Association of Anxiety and Depression in Obstructive Sleep Apnea Patients: A Systematic Review and Meta-Analysis.

Background: Obstructive sleep apnea (OSA) has been associated with mental disorders, but the strength of this association is unknown. The aim of our study was to investigate the association among OSA, depression, and anxiety in adults and to quantitatively summarize the results. Methods: A literature search in Medline, PubMed, PsycInfo, Scopus, and Web of Science was conducted. Seventy-three articles were selected for study. Results: The pooled prevalence of depressive and anxious symptoms in OSA patients was 35% (95% CI, 28-41%) and 32% (95% CI, 22-42%), respectively. Conclusions: The association between OSA, anxiety, and depression indicates the value of an early diagnosis and personalized treatment of OSA to improve mental disorders conditioning compliance to therapy. These conditions share a probably bidirectional relationship.

Recommendations for the implementation of distress screening programs in cancer centers: report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) joint task force.

In 2015, the American College of Surgeons (ACoS) Commission on Cancer will require cancer centers to implement screening programs for psychosocial distress as a new criterion for accreditation. A joint task force from the American Psychosocial Oncology Society, the Association of Oncology Social Work, and the Oncology Nursing Society developed consensus-based recommendations to guide the implementation of this requirement. In this review, the authors provide recommendations regarding each of the 6 components necessary to meet the ACoS standard: 1) inclusion of psychosocial representation on the cancer committee, 2) timing of screening, 3) method/mode of screening, 4) tools for screening, 5) assessment and referral, and 6) documentation.

Association between cancer stigma and depression among cancer survivors: a nationwide survey in Korea.

OBJECTIVE: Cancer patients are more likely to experience depression than the general population. This study aims to evaluate the possible association between cancer stigma and depression among cancer patients. METHODS: As a part of the Korean government's program to develop comprehensive supportive care, we conducted a nationwide survey in 2010 at the National Cancer Center and in nine regional cancer centers across Korea. Cancer stigma was assessed by using a set of 12 questions grouped in three domains-impossibility of recovery, stereotypes of cancer patients, and experience of social discrimination. Depression was measured by using the Hospital Anxiety and Depression Scale. RESULTS: A total of 466 cancer patients were included in the study. Over 30% of the cancer survivors had negative attitudes toward cancer and held stereotypical views of themselves: about 10% of the participants experienced social discrimination due to cancer, and 24.5% reported clinically significant depressive symptoms. Patients who had or experienced cancer stigma were 2.5 times more likely to have depression than patients with positive attitudes. CONCLUSIONS: Regardless of highly developed medical science and increased survivorship, cancer survivors had cancer stigmas, and it was significantly associated with depression. IMPACT: Our findings emphasize the need for medical societies and health professionals to pay more attention to cancer stigma that patients are likely to experience during treatment.

Clinic-based depression screening in lung cancer patients using the PHQ-2 and PHQ-9 depression questionnaires: a pilot study.

OBJECTIVES: This study aims to validate the ability to perform depression screening with the patient health questionnaire (PHQ)-2 and PHQ-9 depression modules in a busy, outpatient practice, and to evaluate the prevalence of depression among lung cancer outpatients at our institution. METHODS: In 2010, 64 patients in a thoracic malignancy clinic completed the Patient Health Questionnaire-2. Patients endorsing either one or both items were then given the Patient Health Questionnaire-9, a nine-item depression assessment tool. Patients with mild or worse depression were offered a referral to a mental health care provider. RESULTS: Eighteen of 64 patients (28 %) endorsed one or both items on the PHQ-2. Thirteen of 18 patients with a positive PHQ-2 screen completed the PHQ-9, with mean score of 10.2 (SD 3.91), suggesting moderate depression. PHQ-9 item 4, evaluating fatigue, was positive in 12 patients, and PHQ-9 item 9, evaluating suicidal ideation, was never reported. Only 1 of 18 patients with a positive PHQ-2 screen was being followed by a psychiatrist, and no patient accepted a new referral to a mental health provider. CONCLUSIONS: The PHQ-2 and PHQ-9 modules are an effective means of depression screening in a busy, outpatient clinic. A high prevalence of depression was reported; yet, suicidal ideation was not reported. Depression severity ranged from mild to severe. The most endorsed PHQ-9 item was fatigue, although it is uncertain if this reflects a symptom of depression, a sequela of lung cancer itself, or both. The lung cancer patients in this sample who reported depression were unlikely to receive mental health services.

Validation of a needs-based biopsychosocial distress instrument for cancer patients.

OBJECTIVE: People with cancer may experience distress related to diagnoses, disease-related symptoms, and treatment side effects. Assessment of cancer-related needs can facilitate timely triage and intervention and contribute to individualized comprehensive cancer care. This study assessed the internal consistency, test-retest reliability and construct validity of the Cancer Needs Distress Inventory (CaNDI), a self-report, needs-based measure of cancer-related distress. METHODS: A sample of 100 patients (27% male) with various cancer diagnoses completed the CaNDI, Hospital Anxiety and Depression Scale, Brief Symptom Inventory, Functional Assessment of Cancer Therapy-General, and the Paulhus Deception Scales. RESULTS: The CaNDI total and depressive and anxiety subscale scores all demonstrated excellent test-retest reliability and moderate to high correlations with other measures of these constructs. The instrument was minimally confounded by social desirability and provided high sensitivity and specificity in detecting depression and anxiety. CONCLUSIONS: Initial results suggest that the CaNDI has strong psychometric properties and may be a useful addition to cancer patient needs assessment, research and care.

Long-term course of pain in breast cancer survivors: a 4-year longitudinal study.

After successful treatment of early breast cancer, many women still report pain symptoms, and attribute them to the previous illness or its treatment. However, knowledge about the long-term course of pain in breast cancer is limited. Baseline assessment included 3,088 women who received a breast cancer diagnosis on average 2 years prior to enrollment, and who completed typical medical treatments. After 4 years, a subsample of 2,160 recurrence-free women (70%) was re-assessed. The major outcome variable was the composite index for general pain symptoms. Over the 4-year course, a slight but significant increase in pain was reported. If only medical variables were examined, a triple interaction between surgery type, breast cancer stage, and time indicated that pain scores increased in most subgroups, while they decreased in stage II women after mastectomy and stage III women after lumpectomy. Using a regression analytical approach, psychological and other variables added significantly to the prediction of pain persistence. Regression analysis revealed that pain symptoms increased in those women taking tamoxifen at baseline, in those reporting depression at baseline or stressful life events during the first 12 months after enrollment. Exercise at baseline had a beneficial effect on pain recovery. The persistence or increase of pain symptoms in women surviving breast cancer is associated with some medical factors (surgery type, tamoxifen use), but also with psychological factors. Pain should be a standard outcome variable in the evaluation of cancer treatment programs.

Depressed mood and flow-mediated dilation: a systematic review and meta-analysis.

OBJECTIVE: This systematic and quantitative review evaluates the literature on associations between depressed mood and flow-mediated dilation (FMD), a measure of endothelial function, in adults. METHODS: Published English-language articles (through December 2010) were identified from literature searches, assessed for data extraction, and evaluated for quality. RESULTS: The literature includes cross-sectional (n = 9) and retrospective examinations (n = 3) of how FMD correlates with clinical or subclinical depression in healthy adults and cardiovascular patients (total N across 12 studies = 1491). FMD was assessed using a variety of methodologies. Samples were predominately older white and Asian subjects with higher socioeconomic status. In eight of the 12 articles selected for this review, at least one significant inverse association was noted between depressed mood and FMD, with primarily moderate effect sizes. The overall meta-analysis (random-effects model) revealed a combined effect size of correlation coefficient r = 0.19 (95% confidence interval = 0.08-0.29, p = .001). Significant combined effects were found for subgroups of studies that a) received better quality ratings (r = 0.29), b) examined patients with cardiovascular disease or with cardiovascular disease risk factors/comorbidity (r = 0.29), c) used maximum vasodilation to quantify FMD (r = 0.27), and d) assessed samples that had a mean age of 55 years and older (r = 0.15). CONCLUSIONS: Diverse studies support the inverse correlation between depressed mood and endothelial function, as measured by FMD. This literature would be strengthened by prospective studies, increased methodological consistency in FMD testing, and broader sampling (e.g., African Americans, younger age, lower socioeconomic status).

Poor physical health predicts time to additional breast cancer events and mortality in breast cancer survivors.

BACKGROUND: Health-related quality of life has been hypothesized to predict time to additional breast cancer events and all-cause mortality in breast cancer survivors. METHODS: Women with early-stage breast cancer (n=2967) completed the SF-36 (mental and physical health-related quality of life) and standardized psychosocial questionnaires to assess social support, optimism, hostility, and depression prior to randomization into a dietary trial. Cox regression was performed to assess whether these measures of quality of life and psychosocial functioning predicted time to additional breast cancer events and all-cause mortality; hazard ratios were the measure of association. RESULTS: There were 492 additional breast cancer events and 301 deaths occurred over a median 7.3 years (range: 0.01-10.8 years) of follow-up. In multivariate models, poorer physical health was associated with both decreased time to additional breast cancer events and all-cause mortality (p trend=0.005 and 0.004, respectively), while greater hostility predicted additional breast cancer events only (p trend=0.03). None of the other psychosocial variables predicted either outcome. The hazard ratios comparing persons with poor (bottom two quintiles) to better (top three quintiles) physical health were 1.42 (95% CI: 1.16, 1.75) for decreased time to additional breast cancer events and 1.37 (95% CI: 1.08, 1.74) for all-cause mortality. Potentially modifiable factors associated with poor physical health included higher body mass index, lower physical activity, lower alcohol consumption, and more insomnia (p<0.05 for all). CONCLUSION: Interventions to improve physical health should be tested as a means to increase time to additional breast cancer events and mortality among breast cancer survivors.

Effects of a weight loss intervention on body mass, fitness, and inflammatory biomarkers in overweight or obese breast cancer survivors.

BACKGROUND: Obesity is characterized by chronic mild inflammation and may influence the risk and progression of cancer. PURPOSE: The current study is an exploratory analysis of the effect of a weight loss intervention that emphasized increased physical activity on inflammatory cytokines (tumor necrosis factor-α [TNF-α], interleukin-6 [IL-6], interleukin-8 [IL-8], and vascular endothelial growth factor [VEGF]) at the end of the 16-week intervention period in overweight breast cancer survivors. METHODS: Study participants averaged 56 years of age (N=68). Intervention participants (n=44 vs. 24 controls) participated in a cognitive behavioral therapy-based weight management program as part of an exploratory randomized trial. The intervention incorporated strategies to promote increased physical activity and diet modification. Baseline and 16-week data included height, weight, body composition, physical activity level, and biomarkers IL-6, IL-8, TNF-α, and VEGF. RESULTS: Weight loss was significantly greater in the intervention group than controls (-5.7 [3.5] vs. 0.2 [4.1] kg, P<0.001). Paired t tests noted favorable changes in physical activity level (P<0.001 intervention, P=0.70 control), marginally lower IL-6 levels (P=0.06 intervention, P=0.25 control) at 16 weeks for participants in the intervention group, and lower TNF-α levels for participants in the intervention (P<0.05) and control groups (P<0.001). Increased physical activity was associated with favorable changes in IL-6 for participants in the intervention group (R(2) =0.18; P<0.03). CONCLUSION: Favorable changes in cytokine levels were observed in association with weight loss in this exploratory study with overweight breast cancer survivors.

A Model for Studying Neuropsychological Effects of Sleep Intervention: The Effect of 3-week Continuous Positive Airway Pressure Treatment.

PURPOSE: Patients with obstructive sleep apnea (OSA) commonly have cognitive complaints. There are few randomized studies that have examined neuropsychological effects of continuous positive airway pressure (CPAP) treatment in patients with OSA. In this double-blind trial, we examined if a 3-week CPAP treatment compared with placebo CPAP treatment has specific therapeutic effects on cognitive impairments in patients with OSA and if there are specific domains of cognitive impairments sensitive to 3-week CPAP treatment. SUBJECTS AND METHODS: Thirty-eight newly diagnosed patients with untreated OSA underwent neuropsychological testing before and after 3-weeks CPAP or Placebo CPAP treatment. The two treatment groups (therapeutic CPAP, and placebo-CPAP) were compared using repeated measures analysis of variance (ANOVA). RESULTS AND CONCLUSION: Impairments in neuropsychological functioning ranged from 2.6% to 47.1% before treatment. In response to 3 weeks of treatment, there was no significant time by treatment interaction for a global deficit score of neuropsychological functioning. Only the Stroop Color (number correct) test showed significant improvement specific to CPAP treatment. The study demonstrates the importance of further randomized placebo controlled studies in this area.

Medical comorbidities predict mortality in women with a history of early stage breast cancer.

This analysis was conducted to determine whether comorbid medical conditions predict additional breast cancer events and all-cause mortality in women with a history of early stage breast cancer. Women (n = 2,542) participating in a randomized diet trial completed a self-administered questionnaire regarding whether they were currently being treated for a wide variety of diseases (cardiovascular, diabetes, gallbladder, gastrointestinal, arthritis, and osteoporosis) and conditions (high blood pressure, elevated cholesterol level). Height and weight were measured at baseline. Participants were followed for a median of 7.3 years (range 0.8-15.0). Cox regression analysis was performed to assess whether comorbidities predicted disease-free and overall survival; hazard ratio (HR) was the measure of association. Overall, there were 406 additional breast cancer events and 242 deaths. Participants with diabetes had over twofold the risk of additional breast cancer events (HR 2.1, 95% CI: 1.3, 3.4) and mortality (HR 2.5, 95% CI: 1.4, 4.4). The presence of multiple comorbidities did not statistically significantly predict additional breast cancer events. However, compared to no comorbidities, participants with 3 or more comorbidities had a HR of 2.1, 95% CI: 1.3, 3.3 for mortality. In conclusion, type 2 diabetes is associated with poor breast cancer prognosis. Given that 85% of deaths were caused by breast cancer, these findings suggest that multiple comorbidities may reduce the likelihood of surviving additional breast cancer events.

Adverse impact of mood on flow-mediated dilation.

OBJECTIVE: To examine the impact of mood states on endothelial function, as measured noninvasively by brachial artery flow-mediated dilation (FMD). Substantial literature indicates that negative mood is linked to cardiovascular disease (CVD). However, the mechanisms underlying this relationship are not well defined. CVD is often preceded by dysfunction of the endothelium. METHODS: Healthy adults (n = 70; mean age, 36 years) completed the Profile of Mood States (POMS), which contains six subscales (depression/dejection; tension/anxiety; anger/hostility; confusion/bewilderment; fatigue/inertia; vigor/activity) that are used to compute a total mood disturbance score for overall psychological distress. FMD was calculated (maximum percentage change in brachial artery diameter) from ultrasound assessment of arterial diameter at baseline and for 10 minutes after occlusion. RESULTS: Regressions showed that increases in POMS total mood disturbance scores were associated with decreases in endothelial function. Mood disturbance explained 10% of the variance in FMD (p < .01), after controlling for age, sex, mean arterial pressure, body mass index, and socially desirable response bias. An exploratory set of separate regressions conducted to decompose the link between FMD and total mood disturbance revealed that the following POMS subscales were inversely correlated with FMD: depression/dejection, tension/anxiety, anger/hostility, fatigue/inertia (p's < .05), and confusion/bewilderment (p < .01). CONCLUSIONS: Mood disturbance could contribute to CVD via impaired vasodilation. These preliminary results show that even mild levels of adverse psychological states, particularly depressed, anxious, angry, confused, and fatigued states, might be linked to increased cardiovascular risk.

Endothelial function: the impact of objective and subjective socioeconomic status on flow-mediated dilation.

BACKGROUND: Although objective and subjective indicators of socioeconomic status (SES) are linked to cardiovascular disease (CVD), little is known about their relationship to endothelial dysfunction, which often precedes CVD. PURPOSE: This study examined how objective and subjective SES relate to brachial artery flow-mediated dilation (FMD). METHODS: FMD was assessed in 72 healthy adults (mean age 36 years). The MacArthur Scale of Subjective Social Status assessed perceived social standing in the USA (SSS-USA) and local community (SSS-Community). Objective SES measures included income and the Hollingshead Two-Factor Index of Social Position (education, occupation). RESULTS: Adjusted regressions revealed that SSS-Community positively correlated with FMD (p < 0.05) and explained 8% of the variance. No other SES measures were significant for FMD. The association between FMD and SSS-Community remained significant (p < 0.01) after adjustment for objective SES and other covariates. CONCLUSIONS: Lower subjective social status in one's community may be linked to CVD via impaired vasodilation.

Relationships between cardiorespiratory fitness, physical activity, and psychosocial variables in overweight and obese breast cancer survivors.

BACKGROUND: Breast cancer survivors not only experience distressing physical symptoms associated with treatments, but also are faced with psychosocial challenges. Despite growing scientific evidence that physical activity (PA) may mitigate psychosocial distress experienced by women treated for breast cancer, the literature is equivocal. PURPOSE: This study investigated the relationships between cardiorespiratory fitness (CRF), PA, and psychosocial factors in breast cancer survivors. METHOD: Data involving overweight or obese breast cancer survivors (N = 260) were examined. CRF was determined by a submaximal graded exercise test. PA, depressive symptoms, total fatigue, and global self-esteem were assessed with self-report measures. Pearson's correlations were conducted to determine associations among CRF, PA, depressive symptoms, total fatigue, and global self-esteem. Multiple regression models, with age and body mass index as covariates, were performed using continuous levels for CRF and PA. RESULTS: Bivariate correlations suggested that CRF and PA were unrelated to the psychosocial variables. One of the regression models identified a marginally significant (P = 0.06) inverse association between depressive symptoms and PA. CONCLUSION: CRF and PA were not associated with psychosocial factors in this sample of breast cancer survivors. However, minimal PA was reported by the majority of participants, so low PA variability likely influenced these findings.

Relationship between inflammation and cognitive function in obstructive sleep apnea.

OBJECTIVES: Obstructive sleep apnea (OSA) can have adverse effects on cognitive functioning, mood, and cardiovascular functioning. OSA brings with it disturbances in sleep architecture, oxygenation, sympathetic nervous system function, and inflammatory processes. It is not clear which of these mechanisms is linked to the decrease in cognitive functioning. This study examined the effect of inflammatory parameters on cognitive dysfunction. MATERIALS AND METHODS: Thirty-nine patients with untreated sleep apnea were evaluated by polysomnography and completed a battery of neuropsychological tests. After the first night of evaluation in the sleep laboratory, blood samples were taken for analysis of interleukin 6, tumor necrosis factor-alpha (TNF-alpha), and soluble TNF receptor 1 (sTNF-R1). RESULTS: sTNF-R1 significantly correlated with cognitive dysfunction. In hierarchical linear regression analysis, measures of obstructive sleep apnea severity explained 5.5% of the variance in cognitive dysfunction (n.s.). After including sTNF-R1, percentage of variance explained by the full model increased more than threefold to 19.6% (F = 2.84, df = 3, 36, p = 0.05). Only sTNF-R1 had a significant individual relationship with cognitive dysfunction (beta = 0.376 t = 2.48, p = 0.02). CONCLUSIONS: sTNF-R1 as a marker of chronic inflammation may be associated with diminished neuropsychological functioning in patients with OSA.

Serum aminotransferase levels are associated with markers of hypoxia in patients with obstructive sleep apnea.

STUDY OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is a disorder that often presents with elevated serum aminotransferase levels. Although it has classically been linked with the metabolic syndrome, recent studies suggest NAFLD may also be associated with obstructive sleep apnea (OSA). This study evaluates the association between serum aminotransferase levels and factors connected with: either the metabolic syndrome (elevated body mass index [BMI], lipid profile, blood pressure, fasting glucose), or with OSA severity (apnea hypopnea index, lowest oxygen saturation level, oxygen desaturation index, percent of time below 90% saturation [%T<90]). DESIGN: Retrospective case series. PATIENTS AND SETTING: 109 adult patients with OSA at a university hospital general clinical research center. MEASUREMENTS AND RESULTS: Markers of hypoxia (lowest oxygen saturation level and %T<90), correlated significantly with aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels (Pearson's r = -0.31 to -0.38, P <0.003), while apnea hypopnea index, body mass index, blood pressure, fasting glucose, triglyceride, and cholesterol levels did not. Hierarchical linear regression was then done to determine the best predictors of aminotransferase levels. Markers of metabolic syndrome were entered as one block and markers of sleep apnea as another. Regression analyses explained 16.3% of the variance in AST and 18.9% of the variance in ALT, with %T<90 playing the largest role. CONCLUSIONS: In patients with obstructive sleep apnea, serum aminotransferase levels are better predicted by markers of oxygen desaturation than by factors traditionally associated with the metabolic syndrome.

Correlation between hemoglobin and fatigue in women undergoing adjuvant chemotherapy without erythropoietin-stimulating-agent support.

BACKGROUND: Fatigue is a common complication of adjuvant chemotherapy and compromises the quality of life of breast cancer survivors. We sought to correlate serial hemoglobin (Hb) levels with fatigue in a population of women on adjuvant chemotherapy, none of whom received erythropoietin-stimulating agents or red blood cell transfusions. PATIENTS AND METHODS: Seventy-five women participated in a study using quality-of-life questionnaires to assess changes in need for psychosocial support over time. Questionnaires were administered within 30 days of initiating adjuvant therapy and at 2, 6, and 12 months. Fatigue was assessed by the 36-Item Short-Form Health Survey (SF-36). Hemoglobin levels at each time point were captured retrospectively. Complete data are included for 40 of the 46 women who received adjuvant chemotherapy. Paired-samples t tests were conducted to compare mean SF-36 Energy/Fatigue scores between time points, and independent-samples t tests were conducted for comparisons against norms. Simple correlations (Pearson R) were conducted between SF-36 variables and Hb levels at each time point. RESULTS: At 2 months, 23.4% of women had Hb<11 g/dL compared with 12.9% at 12 months. Compared with norms for women in the general population and breast cancer survivors, these women reported worse fatigue at baseline and at 2 and 6 months. A strong linear relationship was observed between Hb at 2 months and SF-36 Energy/Fatigue scores at 12 months (r=0.71; P=.002). CONCLUSION: Participants with high fatigue at 12 months had Hb levels at 2 months 13% lower than those with low fatigue. This finding suggests that chemotherapy-induced decline in Hb might be a marker of physiologic reserve.

Impact of Positive Pressure Treatment of the Airway on Health-Related Quality of Life in Elderly Patients With Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is a chronic illness that increases in prevalence with age. Treatment includes continuous positive airway pressure (CPAP) devices. Studies about the use of CPAP in the elderly are scarce. The main objective of this study is to determine whether CPAP contributes to improvement in health-related quality of life (HRQL) in elderly patients with OSA. METHOD: This was a prospective, pre-/postintervention assessment of a cohort of patients ≥65 years of age with OSA diagnosis by polysomnography who were being treated with CPAP and were physically independent and had good cognitive status. We determined HRQL before and after 3 months of CPAP treatment using the Short Form-36 Health Survey (SF-36, a 36-item, patient-reported survey) and Sleep Apnea Quality of Life Index (SAQLI). The effect of CPAP on daytime sleepiness was assessed with the Epworth Sleepiness Scale (ESS). RESULTS: Of the 103 participants with a mean age of 71.5 ± 4.19 years, 66% were male. After 3 months of therapy, the mean CPAP usage was 6.3 ± 1.41 hr/day. The effectiveness of CPAP in controlling the OSA was demonstrated (mean difference pre- and posttherapy: 34.30 ± 18.52 events/hr, p < .001). Postintervention, the categories of the SF-36 improved meaningfully ( p < .001). Moreover, all categories of SAQLI improved ( p < .001) with the exception of "symptoms" ( p = .073). ESS scores also improved significantly (difference = 5.2 ± 4.47, p < .001) postintervention. CONCLUSION: Therapy with CPAP in elderly patients with OSA helps improve their HRQL and reduces daytime sleepiness.

Comparison of the effects of depressive symptoms and apnea severity on fatigue in patients with obstructive sleep apnea: a replication study.

BACKGROUND: Links between fatigue and depressive symptoms in medically ill patients are well-documented; however, few studies controlled for illness severity. Obstructive sleep apnea (OSA) is a common, frequently devastating disease that often includes daytime sleepiness and fatigue. Fatigue is also a hallmark depressive symptom. We previously reported that depressive symptoms explained ten times the variance in fatigue in OSA patients as did OSA severity itself (respiratory disturbance index, oxyhemoglobin saturation). OSA severity explained 4.2% of variance in fatigue while depressive symptoms explained an additional 42.3%. Here, we report a replication of these findings in a new, independent sample. METHODS: 56 untreated OSA patients had their sleep monitored with polysomnography on the UCSD GCRC. Participants completed the Center for Epidemiologic Studies-Depression (CESD), Profile of Mood States (POMS) and Medical Outcomes Studies (MOS) surveys. Data were analyzed using hierarchical linear regression. RESULTS: OSA severity explained 13.4% (p=0.022) of variance in POMS fatigue while CESD scores explained an additional 24.5% (p<0.001). Results were robust to changes in the scales used to measure these constructs. LIMITATIONS: Cross-sectional design precludes determination of direction of causality. Assessment of depressive symptoms and fatigue was based on validated self-report measures. CONCLUSIONS: These results reaffirm that depressive symptoms are dramatically and independently associated with worse fatigue in OSA patients. While the independent contribution of OSA severity varied between studies, depressive symptoms were the strongest predictor of fatigue in both studies. Assessment and treatment of mood symptoms-not just treatment of OSA itself-might reduce fatigue in these patients.

Influence of a diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women's Healthy Eating and Living (WHEL) randomized trial.

CONTEXT: Evidence is lacking that a dietary pattern high in vegetables, fruit, and fiber and low in total fat can influence breast cancer recurrence or survival. OBJECTIVE: To assess whether a major increase in vegetable, fruit, and fiber intake and a decrease in dietary fat intake reduces the risk of recurrent and new primary breast cancer and all-cause mortality among women with previously treated early stage breast cancer. DESIGN, SETTING, AND PARTICIPANTS: Multi-institutional randomized controlled trial of dietary change in 3088 women previously treated for early stage breast cancer who were 18 to 70 years old at diagnosis. Women were enrolled between 1995 and 2000 and followed up through June 1, 2006. INTERVENTION: The intervention group (n = 1537) was randomly assigned to receive a telephone counseling program supplemented with cooking classes and newsletters that promoted daily targets of 5 vegetable servings plus 16 oz of vegetable juice; 3 fruit servings; 30 g of fiber; and 15% to 20% of energy intake from fat. The comparison group (n = 1551) was provided with print materials describing the "5-A-Day" dietary guidelines. MAIN OUTCOME MEASURES: Invasive breast cancer event (recurrence or new primary) or death from any cause. RESULTS: From comparable dietary patterns at baseline, a conservative imputation analysis showed that the intervention group achieved and maintained the following statistically significant differences vs the comparison group through 4 years: servings of vegetables, +65%; fruit, +25%; fiber, +30%, and energy intake from fat, -13%. Plasma carotenoid concentrations validated changes in fruit and vegetable intake. Throughout the study, women in both groups received similar clinical care. Over the mean 7.3-year follow-up, 256 women in the intervention group (16.7%) vs 262 in the comparison group (16.9%) experienced an invasive breast cancer event (adjusted hazard ratio, 0.96; 95% confidence interval, 0.80-1.14; P = .63), and 155 intervention group women (10.1%) vs 160 comparison group women (10.3%) died (adjusted hazard ratio, 0.91; 95% confidence interval, 0.72-1.15; P = .43). No significant interactions were observed between diet group and baseline demographics, characteristics of the original tumor, baseline dietary pattern, or breast cancer treatment. CONCLUSION: Among survivors of early stage breast cancer, adoption of a diet that was very high in vegetables, fruit, and fiber and low in fat did not reduce additional breast cancer events or mortality during a 7.3-year follow-up period. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00003787.