Philosophy as a way of life, spiritual exercises, and palliative care.

This paper proposes that resources from philosophy as a way of life (PWL), in particular the prescription of targeted 'spiritual exercises' (Hadot) can be used in palliative counselling, addressing Alexandrova's critique that philosophy as 'big picture' theories alone are insufficient. Part I shows how the disciplines of philosophy and medicine for a long time intersected, in particular in competing prescriptive notions of 'regimen' or 'way of life' (diaitês) in the ancient world, in which philosophy was considered widely as PWL. Part II applies PWL work on the ancient philosophical spiritual exercises to contemporary clinical settings. We show how six ancient spiritual exercises respond to patients' needs as persons, whose quality of life is importantly shaped by their beliefs and sense-making, as they face profound existential or spiritual challenges, as well as forms of physical disability and diminished capabilities which they may never have previously countenanced.

Digital Health Interventions for Depression and Anxiety Among People With Chronic Conditions: Scoping Review.

BACKGROUND: Chronic conditions are characterized by their long duration (≥1 year), need for ongoing medical attention, and limitations in activities of daily living. These can often co-occur with depression and anxiety as common and detrimental comorbidities among the growing population living with chronic conditions. Digital health interventions (DHIs) hold promise in overcoming barriers to accessing mental health support for these individuals; however, the design and implementation of DHIs for depression and anxiety in people with chronic conditions are yet to be explored. OBJECTIVE: This study aimed to explore what is known in the literature regarding DHIs for the prevention, detection, or treatment of depression and anxiety among people with chronic conditions. METHODS: A scoping review of the literature was conducted using the Arksey and O'Malley framework. Searches of the literature published in 5 databases between 1990 and 2019 were conducted in April 2019 and updated in March 2021. To be included, studies must have described a DHI tested with, or designed for, the prevention, detection, or treatment of depression or anxiety in people with common chronic conditions (arthritis, asthma, diabetes mellitus, heart disease, chronic obstructive pulmonary disease, cancer, stroke, and Alzheimer disease or dementia). Studies were independently screened by 2 reviewers against the inclusion and exclusion criteria. Both quantitative and qualitative data were extracted, charted, and synthesized to provide a descriptive summary of the trends and considerations for future research. RESULTS: Database searches yielded 11,422 articles across the initial and updated searches, 53 (0.46%) of which were included in this review. DHIs predominantly sought to provide treatment (44/53, 83%), followed by detection (5/53, 9%) and prevention (4/53, 8%). Most DHIs were focused on depression (36/53, 68%), guided (32/53, 60%), tailored to chronic physical conditions (19/53, 36%), and delivered through web-based platforms (20/53, 38%). Only 2 studies described the implementation of a DHI. CONCLUSIONS: As a growing research area, DHIs offer the potential to address the gap in care for depression and anxiety among people with chronic conditions; however, their implementation in standard care is scarce. Although stepped care has been identified as a promising model to implement efficacious DHIs, few studies have investigated the use of DHIs for depression and anxiety among chronic conditions using such models. In developing stepped care, we outlined DHI tailoring, guidance, and intensity as key considerations that require further research.

Effects of self-guided e-counseling on health behaviors and blood pressure: Results of a randomized trial.

OBJECTIVE: 1) Evaluate the efficacy of e-Counseling vs. Control to promote lifestyle behaviors at 4 and 12-month follow-ups, 2) examine whether these behaviors changes were associated with lower blood pressure (BP), and Framingham Risk Index (FRI) at 12-month. METHODS: Hypertensive patients (n = 264) were randomized to the e-Counseling or the Control group. Primary trial outcome was BP and secondary outcomes included exercise and diet behaviors. This study presented the results of secondary outcomes. Linear mixed models evaluated treatment effects at 4 and 12-month. Treatment-by-sex exploratory analyses were conducted if no main treatment effect was observed. RESULTS: Daily steps significantly improved in e-Counseling vs. Controls at 12-month. Urinary sodium at 12-month did not significantly differ between the groups, but treatment-by-sex analysis showed that e-Counseling females lowered urinary sodium relative to Controls at 12 months. Improvements in steps and dietary sodium were significantly associated with improvements in BP and FRI at 12-month. CONCLUSION: This hypertension e-Counseling protocol can promote long-term lifestyle behavior changes. Adherence to the lifestyle behavior change was associated with BP and FRI reduction at 12-month. PRACTICE IMPLICATIONS: The hypertension e-counseling protocol has the potential to improve hypertension care and intervention reach.

Randomized Controlled Trial of E-Counseling for Hypertension: REACH.

BACKGROUND: The efficacy of internet-based interventions to improve hypertension management is not established. We evaluated the therapeutic benefit of e-counseling by adapting best evidence guidelines for behavioral counseling. METHODS AND RESULTS: This multicenter double-blind randomized controlled trial included assessments at baseline, 4 months, and 12 months. Participants were 35 to 74 years of age and diagnosed with hypertension: systolic/diastolic blood pressure (BP) 130 to 180/85 to 110 mm Hg. BP was assessed by automated office measurement. E-Counseling used multimedia and interactive tools to increase motivation and skill for self-care (exercise, diet, medication adherence, and smoking cessation). Control used self-care education. Frequency of contact by our e-platform was equal for both trial arms. Primary end points were change at 4 and 12 months in systolic BP, diastolic BP, pulse pressure, total lipoprotein cholesterol, low-density lipoprotein cholesterol, total lipoprotein cholesterol/high-density lipoprotein cholesterol ratio, non-high-density lipoprotein cholesterol, and Framingham 10-year cardiovascular risk index. Intention-to-treat analysis used generalized linear models adjusted for baseline measures, sex, and medications. Among 264 participants, mean age was 57.6 years (SE, 0.6), 58% were women, with 83% on antihypertensive medications. At 12 months, e-counseling versus control evoked greater reduction in systolic BP (-10.1 mm Hg [95% confidence interval (CI), -12.5, -7.6] versus -6.0 mm Hg [95% CI, -8.5, -3.5]; P=0.02); pulse pressure (-5.2 mm Hg [95% CI, -6.9, -3.5] versus -2.7 mm Hg [95% CI, -4.5, -0.9]; P=0.04), and Framingham risk index (-1.9% [95% CI, -3.3, -0.5] versus -0.02% [95% CI, -1.2, 1.7]; P=0.02), respectively. Among males in e-counseling versus control, 12-month end points included lower diastolic BP (P=0.01), non-high-density lipoprotein cholesterol (P=0.04), total lipoprotein cholesterol (P=0.03), and a trend for total lipoprotein cholesterol/high-density lipoprotein cholesterol ratio (P=0.07). CONCLUSIONS: To our knowledge, this is the first double-blind randomized trial of e-counseling for hypertension. Added benefit for medical therapy was achieved by combining available technology with a clinically organized protocol of motivational and cognitive-behavioral counseling. CLINICAL TRIAL REGISTRATION: https://www.clinicaltrials.gov; Unique identifier: NCT01541540.

Effectiveness of User- and Expert-Driven Web-based Hypertension Programs: an RCT.

INTRODUCTION: The effectiveness of self-guided Internet-based lifestyle counseling (e-counseling) varies, depending on treatment protocol. Two dominant procedures in e-counseling are expert- and user-driven. The influence of these procedures on hypertension management remains unclear. The objective was to assess whether blood pressure improved with expert-driven or user-driven e-counseling over control intervention in patients with hypertension over a 4-month period. STUDY DESIGN: This study used a three-parallel group, double-blind randomized controlled design. SETTING/PARTICIPANTS: In Toronto, Canada, 128 participants (aged 35-74 years) with hypertension were recruited. Participants were recruited using online and poster advertisements. Data collection took place between June 2012 and June 2014. Data were analyzed from October 2014 to December 2016. INTERVENTION: Controls received a weekly e-mail newsletter regarding hypertension management. The expert-driven group was prescribed a weekly exercise and diet plan (e.g., increase 1,000 steps/day this week). The user-driven group received weekly e-mail, which allowed participants to choose their intervention goals (e.g., [1] feel more confident to change my lifestyle, or [2] self-help tips for exercise or a heart healthy diet). MAIN OUTCOME MEASURES: Primary outcome was systolic blood pressure measured at baseline and 4-month follow-up. Secondary outcomes included cholesterol, 10-year Framingham cardiovascular risk, daily steps, and dietary habits. RESULTS: Expert-driven groups showed a greater systolic blood pressure decrease than controls at follow-up (expert-driven versus control: -7.5 mmHg, 95% CI= -12.5, -2.6, p=0.01). Systolic blood pressure reduction did not significantly differ between user- and expert-driven. Expert-driven compared with controls also showed a significant improvement in pulse pressure, cholesterol, and Framingham risk score. The expert-driven intervention was significantly more effective than both user-driven and control groups in increasing daily steps and fruit intake. CONCLUSIONS: It may be advisable to incorporate an expert-driven e-counseling protocol in order to accommodate participants with greater motivation to change their lifestyle behaviors, but more studies are needed. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT03111836.

Adult Congenital Heart Disease-Coping And REsilience (ACHD-CARE): Rationale and methodology of a pilot randomized controlled trial.

INTRODUCTION: One-third of North American adults with congenital heart disease (CHD) have diagnosable mood or anxiety disorders and most do not receive mental health treatment. There are no published interventions targeting the psychosocial needs of patients with CHD of any age. We describe the development of a group psychosocial intervention aimed at improving the psychosocial functioning, quality of life, and resilience of adults with CHD and the design of a study protocol to determine the feasibility of a potential full-scale randomized controlled trial (RCT). METHODS/DESIGN: Drawing upon our quantitative and qualitative research, we developed the Adult CHD-Coping And REsilience (ACHD-CARE) intervention and designed a feasibility study that included a 2-parallel arm non-blinded pilot RCT. Eligible participants (CHD, age ≥ 18 years, no planned surgery, symptoms suggestive of a mood and/or anxiety disorder) were randomized to the ACHD-CARE intervention or Usual Care (1:1 allocation ratio). The group intervention was delivered during eight 90-minute weekly sessions. Feasibility will be assessed in the following domains: (i) process (e.g. recruitment and retention), (ii) resources, (iii) management, (iv) scientific outcomes, and (v) intervention acceptability. DISCUSSION: This study underscores the importance of carefully developing and testing the feasibility of psychosocial interventions in medical populations before moving to full-scale clinical trials. At study conclusion, we will be poised to make one of three determinations for a full-scale RCT: (1) feasible, (2) feasible with modifications, or (3) not feasible. This study will guide the future evaluation and provision of psychosocial treatment for adults with CHD.

An Internet-Based Counseling Intervention With Email Reminders that Promotes Self-Care in Adults With Chronic Heart Failure: Randomized Controlled Trial Protocol.

BACKGROUND: Chronic heart failure (CHF) is a public health priority. Its age-standardized prevalence has increased over the past decade. A major challenge for the management of CHF is to promote long-term adherence to self-care behaviors without overtaxing available health care resources. Counseling by multidisciplinary health care teams helps to improve adherence to self-care behaviors and to reduce the rate of death and hospitalization. In the absence of intervention, adherence to self-care is below recommended standards. OBJECTIVE: This trial aims to establish and evaluate a Canadian e-platform that will provide a core, standardized protocol of behavioral counseling and education to facilitate long-term adherence to self-care among patients with CHF. METHODS: Canadian e-Platform to Promote Behavioral Self-Management in Chronic Heart Failure (CHF-CePPORT) is a multi-site, double blind, randomized controlled trial with a 2 parallel-group (e-Counseling + Usual Care vs e-Info Control + Usual Care) by 3 assessments (baseline, 4-, and 12-month) design. We will identify subjects with New York Heart Association Class II or III systolic heart failure from collaborating CHF clinics and then recruit them (n=278) by phone. Subjects will be randomized in blocks within each site (Toronto, Montreal, and Vancouver). The primary outcome will be improved quality of life, defined as an increased number of subjects with an improvement of ≥5 points on the summary score of the Kansas City Cardiomyopathy Questionnaire. We will also assess the following secondary outcomes: (1) diet habits, depression, anxiety, smoking history, stress level, and readiness for change using self-report questionnaires, (2) physical activity level, current smoking status, and vagal-heart rate modulation by physiological tests, and (3) exercise capacity, prognostic indicators of cardiovascular functioning, and medication adherence through medical chart review. The primary outcome will be analyzed using generalized estimation equations with repeated measures on an intention-to-treat basis. Secondary outcomes will be analyzed using repeated-measures linear mixed models with a random effects intercept. All significant main effects or interactions in the statistical models will be followed up with post hoc contrasts using a Bonferroni correction with a 2-sided statistical significance criterion of P<.05. RESULTS: This 3.5-year, proof-of-principle trial will establish the e-infrastructure for a pan-Canadian e-platform for CHF that is comprised of a standardized, evidence-based protocol of e-Counseling. CONCLUSIONS: CHF-CePPORT is designed to improve long-term adherence to self-care behaviors and quality of life among patients with CHF. It will demonstrate a distinct Canadian initiative to build capacity for preventive eHealth services for patients with CHF. TRIAL REGISTRATION: ClinicalTrials.gov NCT01864369; http://clinicaltrials.gov/ct2/show/NCT01864369 (Archived by WebCite at http://www.webcitation.org/6Iiv6so7E).

Listening to the heart-brain talk: persistent depressive symptoms are associated with hsCRP in apparently healthy individuals at high risk for coronary artery disease.

BACKGROUND: This study examined whether mild-to-moderate depressive symptoms are associated with increased high-sensitivity C-reactive protein (hsCRP) and interleukin 6 (IL-6) levels in apparently healthy individuals at high risk for coronary artery disease. We investigated in individuals whether: (1) current depressive symptoms were associated with increased hsCRP and IL-6 levels; (2) persistent depressive symptoms at two time points 6 months apart were associated with hsCRP and IL-6; and (3), sex-based differences in inflammation were a function of depressive symptoms. METHODS: We measured depressive symptoms (twice), hsCRP, and IL-6 (follow-up time point) in 84 apparently healthy individuals (52% women) at high cardiac risk. RESULTS: Patients with persistent depressive symptoms had higher hsCRP, compared to participants without persistent symptoms (5.55 vs. 1.70 mg/l, p < 0.05, 95% CI 0.11 to 1.09, d = 0.67). Participants with current depressive symptoms had higher hsCRP (3.99 vs. 1.70 mg/l, p = 0.059) than those without symptoms. Findings remained unchanged after controlling for covariates. Women had higher adjusted hsCRP than men (2.91 vs. 1.87 mg/l, p < 0.001). When we entered depressive symptoms, the model remained significant, with a significant interaction between sex and symptoms: women with depressive symptoms had higher hsCRP than men with depressive symptoms and than women without symptoms (6.75 vs. 1.11 mg/l). The hypothesized differences were not observed with respect to IL-6, after controlling for body mass index (95% CI-0.77 to 0.73). CONCLUSIONS: Before a first ischaemic coronary event, persistent mild-to-moderate depressive symptoms were associated with increased hsCRP. Women with depressive symptoms had higher hsCRP than men with symptoms.

Prevalence of, and barriers to, preventive lifestyle behaviors in hypertension (from a national survey of Canadians with hypertension).

Patients with hypertension are advised to lower their blood pressure to <140/90 mm Hg through sustained lifestyle modification and/or pharmacotherapy. To describe the use of lifestyle changes for blood pressure control and to identify the barriers to these behaviors, the data from 6,142 Canadians with hypertension who responded to the 2009 Survey on Living With Chronic Diseases in Canada were analyzed. Most Canadians with diagnosed hypertension reported limiting salt consumption (89%), having changed the types of food they eat (89%), engaging in physical activity (80%), trying to control or lose weight if overweight (77%), quitting smoking if currently smoking (78%), and reducing alcohol intake if currently drinking more than the recommended levels (57%) at least some of the time to control their blood pressure. Men, those aged 20 to 44 years, and those with lower educational attainment and lower income were, in general, less likely to report engaging in lifestyle behaviors for blood pressure control. A low desire, interest, or awareness were commonly reported barriers to salt restriction, changes in diet, weight loss, smoking cessation, and alcohol reduction. In contrast, the most common barrier to engaging in physical activity to regulate blood pressure was the self-reported challenge of managing a coexisting physical condition or time constraints. In conclusion, programs and interventions to improve the adherence to lifestyle changes to treat hypertension may need to consider the identified barriers to lifestyle behaviors in their design.

The mineral nature of asbestos.

Fibrous minerals are common in nature but asbestiform minerals are rare. The unique mineralogical characteristic common to all the asbestos minerals is their morphologic form (or habit of crystallization) as polyfilamentous fiber bundles. The individual fibrils within the bundles have a tendency to be very long with a narrow range of diameters and grow with their long fiber axis in parallel orientation to the bundle length. The asbestiform habit imparts to the asbestos minerals sufficient flexibility and tensile strength so that most can be woven into cloth. In the past application has focused on their ability to insulate against the transfer of heat. However, these minerals possess other properties which make them useful in many industrial applications.

Risk assessment due to environmental exposures to fibrous particulates associated with taconite ore.

In the early 1970s, it became a concern that exposure to the mineral fibers associated taconite ore processed in Silver Bay, Minnesota would cause asbestos-related disease including gastrointestinal cancer. At that time data gaps existed which have now been significantly reduced by further research. To further our understanding of the types of airborne fibers in Silver Bay we undertook a geological survey of their source the Peter Mitchell Pit, and found that there are no primary asbestos minerals at a detectable level. However we identified two non-asbestos types of fibrous minerals in very limited geological locales. Air sampling useful for risk assessment was done to determine the type, concentrations and size distribution of the population of airborne fibers around Silver Bay. Approximately 80% of the airborne fibers have elemental compositions consistent with cummingtonite-grunerite and the remaining 20% have elemental compositions in the tremolite-actinolite series. The mean airborne concentration of both fiber types is less than 0.00014 fibers per milliliter that is within the background level reported by the World Health Organization. We calculate the risk of asbestos-related mesothelioma and lung cancer using a variety of different pessimistic assumptions. (i) that all the non-asbestos fibers are as potent as asbestos fibers used in the EPA-IRIS listing for asbestos; with a calculated risk of asbestos-related cancer for environmental exposure at Silver Bay of 1 excess cancer in 28,500 lifetimes (or 35 excess cancers per 1,000,000 lifetimes) and secondly that taconite associated fibers are as potent as chrysotile the least potent form of asbestos. The calculated risk is less than 0.77 excess cancer case in 1,000,000 lifetimes. Finally, we briefly review the epidemiology studies of grunerite asbestos (amosite) focusing on the exposure conditions associated with increased risk of human mesothelioma.

The search for asbestos within the Peter Mitchell Taconite iron ore mine, near Babbitt, Minnesota.

Asbestos crystallizes within rock formations undergoing intense deformation characterized by folding, faulting, shearing, and dilation. Some of these conditions have prevailed during formation of the taconite iron ore deposits in the eastern Mesabi Iron Range of Minnesota. This range includes the Peter Mitchell Taconite Mine at Babbitt, Minnesota. The mine pit is over 8 miles long, up to 1 mile wide. Fifty three samples were collected from 30 sites within areas of the pit where faulting, shearing and folding occur and where fibrous minerals might occur. Eight samples from seven collecting sites contain significant amounts of ferroactinolite amphibole that is partially to completely altered to fibrous ferroactinolite. Two samples from two other sites contain ferroactinolite degraded to ropy masses of fibers consisting mostly of ferrian sepiolite as defined by X-ray diffraction and TEM and SEM X-ray spectral analysis. Samples from five other sites contain unaltered amphiboles, however some of these samples also contain a very small number of fiber bundles composed of mixtures of grunerite, ferroactinolite, and ferrian sepiolite. It is proposed that the alteration of the amphiboles was caused by reaction with water-rich acidic fluids that moved through the mine faults and shear zones. The fibrous amphiboles and ferrian sepiolite collected at the Peter Mitchell Mine composes a tiny fraction of one percent of the total rock mass of this taconite deposit; an even a smaller amount of these mineral fragments enter the ambient air during mining and milling. These fibrous minerals thus do not present a significant health hazard to the miners nor to those non-occupationally exposed. No asbestos of any type was found in the mine pit.

Physical activity behavior, motivational readiness and self-efficacy among Ontarians with cardiovascular disease and diabetes.

This cross-sectional study examined physical activity and its correlates among 355 diabetes, 144 cardiovascular disease, 75 diabetes and cardiovascular disease, and 390 residents with cardiovascular risk factors. Community residents (N=2566) were screened by telephone, and 964 participants completed a self-report survey. Non-diabetes participants participated in a greater range of physical activities (p<.001), more frequently (p=.013). Diabetes participants had lower physical activity readiness and efficacy (ps<.009). In a regression model (p<.001), region and disease, work, marital and smoking status were significant correlates of physical activity frequency. Interventions which increase motivational readiness and efficacy among diabetics are required to prevent and delay complications, particularly in regions with environmental barriers such as cold weather and homogeneous, low-density land use.

Effect of depression on five-year mortality after an acute coronary syndrome.

Previous research has established a relation between depression at the time of cardiac hospitalization and patient mortality. The objective of this study was to examine the role of depressive history and symptomatology during hospitalization on 5-year all-cause mortality after admission for an acute coronary syndrome. We recruited 750 patients who had unstable angina pectoris and myocardial infarction from 12 coronary care units between 1997 and 1999. Measurements included sociodemographic and clinic data and the Beck Depression Inventory (BDI). Data were linked to an administrative database to determine 5-year all-cause mortality. Survival data were adjusted using a Cox's proportional hazards model. One hundred seventy-four participants (23.2%) self-reported a history of depressed mood for >2 weeks, 235 (31.3%) had elevated BDI scores at index hospitalization, with 105 (14.0%) reporting persistent depressive symptomatology. One hundred fifteen participants (15.3%) died by 5 years after hospitalization. After adjusting for prognostic indicators, such as cardiac disease severity, medical history, and smoking, depressive symptomatology during hospitalization was significantly predictive of mortality, but depressive history was not. Hazard ratios associated with BDI scores <10 versus those > or =10 at hospitalization ranged from 1.90 (95% confidence interval 1.12 to 3.24) at 2 years to 1.53 (95% confidence interval 1.04 to 2.24) at 5 years. In conclusion, the significance of depressive symptomatology at the time of, but not before, hospitalization underlines the need for early identification of increased distress and renews calls to identify treatments that not only improve quality of life but also decrease the risk of mortality.

Risk assessment for asbestos-related cancer from the 9/11 attack on the World Trade Center.

OBJECTIVE: We sought to estimate the lifetime risk of asbestos-related cancer for residents of Lower Manhattan attributable to asbestos released into the air by the 9/11 attack on New York City's World Trade Center (WTC). METHODS: Exposure was estimated from available data and reasoned projections based on these data. Cancer risk was assessed using an asbestos risk model that differentiates asbestos fiber-types and the US Environmental Protection Agency's model that does not differentiate fiber-types and combines mesothelioma and lung cancer risks. RESULTS: The upper limit for the expected number of asbestos-related cancers is less than one case over the lifetime of the population for the risk model that is specific for fiber-types and 12 asbestos-related cancers with the US Environmental Protection Agency's model. CONCLUSIONS: The cancer risk associated with asbestos exposures for residents of Lower Manhattan resulting from the collapse of the WTC is negligible.

Evidence against a role for SV40 in human mesothelioma.

SV40 has been implicated in the etiology of 40% to 60% of human mesotheliomas. These studies could have important medical implications concerning possible sources of human infection and potential therapies if human tumors are induced by this agent. We did PCR-based analysis to detect SV40 large T antigen DNA in human mesotheliomas. None of 69 tumors in which a single copy gene was readily amplified contained detectable SV40 large T antigen sequences. Under these conditions, it was possible to detect one copy of integrated SV40 DNA per cell in a mixture containing a 5,000-fold excess of normal cells using formalin-fixed preparations. Kidney, a known reservoir of SV40 in monkeys, from some of these individuals were also negative for SV40 large T antigen sequences. A subset of mesotheliomas was analyzed for SV40 large T antigen expression by immunostaining with a highly specific SV40 antibody. These tumors as well as several human mesothelioma cell lines previously reported to contain SV40 large T antigen were negative for detection of the virally encoded oncoprotein. Moreover, mesothelioma cell lines with wild-type p53 showed normal p53 function in response to genotoxic stress, findings inconsistent with p53 inactivation by the putative presence of SV40 large T antigen. Taken together, these findings strongly argue against a role of SV40 by any known transformation mechanism in the etiology of the majority of human malignant mesotheliomas.