Creation and validation of a NOVA scored picture set to evaluate ultra-processed foods.

There has been a rapid shift in the modern food environment towards increased processing in foods consumed in the United States (US) and globally. The NOVA system (not an acronym) for classifying food on degree of processing currently has the most empirical support. Consumption of foods in the NOVA 4 category, ultra-processed foods (UPF), is a risk factor for a host of poor health outcomes including heart disease, stroke, and cancer. Despite these poor health outcomes, UPF make up 58% of calories consumed in the US. Methodologies for assessing the reinforcing and rewarding properties of these foods are necessary tools. The Becker-DeGroot-Marschak auction paradigm (BDM) is a well validated tool for measuring value and is amenable to neuromonitoring environments. To allow for the testing of hypotheses based on level of food processing, we present a picture set of 14 UPF and 14 minimally-processed foods (MPF) matched on visual properties, food characteristics (fat, carbohydrate, cost, etc.), and rated perceptual properties. Further, we report our scoring of these foods using the NOVA classification system and provide additional data from credentialed nutrition professionals and on inter-rater reliability using NOVA, a critique of the system. Finally, we provide all pictures, data, and code used to create this picture set as a tool for researchers.

National assessment of obstetrics and gynecology and family medicine residents' experiences with CenteringPregnancy group prenatal care.

OBJECTIVE: To examine family medicine (FM) and obstetrician-gynecologist (OB/GYN) residents' experiences with CenteringPregnancy (CP) group prenatal care (GPNC) as a correlate to perceived likelihood of implementing CP in future practice, as well as knowledge, level of support, and perceived barriers to implementation. METHODS: We conducted a repeated cross-sectional study annually from 2017 to 2019 with FM and OB/GYN residents from residency programs in the United States licensed to operate CP. We applied adjusted logistic regression models to identify predictors of intentions to engage with CP in future practice. RESULTS: Of 212 FM and 176 OB/GYN residents included in analysis, 67.01% of respondents intended to participate as a facilitator in CP in future practice and 51.80% of respondents were willing to talk to decision makers about establishing CP. Both FM and OB/GYN residents who spent more than 15 h engaged with CP and who expressed support towards CP were more likely to participate as a facilitator. FM residents who received residency-based training on CP and who were more familiar with CP reported higher intention to participate as a facilitator, while OB/GYN residents who had higher levels of engagement with CP were more likely to report an intention to participate as a facilitator. CONCLUSION: Engagement with and support towards CP during residency are key factors in residents' intention to practice CP in the future. To encourage future adoption of CP among residents, consider maximizing resident engagement with the model in hours of exposure and level of engagement, including hosting residency-based trainings on CP for FM residents.

Predictors of Mortality and Revision Following Digital Amputation for Infection and Necrosis.

PURPOSE: Digital amputation is a commonly performed procedure for infection and necrosis in patients with diabetes, peripheral vascular disease (PVD), and on dialysis. There is a lack of data regarding prognosis for revision amputation and mortality following digital amputation in these patients. METHODS: All digital amputations over 10-year period (2008-2018) at a single center were reviewed. There were 484 amputations in 360 patients, among which 358 were performed for trauma (reference sample) and 126 for infection or necrosis (sample of interest). Patient death and revision were determined from National Vital Statistics System and medical records. Propensity score matching was performed to compare groups. Data were then compared to the Social Security Administration Actuarial Life Table for 2015 to determine age-matched expected mortality. RESULTS: The 2-year revision rate was 34% for amputations performed for infection or necrosis, compared to 15% for amputations due to trauma. For amputations performed for infection or necrosis, the revision rate was 47.7% when diabetes, PVD, and dialysis were present. Among all patients with infection or necrosis (n = 104) undergoing a digital amputation, overall survival at 2, 5, and 10 years was 79.4%, 57.3%, and 17.5%, respectively, which represented a 3.2-fold increased risk of death compared to controls. (hazard ratio, 3.19; 95% confidence interval, 1.47-6.93). For amputations due to trauma, mortality was no different from that in the age-matched general population. CONCLUSIONS: Mortality and revision risk are high for patients requiring a digital amputation for infection or necrosis and are further increased with medical comorbidities. Hand surgeons should consider the prognostic implications of these data when counseling patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Understanding the mediated relationship between moral distress, depression, and suicide risk in undergraduate nursing students.

BACKGROUND: Nursing students are at higher risk for depression, suicide, and other mental health concerns as compared to the general college student population. Moral distress and other ethical issues may be a significant source of psychological harm within nursing student experiences and warrants further attention. PURPOSE: The purpose of this study was to understand the mediating effect of depression on the relationship between moral distress and suicide risk among undergraduate nursing students. METHODS: This cross-sectional analysis was derived from a larger sequential mixed methods study. The first phase was an online survey completed by a national sample of N = 679 nursing students in the United States. FINDINGS: The relationship between moral distress and suicide risk was fully mediated by depression and statistically significant at the alpha = 0.05 level. CONCLUSION: All three psychological variables (depression, moral distress, suicide risk) impact nursing students and require innovative solutions within nursing and educational programs.

Maternal parenting stress changes over the first year of life in infants with complex cardiac defects and in healthy infants.

OBJECTIVES: Parents of infants with CHDs experience increased parenting stress compared to the general population, potentially interfering with parenting practices and bear adverse family outcomes. The changes in stress over the critical period of infancy have yet to be studied. The current study aimed to compare parenting stress changes over time between parents of infants with CHDs and parents of healthy infants during the first year of infants' life. METHODS: Data from a larger prospective cohort study were longitudinally analysed using mixed-effects multivariable regression modelling. Sample included mothers of 129 infants with complex cardiac defects and healthy infants, recruited from the cardiac ICU of a large cardiac centre and outpatient paediatric practices in Northeastern America. Outcome was measured over four visits via the Parenting Stress Index Long Form. RESULTS: Stress in the cardiac group has significantly decreased over time on the Parent Domain (p = 0.025), and stress in the healthy group has significantly increased over time on the Child Domain (p = 0.033). Parenting stress trajectories demonstrated significant differences between groups on the Parent Domain (p = 0.026) and on the Total Stress (p = 0.039) subscales. CONCLUSIONS: Parenting stress in the paediatric cardiac population changes over time and differs from stress experienced by parents of healthy infants. Findings highlight stressful periods that may be potentially risky for parents of infants with CHDs and introduce additional illness-related and psychosocial/familial aspects to the parenting stress concept.

Medical Complexity Mediates Healthcare Resource Use in the Socially Vulnerable.

GOAL: The objective of this retrospective, observational study was to assess the mediating effect of medical complexity on the relationship between social vulnerability and four acute care resource use outcomes-number of hospitalizations, emergency department (ED) visits, observation stays, and total visits. Such information may help healthcare managers better anticipate the effects of interventions targeted to the socially vulnerable in their patient population. METHODS: Electronic health records of 147,496 adults served by 27 primary care practices in one large health system from 2015 to 2017 were used. Descriptive statistics were applied to characterize patients and the primary care practices included in the study. Causal mediation analyses using a modified Baron and Kenny approach were performed. PRINCIPAL FINDINGS: Causal mediation analyses demonstrated that increased social vulnerability was associated with increased medical complexity (incidence rate ratio [IRR] = 1.57) and increased numbers of hospitalizations (IRR = 1.63), ED visits (IRR = 2.14), observation stays (IRR = 1.94), and total visits (IRR = 2.04). Effects remained significant, though attenuated, after adjusting for medical complexity (mediator), demographics, and medications (hospitalizations IRR = 1.44, ED visits IRR = 2.02, observation stays IRR = 1.74, total visits IRR = 1.86). Social vulnerability, given medical complexity, explained between 8% (ED visits) and 26% (hospitalizations) of the variation in outcomes. PRACTICAL APPLICATIONS: These findings reinforce the need to modify interventions for medically complex adults to address their social needs and, consequently, reduce costly health services. Health systems seeking to reduce costly care can use these results to estimate savings in the treatment of patients with high social vulnerability-before they get chronic conditions and later as they seek care.

Older Adult and Family Caregiver Perspectives on Engagement in Primary Care.

The purpose of the current in-depth qualitative study was to explore the experiences of older adults and family caregivers in primary care. Twenty patients and caregivers from six Comprehensive Primary Care Plus (CPC+) practices' Patient and Family Advisory Councils within a large academic health system participated in telephone interviews from December 2018 to May 2019. Participants were mostly women (60%), with an average age of 71 years and nine chronic conditions. Transcripts were coded using conventional content analysis. Two key themes emerged related to person-centered care (PCC): Engagement in Health Care and Patient-Provider Relationship. Engagement in health care was defined by participants as: being proactive, centering on patient goals in treatment discussions, adherence, and self-triaging. Approximately all participants discussed the importance of the relationship and interactions with their provider as influencing their engagement. The identified themes offer recommendations for further improvement of primary PCC. [Journal of Gerontological Nursing, 48(11), 7-13.].

The conduction velocity-potassium relationship in the heart is modulated by sodium and calcium.

The relationship between cardiac conduction velocity (CV) and extracellular potassium (K+) is biphasic, with modest hyperkalemia increasing CV and severe hyperkalemia slowing CV. Recent studies from our group suggest that elevating extracellular sodium (Na+) and calcium (Ca2+) can enhance CV by an extracellular pathway parallel to gap junctional coupling (GJC) called ephaptic coupling that can occur in the gap junction adjacent perinexus. However, it remains unknown whether these same interventions modulate CV as a function of K+. We hypothesize that Na+, Ca2+, and GJC can attenuate conduction slowing consequent to severe hyperkalemia. Elevating Ca2+ from 1.25 to 2.00 mM significantly narrowed perinexal width measured by transmission electron microscopy. Optically mapped, Langendorff-perfused guinea pig hearts perfused with increasing K+ revealed the expected biphasic CV-K+ relationship during perfusion with different Na+ and Ca2+ concentrations. Neither elevating Na+ nor Ca2+ alone consistently modulated the positive slope of CV-K+ or conduction slowing at 10-mM K+; however, combined Na+ and Ca2+ elevation significantly mitigated conduction slowing at 10-mM K+. Pharmacologic GJC inhibition with 30-µM carbenoxolone slowed CV without changing the shape of CV-K+ curves. A computational model of CV predicted that elevating Na+ and narrowing clefts between myocytes, as occur with perinexal narrowing, reduces the positive and negative slopes of the CV-K+ relationship but do not support a primary role of GJC or sodium channel conductance. These data demonstrate that combinatorial effects of Na+ and Ca2+ differentially modulate conduction during hyperkalemia, and enhancing determinants of ephaptic coupling may attenuate conduction changes in a variety of physiologic conditions.

Parental Post-traumatic Stress and Healthcare Use in Infants with Complex Cardiac Defects.

OBJECTIVE: To examine the associations between post-traumatic stress of parents of infants with complex congenital heart defects and their healthcare use for their infants during the early months of life. STUDY DESIGN: The current study is a secondary data analysis from a randomized controlled trial in which 216 parent-infant dyads were recruited from 3 cardiac intensive care units of large pediatric centers in Northeastern America. The current sample included 153 dyads with post-traumatic stress data at hospital discharge and at 4-months' follow-up. Poisson regressions were used to estimate the effect of post-traumatic stress change scores on number of emergency department (ED) visits, unscheduled cardiologist visits, and unscheduled pediatrician visits outcomes. RESULTS: Infants whose parents gained post-traumatic stress disorder over the study period were at increased risk for ED visits and unscheduled cardiologist visits. Increased symptom severity predicted more unscheduled cardiologist visits and more unscheduled pediatrician visits. Increased symptom clusters (avoidance, arousal, re-experiencing) predicted more ED visits, more unscheduled cardiologist visits, and more unscheduled pediatrician visits. CONCLUSIONS: Parents of infants with cardiac conditions may experience post-traumatic stress following cardiac surgery, which can be linked to greater healthcare use. Findings highlight the importance of screening and treating post-traumatic stress to preserve parental mental health and prevent adverse outcomes.

Results from Project GOLD: A pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention for black youth.

Black youth face significant disparities in HIV/sexually transmitted infection (STI) disease burden. Mental illness and emotion regulation are ontributors to HIV/STI risk, yet many HIV/STI prevention interventions do not address these factors. Project GOLD was a pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention designed to address the role of mental illness and emotion regulation in HIV/STI risk among heterosexually active Black youth aged 14-17 (N = 108). Participants were recruited from outpatient mental health treatment programs and general community settings via community partner referrals, face-to-face encounters, flyers and social media. Assessments were conducted pretest, immediate posttest, and at 3-, 6-, and 12-month follow-up. Although there were no statistically significant differences in behavior change from baseline, there were practically significant effect sizes among HIV condition participants when compared to the general health condition (e.g., fewer sexual partners at 6 months). An increase in theoretical mediators (e.g., condom use negotiation beliefs) was sustained at 12 months. HIV condition participants also reported lower depressive symptom severity, with statistical significance noted at immediate post and at 3 months. The findings highlight the importance and challenges of engaging Black youth in culturally and contextually relevant, developmentally and psychologically appropriate HIV/STI prevention interventions.

Predictors of change over time in subjective daytime sleepiness among older adult recipients of long-term services and supports.

OBJECTIVES: Daytime sleepiness is associated with multiple negative outcomes in older adults receiving long-term services and supports (LTSS) including reduced cognitive performance, need for greater assistance with activities of daily living and decreased social engagement. The purpose of this study was to identify predictors of change in subjective daytime sleepiness among older adults during their first 2 years of receiving LTSS. DESIGN AND SETTING: Secondary analysis of data from a prospective longitudinal study of older adults who received LTSS in their homes, assisted living communities or nursing homes interviewed at baseline and every 3 months for 24 months. PARTICIPANTS: 470 older adults (60 years and older) newly enrolled in LTSS (mean = 81, SD = 8.7; range 60-98; 71% women). MEASUREMENTS: Subjective daytime sleepiness was assessed every 3 months through 2 years using the Epworth Sleepiness Scale. Multiple validated measures were used to capture health-related quality of life characteristics of enrollees and their environment, including symptom status (Symptom Bother Scale), cognition (Mini Mental Status Exam), physical function (Basic Activities of Daily Living), physical and mental general health, quality of life (Dementia Quality of Life, D-QoL), depressive symptoms (Geriatric Depression Scale) and social support (Medical Outcomes Survey-Social Support). RESULTS: Longitudinal mixed effects modeling was used to examine the relationship between independent variables and continuous measure of daytime sleepiness. Increased feelings of belonging, subscale of the D-QoL (effect size = -0.006, 95% CI: -0.013 to -0.0001, p = 0.045) and higher number of depressive symptoms (effect size = -0.002, 95% CI: -0.004 to -0.001, p = 0.001) at baseline were associated with slower rates of increase in daytime sleepiness over time. CONCLUSIONS: Comprehensive baseline and longitudinal screening for changes in daytime sleepiness along with depression and perceived quality of life should be used to inform interventions aimed at reducing daytime sleepiness among older adults receiving LTSS.

Fear of falling in sensory impaired nursing home residents.

Objectives: Fear of falling (FOF) causes excess disability in nursing home (NH) residents and is associated with vision and hearing impairment. We explored factors associated with FOF in 225 NH residents with vision, hearing or dual sensory impairment.Methods: We explored age, gender, cognition, depression, social engagement, illness burden, falls, physical function, mobility, falls self-efficacy and outcome expectancy as predictors of FOF using univariate logistic regression modeling, followed by multivariate analysis by group (visual, hearing, dual, total sample).Results: Fifty-one percent of residents had FOF. Residents who had FOF reported better cognition, lower falls self-efficacy, and higher outcome expectancy in the total sample and in most impairment groups. Falls outcome expectancy predictedFOF in the total sample and in the visual and hearing sensory impairment groups.Conclusion: When addressing FOF in NH residents it is important to address sensory status along with fears about falling to promote function.

The Associations Between Infant Development and Parenting Stress in Infants with Congenital Heart Disease at Six and Twelve Months of Age.

PURPOSE: Developmental delays are among the major morbidities of children with complex congenital heart disease. Parents of infants with complex congenital heart disease experience increased parenting stress levels, which can interfere with parenting processes during infancy. The current study examined associations between infant development and parenting stress in infants with complex congenital heart disease at six and twelve months of age. DESIGN AND METHODS: A secondary analysis of data examined cross-sectional associations between infant's mental and psychomotor development and parenting stress, using general linear regression modeling (N = 75). Data were obtained from a larger prospective cohort study. RESULTS: Mental development was negatively associated with the Parent Domain at six months, and with the Parent Domain and Total Stress at twelve months. Psychomotor development was not significantly associated with parenting stress at six and twelve months. CONCLUSIONS: Parenting stress in parents of infant with complex congenital heart disease may be among the factors shaping the parent-child relationship during the first year of life, which plays an important role in infant development. A potential bidirectional relationship between parenting stress and infant development may fit a transactional model representing the phenomena. PRACTICE IMPLICATIONS: Family interventions aiming to reshape illness perceptions may promote parental adaptive coping and productive parenting practices in populations at risk.

Project GOLD: A pilot randomized controlled trial of a novel psychoeducational HIV/STI prevention intervention for heterosexually-active black youth.

Black youth account for the largest number of new HIV infections among heterosexual youth. Mental illness and difficulties in emotion regulation contribute to increased reports of HIV/sexually transmitted infection (STI) risk-related sexual behaviors in this group. Yet limited interventions exist to address this affective component of the sexual decision-making process. The purpose of this paper was to describe the trial design, research challenges, and baseline characteristics from a study designed to fill this gap. Project GOLD was a pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention designed to address the role of mental illness and emotion regulation in HIV/STI risk among heterosexually-active Black youth aged 14 to 17 (N = 108). Challenges encountered in the research process warrant further attention in future research (e.g., disagreement among the regulatory bodies on parental permission requirements). The most common mental health diagnoses were Recurrent Major Depressive Disorder (15.7%) and current substance abuse (7.4%). Participants reported higher levels of emotional suppression, and adaptive methods of emotion management, than culturally inappropriate expressions of anger or sadness. They also reported a mean age of 13.6 at first vaginal sex, used condoms 66% of the time for vaginal sex, and had an average of three sexual partners in the past 6 months. More than one-quarter (26.9%) had sex with more than one person in the same day. These findings indicate intervention is crucial for this population. The forthcoming trial evaluation will indicate the promise of such interventions in reducing HIV/STI infections in this key population.

Association of health related quality of life domains with daytime sleepiness among elderly recipients of long-term services and supports.

Excessive daytime sleepiness (EDS) is prevalent in older adults; however, data are lacking that examine EDS across living environments. The aims of this secondary data analysis were to identify the prevalence and predictors of EDS among older adults receiving long-term services and supports (LTSS) in assisted living communities (ALCs), nursing homes (NHs), and the community. Participants (n = 470) completed multiple measures including daytime sleepiness. Logistic regression modeling was used to identify EDS predictors. Participants were primarily female and white with a mean age of 81 ± 9 years. The overall prevalence of EDS was 19.4%; the prevalence differed across living environment. Older adults in ALCs and NHs had higher odds of EDS than those living in the community. Also, depressive symptoms and number of bothersome symptoms predicted EDS. Upon admission for LTSS, evaluating older adults, especially those in ALCs and NHs, for depression and bothersome symptoms may reveal modifiable factors of EDS.

Efficacy of a community-based participatory and multilevel intervention to enhance hepatitis B virus screening and vaccination in underserved Korean Americans.

BACKGROUND: The primary objective of the current study was to evaluate the efficacy of a community-based participatory intervention program in improving hepatitis B virus (HBV) screening and vaccination among Korean Americans who were not previously screened. METHODS: A cluster randomized trial involving 32 Korean church-based community organizations (1834 participants) was conducted. Sixteen churches were randomly assigned to an HBV screening and vaccination multicomponent intervention condition (972 participants) and 16 were assigned to a general cancer education control condition (862 participants). The main components of the intervention program included interactive group education; patient navigation; and the engagement of health care providers, church leadership, and church members in the medical field. The application of community-based participatory research principles was monitored and evaluated. HBV screening and vaccination rates (self-reported and medical record verification) were assessed at 6-month and 12-month follow-ups, respectively. RESULTS: The results of the current study demonstrated significant efficacy in the HBV screening rate (92.5% in the intervention group vs 5.5% in the control group), 3-series HBV vaccination completion rate (84% in the intervention group vs 17.6% in the control group), and overall screening and vaccination compliance rate (87% in the intervention group vs 3.8% in the control group). Participants in the intervention group were significantly more likely to receive HBV screening (92.5%) compared with those in the control group (5.5%). In multivariate mixed-effect logistic regression analysis, the odds ratio for an intervention effect on HBV screening was 512.3 after adjusting for cluster effect and other demographic variables. With regard to vaccination rates, of the 332 participants who were screened with no immunity in the intervention group, 308 (92.8%) received at least 1 HBV vaccination, 300 (90.4%) received at least 2 shots, and 279 participants (84%) received all 3 shots. CONCLUSIONS: A combination of community-based participatory research and a multilevel approach may produce the most optimal results and be essential in producing a considerable effect for enhancing HBV screening and vaccination, particularly for Korean American populations with limited language proficiency and insurance coverage. Cancer 2018;124:973-82. © 2017 American Cancer Society.

CPAP, weight loss, or both for obstructive sleep apnea.

BACKGROUND: Obesity and obstructive sleep apnea tend to coexist and are associated with inflammation, insulin resistance, dyslipidemia, and high blood pressure, but their causal relation to these abnormalities is unclear. METHODS: We randomly assigned 181 patients with obesity, moderate-to-severe obstructive sleep apnea, and serum levels of C-reactive protein (CRP) greater than 1.0 mg per liter to receive treatment with continuous positive airway pressure (CPAP), a weight-loss intervention, or CPAP plus a weight-loss intervention for 24 weeks. We assessed the incremental effect of the combined interventions over each one alone on the CRP level (the primary end point), insulin sensitivity, lipid levels, and blood pressure. RESULTS: Among the 146 participants for whom there were follow-up data, those assigned to weight loss only and those assigned to the combined interventions had reductions in CRP levels, insulin resistance, and serum triglyceride levels. None of these changes were observed in the group receiving CPAP alone. Blood pressure was reduced in all three groups. No significant incremental effect on CRP levels was found for the combined interventions as compared with either weight loss or CPAP alone. Reductions in insulin resistance and serum triglyceride levels were greater in the combined-intervention group than in the group receiving CPAP only, but there were no significant differences in these values between the combined-intervention group and the weight-loss group. In per-protocol analyses, which included 90 participants who met prespecified criteria for adherence, the combined interventions resulted in a larger reduction in systolic blood pressure and mean arterial pressure than did either CPAP or weight loss alone. CONCLUSIONS: In adults with obesity and obstructive sleep apnea, CPAP combined with a weight-loss intervention did not reduce CRP levels more than either intervention alone. In secondary analyses, weight loss provided an incremental reduction in insulin resistance and serum triglyceride levels when combined with CPAP. In addition, adherence to a regimen of weight loss and CPAP may result in incremental reductions in blood pressure as compared with either intervention alone. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT0371293 .).

Factors associated with hospital admission after an emergency department treat and release visit for older adults with injuries.

INTRODUCTION: Emergency Department (ED) visits for injury often precede hospital admissions in older adults, but risk factors for these admissions are poorly characterized. We sought to determine the incidence and risk factors for hospitalization shortly following discharge home from an ED visit for traumatic injury in older adults. We hypothesized higher risk for admission in those with increased age, discharged home after falls, with increased comorbidity burden, and who live in poor neighborhoods. METHODS: We identified all community-dwelling patients ≥65years old treated and released for traumatic injury at non-federal EDs in Florida using the 2011 State Inpatient Database and State ED Database of the Agency for Healthcare Research and Quality. Outcome measures were hospitalization within 9 and 30days of discharge from the ED. Multivariable logistic regression was used to establish independent risk factors for hospital admission. RESULTS: Of 163,851 index ED injury visits, 6298 (3.8%) resulted in inpatient admissions within 9days and 12,938 (7.9%) within 30days. Factors associated with increased odds of admission within 9days included: each additional comorbidity, ≥moderate injury to abdomen or pelvis/extremities, and median neighborhood income<$39,000. Additional factors associated with increased odds of admission within 30days included: lack of private insurance supplement and median neighborhood income<$48,000. CONCLUSION: Among older adults treated and discharged from the ED for an injury, those who have high comorbidity burdens, have abdominal or orthopedic injuries, and live in poor neighborhoods are at increased risk of hospitalization within 9 or 30days of ED discharge.

Depressive symptoms in patients with obstructive sleep apnea: biological mechanistic pathways.

This study examined the association between depressive symptoms, as well as depressive symptom dimensions, and three candidate biological pathways linking them to Obstructive sleep apnea (OSA): (1) inflammation; (2) circulating leptin; and (3) intermittent hypoxemia. Participants included 181 obese adults with moderate-to-severe OSA enrolled in the Cardiovascular Consequences of Sleep Apnea (COSA) trial. Depressive symptoms were measured using the Beck Depression Inventory-II (BDI-II). We assessed inflammation using C-reactive protein levels (CRP), circulating leptin by radioimmunoassay using a double antibody/PEG assay, and intermittent hypoxemia by the percentage of sleep time each patient had below 90% oxyhemoglobin saturation. We found no significant associations between BDI-II total or cognitive scores and CRP, leptin, or percentage of sleep time below 90% oxyhemoglobin saturation after controlling for relevant confounding factors. Somatic symptoms, however, were positively associated with percentage of sleep time below 90% saturation (ß = 0.202, P = 0.032), but not with CRP or circulating leptin in adjusted models. Another significant predictor of depressive symptoms included sleep efficiency (ßBDI Total = -0.230, P = 0.003; ßcognitive = -0.173, P = 0.030 (ßsomatic = -0.255, P = 0.001). In patients with moderate-to-severe OSA, intermittent hypoxia may play a role in somatic rather than cognitive or total depressive symptoms.

Adaptive Modeling: An Approach for Incorporating Nonlinearity in Regression Analyses.

Although regression relationships commonly are treated as linear, this often is not the case. An adaptive approach is described for identifying nonlinear relationships based on power transforms of predictor (or independent) variables and for assessing whether or not relationships are distinctly nonlinear. It is also possible to model adaptively both means and variances of continuous outcome (or dependent) variables and to adaptively power transform positive-valued continuous outcomes, along with their predictors. Example analyses are provided of data from parents in a nursing study on emotional-health-related quality of life for childhood brain tumor survivors as a function of the effort to manage the survivors' condition. These analyses demonstrate that relationships, including moderation relationships, can be distinctly nonlinear, that conclusions about means can be affected by accounting for non-constant variances, and that outcome transformation along with predictor transformation can provide distinct improvements and can resolve skewness problems.© 2017 Wiley Periodicals, Inc.