Nancy L. McCain

Development and validation of the Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) quality of life instrument

The Functional Assessment of Human Immunodeficiency Virus (HIV) Infection (FAHI) quality of life instrument was developed using a combination of conceptual and empirical strategies. The core, general health-related quality of life instrument is the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire. The FACT-G was selected to enable comparison of data across two similar, life-threatening conditions and because of its desirable psychometric properties. Initial data on both the relevance (applicability) of the FACT-G to the HIV population and the generation and testing of questions for an HIV-specific subscale were encouraging. Consequently, the FACT-G and a 9-item HIV-specific subscale were combined and tested in 196 patients in three categories: an English-speaking stress management sample from Chicago, Illinois (n=110); an English-speaking urban, mixed race sample from Chicago (n=71); and a Spanish-speaking urban sample from Chicago and San Juan, Puerto Rico (n=64). With the exception of the Social Well-being subscale, the subscales of the FACT-G demonstrated good internal consistency reliability across all three samples (α range=0.72–0.88). Total FAHI scores produced consistently high alpha coefficients (0.89–0.91). Concurrent validity data included moderately strong associations with other measures of similar concepts and an ability to distinguish groups of patients by activity level and disease severity. Sensitivity to change in mood disturbance and responsiveness to a stress management intervention were also evident. The 9-item HIV-specific subscale demonstrated relatively low α coefficients (range=0.53–0.71) and marginal sensitivity to change, leading to supplementation of content with an additional 11 items, creating a 20-item HIV-specific subscale that is currently being tested. Clinical trial and clinical practice investigators are encouraged to use the FACT-G in its current (version 3) form when evaluating group differences and within-group change over time. It should prove particularly useful when comparing clinical trial and clinical practice data for cancer vs. HIV-infected patients and in the evaluation of treatments for HIV disease and HIV-related malignancy. The supplemental 20 questions comprising the revised HIV-specific subscale are undergoing further testing, and may ultimately enhance the value of this measurement system.

Psychometric validation of the revised Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) quality of life instrument.

The revised Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) quality of life (QoL) instrument has been updated and expanded to provide more complete and accurate coverage of human immune deficiency virus/ acquired immune deficiency syndrome (HIV/AIDS)-related QoL. Factor analysis and the Rasch measurement model were used to determine a new subscale structure for the FAHI. The content of these subscales, including physical well-being (ten items, α = 0.91), function and global well-being (13 items, α = 0.86), emotional well-being/living with HIV (10 items, α = 0.82), social well-being (eight items, α = 0.73), and cognitive functioning (three items; α = 0.75), reflect both general illness- and HIV/AIDS-specific QoL concerns: a total QoL score can also be calculated for the FAHI (44 items, α =0.91). Psychometric evaluation revealed good internal consistency reliability for the FAHI and its subscales. In addition, construct validity, known groups validity and sensitivity to change were demonstrated by significant associations between the FAHI and additional indicators of functional status, psychological symptoms, stress and illness severity. In summary, the FAHI is a psychometrically sound instrument that captures multiple important dimensions of HIV/AIDS-related QoL. It is brief, easy to administer and score, has been translated into nine languages other than English and is appropriate for use in clinical trials and clinical practice.

Measuring stress and immune response in healthcare professionals following interaction with a therapy dog: a pilot study

This study investigated the optimal time for measuring stress and immune function in 20 healthcare professionals (19 women and 1 man) following interaction with a therapy dog. A nonclinical sample of healthcare professionals was assigned to 20 min. of quiet rest, and 5 and 20 min. with a therapy dog. Serum cortisol, epinephrine, and norepinephrine were collected at baseline, 5, 15, 30, 45, and 60 min. postcondition. Salivary cortisol, salivary IgA, and blood for lymphocytes were collected at baseline, 30, 45, and 60 min. postcondition. Analysis indicated significant reductions in serum and salivary cortisol. The optimal time for measuring serum or salivary cortisol following interaction with a therapy dog was 45 min., with changes in salivary cortisol reflecting serum cortisol changes. Findings also suggest stress reduction in healthcare professionals may occur after as little as 5 min. of interaction with a therapy dog and warrants further investigation.

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.

The influence of stress management training in HIV disease.

A pretest-posttest design (with a 6-week wait-list control and a 6-month comparison group) was used to compare the effectiveness of a 6-week stress management training program with standard outpatient care for 45 men with HIV disease. Outcomes included stress levels, coping patterns, quality of life, psychological distress, illness-related uncertainty, and CD4+ T-lymphocyte levels. At 6 weeks, intervention was associated with increases in the emotional well-being dimension of quality of life. After 6 months, the intervention group had a relative decline in HIV-related intrusive thinking, indicating that stress management training may have buffered illness-related psychological distress over time.

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.

A randomized clinical trial of alternative stress management interventions in persons with HIV infection.

Research in psychoneuroimmunology suggests that immunosuppression associated with perceived stress may contribute to disease progression in persons with HIV infection. While stress management interventions may enhance immune function, few alternative approaches have yet been tested. This randomized clinical trial was conducted to test effects of three 10-week stress management approaches--cognitive-behavioral relaxation training (RLXN), focused tai chi training (TCHI), and spiritual growth groups (SPRT)--in comparison to a wait-listed control group (CTRL) among 252 individuals with HIV infection. Using repeated measures mixed modeling, the authors found that in comparison to the CTRL group, (a) both the RLXN and TCHI groups used less emotion-focused coping, and (b) all treatment groups had augmented lymphocyte proliferative function. Despite modest effects of the interventions on psychosocial functioning, robust findings of improved immune function have important clinical implications, particularly for persons with immune-mediated illnesses.

Correlates of Stress in HIV Disease

A group of 53 men with HIV Disease participated in this correlational study of the relationships among psychological distress, quality of life, uncertainty, coping patterns, stress, and CD4+ T-lymphocyte levels. Meaningful correlations (r > .40, p < .01) indicated that higher levels of negative-impact stressful experiences were associated with more frequent use of emotionfocused coping; both higher levels of negative stress and more frequent use of emotion-focused coping were associated with lower quality of life, higher psychological distress, and more uncertainty; lower quality of life was associated with higher psychological distress and more uncertainty; and lower CD4+ counts were associated with higher levels of positive-impact stressful experiences.

Implementing a comprehensive approach to the study of health dynamics using the psychoneuroimmunology paradigm.

This article addresses psychoneuroimmunology (PNI) as an integrative paradigm for advancing both theoretical and empirical knowledge of physiological patterns that contribute to the dynamics of health. We depict relationships among relevant psychobehavioral and physiological components in a PNI-based framework. We then provide examples of how this framework guided 2 clinical trials designed to assess the effectiveness of selected nursing interventions to reduce stress and enhance coping, one in persons with human immunodeficiency viral disease and the other in persons with cancer. The examples address disease-specific measures for assessing the components of the PNI-based framework.

Association of mitochondrial dysfunction and fatigue: A review of the literature

Fatigue is often described by patients as a lack of energy, mental or physical tiredness, diminished endurance, and prolonged recovery after physical activity. Etiologic mechanisms underlying fatigue are not well understood; however, fatigue is a hallmark symptom of mitochondrial disease, making mitochondrial dysfunction a putative biological mechanism for fatigue. Therefore, this review examined studies that investigated the association of markers of mitochondrial dysfunction with fatigue and proposes possible research directions to enhance understanding of the role of mitochondrial dysfunction in fatigue. A thorough search using PubMed, Scopus, Web of Science, and Embase databases returned 1220 articles. After the application of inclusion and exclusion criteria, a total of 25 articles meeting eligibility criteria were selected for full review. Dysfunctions in the mitochondrial structure, mitochondrial function (mitochondrial enzymes and oxidative/nitrosative stress), mitochondrial energy metabolism (ATP production and fatty acid metabolism), immune response, and genetics were investigated as potential contributors to fatigue. Carnitine was the most investigated mitochondrial function marker. Dysfunctional levels were reported in all the studies investigating carnitine; however, the specific type of carnitine that was dysfunctional varied. Genetic profiles were the second most studied mitochondrial parameter. Six common pathways were proposed: metabolism, energy production, protein transport, mitochondrial morphology, central nervous system dysfunction and post-viral infection. Coenzyme Q10 was the most commonly investigated mitochondrial enzyme. Low levels of Coenzyme Q10 were consistently associated with fatigue. Potential targets for further investigation were identified as well as gaps in the current literature.