The role of anxiety sensitivity in exercise tolerance and anxiety and depressive symptoms among individuals seeking treatment in cardiopulmonary rehabilitation.

The aim of the current cross-sectional study was to examine the effects of specific anxiety sensitivity (AS) dimensions (AS -Physical, -Cognitive, and -Social concerns) on exercise tolerance (i.e. 6-minute walk test) and factors that interfere with cardiopulmonary rehabilitation (CPR) and exercise adherence (i.e. depression and anxiety symptoms) among individuals seeking treatment in cardiopulmonary rehabilitation (CPR). Participants were 69 individuals (65.2% male, Mage = 63.60, SD = 12.55, Range = 27-85 years) with various cardiovascular or pulmonary conditions meeting criteria for CPR entry, who presented for an intake appointment at an outpatient phase 2 CPR clinic. Higher levels of AS-Physical and-Social concerns were significantly associated with poorer exercise tolerance and greater generalized anxiety symptoms, respectively. Though none of the AS dimensions were significant individual predictors, they were collectively associated with greater depressive symptoms. Future work should assess whether it may be useful to target AS in some patients prior to or throughout CPR.

Implementation, feasibility, and acceptability of quality of life therapy to improve positive emotions among patients with implantable cardioverter defibrillators.

Implantable cardioverter defibrillators (ICDs) save lives, but often induce significant psychological distress among patients. Positive psychological constructs are associated with improved outcomes among cardiac patients. In this NHLBI-funded randomized controlled trial, one aim was to evaluate the feasibility and acceptability of a positive psychology intervention (Quality of Life Therapy; QOLT, n = 11), compared to a Heart Healthy Education (HHE) control (n = 10), among ICD patients. A majority of participants across groups attended all 12 sessions (71%) and completed homework assignments (80%). Agreement on participant engagement and interventionist protocol adherence were high, with no differences between groups (ps > 0.20). A greater proportion of QOLT participants rated their sessions was "very" helpful compared to HHE participants (63% vs. 10%, p = 0.19). These initial data support the feasibility and acceptability of QOLT. A larger-scale trial using positive psychology interventions among ICD patients is indicated to determine potential mechanisms underlying the relationship between positive psychological constructs and cardiovascular health.

An Examination of the Association Between Post-traumatic Growth and Stress Symptomatology in Cardiac Outpatients.

This study examined the association between post-traumatic growth (PTG), post-traumatic stress disorder (PTSD), and trauma-related factors in cardiac outpatients. Participants recruited from four cardiology clinics between November 2014 and July 2015 (N = 52, 69.2% men, Mage = 65 years) completed self-assessments of PTG and PTSD along with demographic, cardiac health index, and trauma-related factors. In total, 75% of the sample endorsed their cardiac event as traumatic, while 17.2% reported their cardiac event as their 'worst trauma'; those endorsing the latter did not significantly differ from those endorsing 'other traumas' as their worst. Chi-square analyses indicated that the lifetime traumas of experiencing loss or abandonment, witnessing trauma, and experiencing a natural disaster were significantly related to PTG factors of new possibilities, relating to others, and spirituality. Bivariate correlations on all PTSD symptom clusters and factors of PTG revealed the strongest associations between the PTG factors of spiritual change and appreciation of life. Lifetime PTSD symptoms, duration of negative reactions, and re-experiencing symptoms were found to be significantly associated with higher PTG, and a unique independent effect emerged with avoidance symptoms. Our results suggest that PTG may be associated with particular facets of PTSD symptomatology.

A Ventricular Assist Device Recipient and Suicidality: Multidisciplinary Collaboration With a Psychiatrically Distressed Patient.

BACKGROUND: Ventricular assist device (VAD) recipients are at high risk of depression and anxiety, and poor psychosocial functioning is associated with worse medical outcomes. PURPOSE: We present a case of a 31-year-old depressed patient who demonstrated passive suicidal behavior through multiple episodes of noncompliance, including temporarily discontinuing warfarin (Coumadin) several months after VAD implantation. The patient's psychosocial and medical histories and outcomes are presented. CONCLUSIONS: This case underscores the importance of pre-VAD as well and ongoing psychosocial evaluation and management for this unique patient population. CLINICAL IMPLICATIONS: Medical teams who are treating patients with cardiovascular disease who are under consideration for VAD or heart transplantation need to be aware of the multitude of ways in which patients can express depressed and suicidal mood and work with a multidisciplinary team to treat such symptoms to optimize patients' success with VAD/heart transplantation.

Positive Psychotherapy to Improve Autonomic Function and Mood in ICD Patients (PAM-ICD): Rationale and Design of an RCT Currently Underway.

BACKGROUND: Improving mental and physical health of patients with implantable cardioverter defibrillators (ICD) is critical because this group is at high risk for ventricular arrhythmias and sudden death and depressed or anxious cardiovascular disease (CVD) patients appear to be at even higher risk for mortality compared to nondepressed or nonanxious CVD patients. Further, autonomic dysfunction is present in these patients, and negative emotions and arrhythmias form a downward spiral further worsening mood, well-being, and cardiovascular health. Much research demonstrates that positive emotion is related to health benefits, improved physiology, and increased survival. METHODS AND RESULTS: This is a two-arm randomized controlled trial aiming to recruit 60 adult ICD patients comparing 12 individually delivered, weekly sessions of: (1) a positive emotion-focused cognitive-behavioral therapy (Quality of Life Therapy [QOLT]), and (2) Heart Healthy Education. Autonomic functioning, heart rhythm indices, and psychosocial health are measured at baseline, 3 months, and 9 months. The first goal is feasibility and acceptability, with the primary outcome being arrhythmic event frequency data. CONCLUSION: This study is designed to test whether QOLT produces changes in mood, quality of life/well-being, autonomic function, and arrhythmic and ICD therapy event rates. This feasibility trial is a foundational step for the next trial of QOLT to help determine whether a 3-month QOLT trial can reduce arrhythmias occurrences among ICD patients, and examine a mechanism of autonomic functioning. This study may help to develop and implement new medical or psychological therapies for ICD patients.

Psychosocial management in cardiac rehabilitation: Current practices, recommendations, and opportunities.

Psychosocial management is a core component of outpatient Phase-II cardiac rehabilitation (CR) and includes psychosocial assessment, providing interventions, measuring outcomes, and care coordination. Psychosocial management contributes to the effectiveness of comprehensive CR, but the implementation is not always consistent or clearly described in the literature, in part due to the availability of behavioral health specialists. Patients in CR have many psychosocial needs including anxiety, depression, substance use disorders, sleep problems, psychosocial stress, and cognitive impairment. Behavioral considerations are inherent in many other aspects of CR,such as participation in CR, health behaviors, adherence, and tobacco cessation. Evaluation, or psychosocial assessment, should identify significant issues, record related medications, and incorporate findings in the individual treatment plan. Some patients require further evaluation and treatment by a qualified behavioral health specialist. Psychosocial interventions provided to all patients include patient education, counseling, stress-management, a supportive environment, and exercise. Measuring outcomes entails repeating the psychosocial assessment when patients finish CR and documenting changes. Coordinating care requires understanding available local mental health infrastructure and procedures for making referrals, and may entail identifying additional resources. Interventions provided concurrently with CR to a subset of patients with more extensive needs are typically pharmacotherapy, psychotherapy, or addictions counseling, which are beyond the scope of practice for most CR professionals. The way psychosocial management is implemented suggests clinical and research opportunities. For example, the combined effects of antidepressants and CR on depression and anxiety are not known. A prominent clinical opportunity is to fully implement psychosocial assessment, as required by statute and the core components. This could involve referring patients for whom clinically significant psychosocial concerns are identified during the evaluation for a more thorough assessment by a behavioral health specialist using an appropriate billing model. A research priority is a contemporary description of behavioral health services available to CR programs, including how psychosocial management is implemented. As delivery of CR comes to include more alternative models (e.g., home-based), research is needed on how that affects the delivery of psychosocial management. Increased use of telehealth may broaden clinical opportunities for psychosocial management.

The nuclear cardiology report: problems, predictors, and improvement. A report from the ICANL database.

BACKGROUND: The quality of nuclear cardiology reports is essential for the effective communication of results of cardiac radionuclide imaging and has never been evaluated for compliance with the ICANL standards. This retrospective study was designed to evaluate required reporting elements and site characteristics to determine differences in the compliance of applicant nuclear cardiology laboratories with The ICANL Standards, and identify potential mechanisms for improvement. METHODS AND RESULTS: Site characteristics and the 18 elements of the ICANL nuclear cardiology reporting standard ranked by level of importance were evaluated in 1,301 labs applying for accreditation from 1/1/08 to 1/1/09. A majority of labs were non-compliant (57.2%) with ≥1 of the 18 elements, mean number of errors 2.13 ± 2.58. There were significant differences among applications with different accreditation decisions, first application and repeat applications, and region of the United States. Laboratories with multiple re-accreditations had significantly increased compliance. These findings were confirmed following analysis of the ranked importance of the non-compliant elements. CONCLUSIONS: Nuclear cardiology reports have a high degree of non-compliance with the current ICANL standards. There were identifiable characteristics defining labs more likely to be non-compliant. Feedback from prior applications improves compliance with reporting standards on subsequent applications.

Exercise Video Games are Associated with More Positive Affective Response, which Predicts Physical Activity Adherence.

Background: A more positive affective valence during exercise is predictive of adherence to physical activity programs. This study examines the relationship between affective response during exercise and longer-term maintenance of physical activity among individuals using exercise video games (EVGs) and standard modalities of physical activity (i.e., walking, cycling). Methods: Healthy adults (mean age 45.4, SD=14.5) were randomly assigned to a 12-week supervised, thrice weekly program of EVGs (n=93) or Standard exercise (n=96), and were assessed for affect immediately before, at the mid-point, and immediately after one exercise session per week. Participation in moderate-to-vigorous physical activity (MVPA) was conducted at end of treatment (EOT) and 6-month follow up. Results: EVG participants reported more positive affective valence during exercise compared to Standard participants (b=.63, SE=.08, p<.001), and perceived less exertion (b=.52, SE=.36, p=.04) compared to Standard participants. For both groups, a more positive affective valence during exercise was significantly predictive of continued physical activity at 6-months (b=6.64, SE=2.50, p=.01). EVG participants also showed a significant chronic effect such that week-to-week there were improvements in affect prior to exercise and this effect was significantly associated with greater MPVA at EOT and follow-up (b=21.96, SE=10.10, p=.03 at EOT). Among Standard participants no significant chronic effect was seen over time. Conclusions: EVGs may provide an effective means of promoting more positive shifts in affective valence both during, and in anticipation of, physical activity that encourages longer-term participation.

Disparities in preferences for receiving support and education among patients with implantable cardioverter defibrillators.

BACKGROUND: The implantable cardioverter-defibrillator (ICD) is the established treatment for patients with a history of or at risk for sudden cardiac arrest. Patients receiving an ICD are diverse, and little is known regarding their preferences for support and education postimplantation. The purpose of this study was to examine race, gender, and age preferences for receiving support and education (e.g., written, verbal). METHODS: Participants (N = 108, 75% Caucasian, 74% male, age 65 +/- 11 years) completed a research team-designed survey at a regularly scheduled clinic visit with the cardiac electrophysiologist at an academic medical center or offsite clinic. Descriptive statistics, Pearson chi(2), and independent t-tests were conducted. RESULTS: The study demonstrates important associations between race, gender, and age with patient preferences for support and education with regard to ICD care. African Americans preferred written materials (P = 0.006) and a phone call with the cardiologist (P =0.036). Women preferred an ICD support group (P = 0.023), a phone call with the device nurse (P = 0.027), and a professional counselor (P = 0.049). Women's choice to receive education from their cardiologist approached significance (P = 0.055). Patients < or =67 years of age preferred to receive support via an Internet chat room with other ICD patients (P =0.036), and to receive education via an Internet Web site (P = 0.022). CONCLUSIONS: Findings suggest methods of providing better care to ICD patients by offering them support and educational materials in their preferred modality. These data can aid in optimizing clinical care. Incorporating assessments of individual preferences into future clinical trial design is desirable.

Mediators of physical activity between standard exercise and exercise video games.

OBJECTIVE: Exercise video games (EVGs) may offer an attractive, sustainable alternative or supplement to traditional modes of exercise. Understanding the psychosocial factors that influence the appeal of EVGs is important for improving the efficacy of video games as a method of promoting the uptake and long-term maintenance of physical activity. METHODS: This study examined changes in psychosocial constructs from self-determination theory and self-efficacy theory as mediators of intervention efficacy among 189 healthy, sedentary adults randomized to 12-week programs of either EVGs or standard exercise (e.g., treadmill walking, stationary cycling) followed by 6 months of follow-up. The EVG group engaged in significantly more weekly minutes of moderate to vigorous physical activity (MVPA) at the end of treatment compared with the standard exercise group. Univariate and multivariate mediational models were used to examine theoretically derived psychosocial constructs as potential mediators of differential intervention effects. RESULTS: Univariate mediational models suggest a significant indirect effect of treatment on MVPA outcomes through enjoyment, self-efficacy, stress management, depressive symptoms, and positive engagement (p < .05). Multiple mediational analyses confirm all the univariate results (p < .05), with the exception of enjoyment. CONCLUSIONS: Differences in the efficacy of EVG versus standard exercise interventions were mediated by several psychosocial constructs, suggesting that qualities specific to game play may enhance adherence to physical activity both in and outside of the laboratory environment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Reduction in HbA1c with Exercise videogames among participants with elevated HbA1c: Secondary analysis of the Wii Heart Fitness trial.

AIMS: Physical activity plays an important role in blood glucose management, yet most adults with elevated blood glucose do not engage in regular physical activity. Exercise videogames (EVGs) may be an attractive alternative for persons who have not found standard exercise modalities appealing. METHODS: This sub-study within a larger trial examined the effects of 12 weeks of EVGs versus standard exercise (e.g., treadmill, cycling) and a control condition among individuals with elevated HbA1c (100% prediabetic). This study was conducted at a university research lab. Outcomes included HbA1c and weekly minutes of moderate to vigorous physical activity (MVPA) assessed using self-report and accelerometer.Other health risk indices (e.g., lipids) and psychosocial constructs shown to influence exercise participation (e.g., intrinsic motivation) were assessed. RESULTS: Participants (n = 84), averaged age 51.4 years (range 20-79), 80% were female, and 77.4% were non-Hispanic. Baseline HbA1c ranged from 5.7% to 6.4% (39-49 mmol/mol). At week 12, EVG participants demonstrated an average 2% reduction in HbA1c compared to a 0.6% reduction in Standard and Control groups (p's = 0.04 and 0.03). EVG participants engaged in significantly more MVPA than Standard (+17 min/week) and Controls (+54 min/week) (p's < 0.05), had reduced LDL cholesterol (p = 0.05) and trends suggesting reduced body fat (p = 0.10). EVG participants reported higher exercise enjoyment and motivation compared to other participants. CONCLUSIONS: EVGs may be an attractive and effective tool to improve management of blood glucose that might contribute toward preventing the onset of type 2 diabetes among those with prediabetes.

Exercise Videogames, Physical Activity, and Health: Wii Heart Fitness: A Randomized Clinical Trial.

INTRODUCTION: Adults who engage in regular physical activity have lower rates of morbidity and mortality than those who do not. Exercise videogames may offer an attractive, sustainable alternative or supplement to traditional modes of exercise. This study compared exercise videogames with standard exercise modalities for improving uptake and maintenance of moderate to vigorous physical activity, and health risk indices. STUDY DESIGN: A three-arm clinical RCT including 12 weeks of supervised laboratory-based moderate to vigorous physical activity followed by 6 months follow-up. SETTING/PARTICIPANTS: This study was conducted at a university affiliated hospital research lab. Healthy, sedentary adults were eligible. INTERVENTIONS: This study compared a 12-week program of supervised exercise videogames versus standard exercise (e.g., treadmill) versus control. Data were collected from January 2012 to September 2017 and analyzed in 2018. MAIN OUTCOME MEASURES: The primary outcome was weekly minutes of moderate to vigorous physical activity at end of treatment, assessed at 3 and 6 months post-intervention by using self-report and accelerometer data. Health risk indices (e.g., HbA1c, lipids) were also assessed. RESULTS: Participants (N=283) had an average age of 46.2 ±13.5 years; 79% were female. At end of treatment, those in the exercise videogame arm engaged in 30 minutes/week more moderate to vigorous physical activity compared with standard exercise and 85 more minutes/week than controls (all p<0.05). Exercise videogame participants had greater reductions in cholesterol, HbA1c, and body fat versus other groups. Reductions in cholesterol were twice as large in exercise videogame versus standard participants. CONCLUSIONS: Exercise videogames produced greater uptake and maintenance of moderate to vigorous physical activity compared with standard exercise and improvements in multiple health risk indices. Exercise videogames may promote sustainable physical activity with significant health benefits. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT03298919.

Depression, anxiety, and quality of life in patients with obstructive hypertrophic cardiomyopathy three months after alcohol septal ablation.

Patients with obstructive hypertrophic cardiomyopathy are presumed to have poor quality of life (QOL) and distress related to their cardiac symptoms and functional limitations. Alcohol septal ablation (ASA) is designed to improve heart function and reduce cardiac symptoms. The purpose of this study was to examine psychosocial factors and QOL in patients with obstructive hypertrophic cardiomyopathy before and 3 months after ASA. Twenty-two adult participants (mean age 57 +/- 14 years, 59% women, 100% Caucasian, 67% married) were recruited during their initial evaluations or scheduled index hospitalizations for ASA. Psychosocial and medical measures were collected before and 3 months after ASA. The results indicated that before ASA, 57% of patients reported clinically relevant levels of depression (Center for Epidemiologic Studies Depression Scale score >16), symptoms of anxiety, and reduced QOL. Repeated-measures analyses of variance revealed that ASA is an effective procedure in reducing disease severity (i.e., peak left ventricular outflow tract gradient, septal thickness, posterior wall thickness) (p = 0.001 to 0.05), depression (p = 0.005), and anxiety (p = 0.029) and improving cardiac-specific QOL (p < 0.001) and generic physical health-related QOL (p = 0.009). Changes in satisfaction with life, optimism, and generic mental health-related QOL were not significant (p = 0.143 to 0.899). In conclusion, significant psychological distress and compromised well-being were present in this sample of pre-ASA patients with obstructive hypertrophic cardiomyopathy. After ASA, significant reductions in psychological distress and improvements in well-being and echocardiographic parameters indicating disease severity were demonstrated. These results suggest that patients perceived broad health benefits from ASA in short-term follow-up.

The feasibility of exercise videogames for cardiovascular risk reduction among adults: a pilot for "Wii heart fitness".

BACKGROUND: More than 30% of the U.S. population is prehypertensive, and the recommended treatment of lifestyle modification includes increased physical activity. Exercise videogames (EVG) are widely marketed to Americans as a means of increasing fitness. This study aimed to examine EVG among a sample of prehypertensive adults, to determine (1) feasibility and acceptability of EVG for physical activity, and (2) assess changes in (1) estimates of cardiovascular fitness and risk indices, and psychosocial constructs. METHODS: Participants with prehypertension completed a 12-week program including; 36, 1-hour sessions; supervised EVG program using Nintendo Wii platform and games. Assessments were at baseline and 13 weeks. Paired t-tests were conducted. RESULTS: Fourteen adults (84% female; mean age=53 years; 93% Caucasian; 87% employed) completed the study. The study retention rate was 74% and all participants reported satisfaction and enjoyment in the intervention and using the Wii for exercise. Despite the small sample size, significant improvements were seen in: physical activity minutes (P<0.01), peak heart rate (P=0.02), resting systolic blood pressure (P=0.02), and hip circumference (P=0.03). Significant improvements were also seen in the 36-item short-form survey (SF-36) as for general health (P=0.05), role limitations due to emotional problems (P=0.04), and vitality (P=0.01). CONCLUSIONS: Findings support that an EVG program is feasible, acceptable, and promising in promoting benefit to cardiovascular fitness and psychosocial health. These data provide pilot data for the necessary randomized clinical trials to examine efficacy and sustainability of EVG for adult engagement in physical activity for cardiovascular health promotion.

Exercise videogames for physical activity and fitness: Design and rationale of the Wii Heart Fitness trial.

INTRODUCTION: Despite numerous health benefits, less than half of American adults engage in regular physical activity. Exercise videogames (EVG) may be a practical and attractive alternative to traditional forms of exercise. However there is insufficient research to determine whether EVG play alone is sufficient to produce prolonged engagement in physical activity or improvements in cardiovascular fitness and overall health risk. The goal of the present study is to test the efficacy of exercise videogames to increase time spent in moderate to vigorous physical activity (MVPA) and to improve cardiovascular risk indices among adults. METHODS: Wii Heart Fitness is a rigorous 3-arm randomized controlled trial with adults comparing three 12-week programs: (1) supervised EVGs, (2) supervised standard exercise, and (3) a control condition. Heart rate is monitored continuously throughout all exercise sessions. Assessments are conducted at baseline, end of intervention (week 12), 6 and 9 months. The primary outcome is time spent in MVPA physical activity. Secondary outcomes include changes in cardiovascular fitness, body composition, blood lipid profiles and maintenance of physical activity through six months post-treatment. Changes in cognitive and affective constructs derived from Self Determination and Social Cognitive Theories will be examined to explain the differential outcomes between the two active treatment conditions. CONCLUSION: The Wii Heart Fitness study is designed to test whether regular participation in EVGs can be an adequate source of physical activity for adults. This study will produce new data on the effect of EVGs on cardiovascular fitness indices and prolonged engagement with physical activity.

The influence of age on fibromyalgia symptoms.

OBJECTIVES: Studies of the influence of age on health and well-being in chronically ill patients have produced mixed findings. This study examined young (20-39), middle-aged (40-59), and older (60-85) individuals with fibromyalgia (FMS), a chronic pain condition. The purpose of this study was to determine whether there were differences among the age groups in symptomatology and to examine potential mediating psychosocial variables. METHODS: Participants were 600 (95% female, mean age = 54, SD = 11) diagnosed FMS patients who were members of a health maintenance organization. Multivariate analyses of covariance were used to examine differences. RESULTS: There were significant differences among the age groups in most of the variables: With increasing age symptom duration increased but FMS symptomatology decreased. No age differences were found among the psychosocial mediators. The results suggest that the effects of FMS decrease over time.

Depression and Anxiety Symptoms Relate to Distinct Components of Pain Experience among Patients with Breast Cancer.

Breast cancer is a leading cancer diagnosis among women worldwide, with more than 210,000 new cases and 40,000 deaths per year in the United States. Pain, anxiety, and depression can be significant factors during the course of breast cancer. Pain is a complex experience with sensory, affective, and cognitive dimensions. While depression and anxiety symptoms are relatively common among breast cancer patients, little is known about the relation between these psychiatric factors and distinct components of the pain experience. In the present study 60 females presenting to an NCI-designated Cancer Center with newly diagnosed breast cancer completed the Center for Epidemiological Studies 10-item Depression Scale, the State Instrument of the Spielberger State-Trait Anxiety Inventory, and the McGill Pain Questionnaire. Findings indicate that anxiety and depression are common among newly diagnosed breast cancer patients; furthermore, patients experience an appreciable amount of pain even before oncologic treatment starts. State anxiety serves as a predictor of the sensory dimension of the pain experience, whereas depression serves as a predictor of the affective dimension of the pain experience.

Depressive Symptoms, Pain, and Quality of Life among Patients with Nonalcohol-Related Chronic Pancreatitis.

Objective. The present study was conducted to determine if depressive symptoms were associated with variability in pain perception and quality of life among patients with nonalcohol-related chronic pancreatitis. Methods. The research design was cross-sectional, and self-report data was collected from 692 patients with nonalcohol-related, intractable pancreatitis. The mean age of the sample was 52.6 (SD = 14.7); 41% of the sample were male. Participants completed the MOS SF12 Quality of Life Measure, the Center for Epidemiological Studies 10-item Depression Scale (CESD), and a numeric rating scale measure of "pain on average" from the Brief Pain Inventory. Results. Depressive symptoms were significantly related to participants' reports of increased pain and decreased quality of life. The mean CESD score of the sample was 10.6 (SD = 6.5) and 52% of the sample scored above the clinical cutoff for the presence of significant depressive symptomology. Patients scoring above the clinical cutoff on the depression screening measure rated their pain as significantly higher than those below the cutoff (P < 0.0001) and had significantly lower physical quality of life (P < 0.0001) and lower mental quality of life (P < 0.0001). Conclusion. Although causality cannot be determined based on cross-sectional, correlational data, findings suggest that among patients with nonalcoholic pancreatitis, the presence of depressive symptoms is common and may be a risk factor associated with increased pain and decreased quality of life. Thus, routine screening for depressive symptomology among patients with nonalcoholic pancreatitis may be warranted.