerobic and resistance exercise program had significantly improved physical function, muscle strength, symptom severity, and HRQOL compared with the ACWL group. The findings of this study must be interpreted cautiously owing to the limitations of a small sample, data collection from a single center, and differences between control and interventions groups at baseline. A combined aerobic and resistance exercise approach may improve physical function in stable HF patients, but further study in a larger, more diverse population is recommended. However, in this study, the CS-PFP10 instrument demonstrated its ability to identify functional health status in HF patients and thus warrants further testing in a larger sample for possible use in clinical practice.

Family partner intervention influences self-care confidence and treatment self-regulation in patients with heart failure:

Background: Heart failure self-care requires confidence in one’s ability and motivation to perform a recommended behavior. Most self-care occurs within a family context, yet little is known about the influence of family on heart failure self-care or motivating factors. Aims: To examine the association of family functioning and the self-care antecedents of confidence and motivation among heart failure participants and determine if a family partnership intervention would promote higher levels of perceived confidence and treatment self-regulation (motivation) at four and eight months compared to patient–family education or usual care groups. Methods: Heart failure patients (N=117) and a family member were randomized to a family partnership intervention, patient–family education or usual care groups. Measures of patient’s perceived family functioning, confidence, motivation for medications and following a low-sodium diet were analyzed. Data were collected at baseline, four and eight months. Results: Family functioning was related to self-care confidence for diet (p=0.02) and autonomous motivation for adhering to their medications (p=0.05) and diet (p=0.2). The family partnership intervention group significantly improved confidence (p=0.05) and motivation (medications (p=0.004; diet p=0.012) at four months, whereas patient–family education group and usual care did not change. Conclusion: Perceived confidence and motivation for self-care was enhanced by family partnership intervention, regardless of family functioning. Poor family functioning at baseline contributed to lower confidence. Family functioning should be assessed to guide tailored family–patient interventions for better outcomes.