Economic, Psychological, and Emotional Well-Being of Pregnant Women During the COVID-19 Pandemic.

INTRODUCTION: The intersection between perinatal mental health and the coronavirus disease 2019 (COVID-19) pandemic remains of significant public health importance. The current study examined the emotional and financial well-being and predictors of elevated depressive symptoms among pregnant women during the COVID-19 pandemic. METHODS: This online survey was conducted with 2118 women ≥18 years old who were pregnant at the time of the survey and living in the United States or Puerto Rico. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale, with scores ≥10 indicative of elevated depressive symptoms. The final logistic regression model included housing insecurity, financial distress, COVID-19 diagnosis, exposure to COVID-19, and demographic covariates. RESULTS: More than half the sample (53.8%) had elevated depressive symptoms. In logistic regression analyses, the odds of having elevated depressive symptoms were significantly higher for participants reporting housing insecurity (adjusted odds ratio [aOR], 1.56; 95% CI, 1.22-2.01), financial distress (aOR, 1.57; 95% CI, 1.17-2.12), COVID-19 diagnosis (aOR, 2.53; 95% CI, 1.53-4.17), and COVID-19 exposure (aOR, 1.41; 95% CI, 1.07-1.86), after adjusting for covariates. The association of elevated depressive symptoms with housing insecurity was especially strong among those who experienced COVID-19 (aOR, 6.04; 95% CI, 2.15-17.0). DISCUSSION: Our findings are consistent with previous literature revealing that diagnosis, exposure, concerns about family, and effects on financial stability were related to depressive symptoms during the pandemic. The relationships between financial and housing concerns with elevated depressive symptoms, independent of concerns about infection in family members, suggest that there may be direct and indirect effects of the pandemic on mental health.

Depressive Symptoms, Antidepressants, and Clinical Outcomes in Chronic Kidney Disease: Findings from the CRIC Study.

Rationale & Objective: The extent to which depression affects the progression of chronic kidney disease (CKD) and leads to adverse clinical outcomes remains inadequately understood. We examined the association of depressive symptoms (DS) and antidepressant medication use on clinical outcomes in 4,839 adults with nondialysis CKD. Study Design: Observational cohort study. Setting and Participants: Adults with mild to moderate CKD who participated in the multicenter Chronic Renal Insufficiency Cohort Study (CRIC). Exposure: The Beck Depression Inventory (BDI) was used to quantify DS. Antidepressant use was identified from medication bottles and prescription lists. Individual effects of DS and antidepressants were examined along with categorization as follows: (1) BDI <11 and no antidepressant use, (2) BDI <11 with antidepressant use, (3) BDI ≥11 and no antidepressant use, and (4) BDI ≥11 with antidepressant use. Outcomes: CKD progression, incident cardiovascular disease composite, all-cause hospitalizations, and mortality. Analytic Approach: Cox regression models were fitted for outcomes of CKD progression, incident cardiovascular disease, and all-cause mortality, whereas hospitalizations used Poisson regression. Results: At baseline, 27.3% of participants had elevated DS, and 19.7% used antidepressants. Elevated DS at baseline were associated with significantly greater risk for an incident cardiovascular disease event, hospitalization, and all-cause mortality, but not CKD progression, adjusted for antidepressants. Antidepressant use was associated with higher risk for all-cause mortality and hospitalizations, after adjusting for DS. Compared to participants without elevated DS and not using antidepressants, the remaining groups (BDI <11 with antidepressants; BDI ≥11 and no antidepressants; BDI ≥11 with antidepressants) showed higher risks of hospitalization and all-cause mortality. Limitations: Inability to infer causality among depressive symptoms, antidepressants, and outcomes. Additionally, the absence of nonpharmacological data, and required exploration of generalizability and alternative analytical approaches. Conclusions: Elevated DS increased adverse outcome risk in nondialysis CKD, unattenuated by antidepressants. Additionally, investigation into the utilization and counterproductivity of antidepressants in this population is warranted.

We analyzed data from 4,839 nondialysis chronic kidney disease (CKD) patients in the Chronic Renal Insufficiency Cohort Study to explore how depression and antidepressants affect CKD-related outcomes. Using the Beck Depression Inventory (BDI), we assessed depressive symptoms (DS) and identified antidepressant use through medication records. Outcomes included CKD progression, cardiovascular events, hospitalizations, and mortality. Elevated DS at baseline raised the risk of cardiovascular events, hospitalizations, and mortality, regardless of antidepressant use. Antidepressant use alone was associated with higher mortality and hospitalization risks. In comparison to those without elevated DS and no antidepressant use, all other groups faced increased hospitalization and mortality risks. Elevated DS posed a significant risk to nondialysis CKD patients, and antidepressants did not mitigate this risk.

Positive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial.

BACKGROUND: Depression is highly prevalent in individuals on hemodialysis, but it is infrequently identified and remains undertreated. In this paper, we present details of the methodology of a randomized controlled trial (RCT) aimed at testing the feasibility and preliminary efficacy of a 5-week positive psychological intervention in individuals on hemodialysis with comorbid depression delivered using immersive virtual reality (VR) technology. OBJECTIVE: We aim to describe the protocol and design of the Joviality trial whose main objectives are 2-fold: determine the feasibility of the Joviality VR software through metrics capturing rates of recruitment, refusal, retention, noncompliance, and adherence, as well as end-user feedback; and assess preliminary efficacy for outcomes measures of depressive symptoms, psychological well-being and distress, quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalizations. METHODS: This 2-arm RCT is scheduled to enroll 84 individuals on hemodialysis with comorbid depression from multiple outpatient centers in Chicago, Illinois, United States. Enrollees will be randomized to the following groups: VR-based Joviality positive psychological intervention or sham VR (2D wildlife footage and nature-based settings with inert music presented using a head-mounted display). To be eligible, individuals must be on hemodialysis for at least 3 months, have Beck Depression Inventory-II scores of ≥11 (ie, indicative of mild-to-severe depressive symptoms), be aged ≥21 years, and be fluent in English or Spanish. The Joviality VR software was built using agile design principles and incorporates fully immersive content, digital avatars, and multiplex features of interactability. Targeted skills of the intervention include noticing positive events, positive reappraisal, gratitude, acts of kindness, and mindful or nonjudgmental awareness. The primary outcomes include metrics of feasibility and acceptability, along with preliminary efficacy focused on decreasing symptoms of depression. The secondary and tertiary outcomes include quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalization rates. There are 4 assessment time points: baseline, immediately after the intervention, 3 months after the intervention, and 6 months after the intervention. We hypothesize that depressive symptoms and hemodialysis-related markers of disease will substantially improve in participants randomized to the VR-based Joviality positive psychology treatment arm compared with those in the attention control condition. RESULTS: This RCT is funded by the National Institute of Diabetes and Digestive and Kidney Diseases and is scheduled to commence participant recruitment in June 2023. CONCLUSIONS: This trial will be the first to test custom-built VR software to deliver a positive psychological intervention, chairside, in individuals on hemodialysis to reduce symptoms of depression. Within the context of an RCT using an active control arm, if proven effective, VR technology may become a potent tool to deliver mental health programming in clinical populations during their outpatient treatment sessions. TRIAL REGISTRATION: ClinicalTrials.gov NCT05642364; https://clinicaltrials.gov/ct2/show/NCT05642364. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45100.

Feasibility and impact of a remote moderate-intensity yoga intervention on stress and executive functioning in working adults: a randomized controlled trial.

The feasibility of a moderate-intensity yoga intervention, delivered remotely via supervised and unsupervised sessions, and its psychosocial and cognitive effects have not been thoroughly investigated. This randomized controlled trial assessed feasibility and preliminary efficacy of an 8-week moderate-intensity yoga intervention (3×/week, 50 min) delivered remotely (vs. a waitlist control arm), on stress and cognitive functioning. Participants (n = 86) were low active, full-time working adults (81.40% female; Mage = 41 years) with symptoms of stress. Feasibility was assessed via adherence, enjoyment, and safety; stress and anxiety via self-report questionnaires; and executive functioning via neuropsychological tests. Overall attendance was 75.1%, 100% of participants enjoyed the intervention, and only one adverse event was reported. At follow-up, the yoga group had significantly lower stress and anxiety, and higher accuracy on working memory tasks. Remote moderate intensity yoga practice proved safe, enjoyable, and may reduce stress and improve cognitive functioning. This study was pre-registered on ClinicalTrials.gov (NCT04740229).

Efficacy of virtual reality assisted guided imagery (VRAGI) in a home setting for pain management in patients with advanced cancer: protocol for a randomised controlled trial.

INTRODUCTION: Patients with advanced cancer often experience high levels of debilitating pain and pain-related psychological distress. Although there is increasing evidence that non-pharmacological interventions are needed to manage their pain, pharmacologic modalities remain the preferred treatment . Guided imagery is a form of focused relaxation that helps create harmony between the mind and body and has been shown to significantly improve cancer pain. Our study presents Virtual Reality Assisted Guided Imagery (VRAGI) as a complementary treatment modality to manage chronic pain in patients with cancer. We will conduct a randomised controlled trial to test its impact on patients with advanced cancer in a home setting. METHODS AND ANALYSIS: We will recruit 80 patients from Prisma Health, a tertiary-level healthcare centre based in Greenville, South Carolina, USA. The prospective 2×2 randomised controlled trial will randomise participants into four groups: (1) VRAGI, (2) laptop-assisted guided imagery, (3) VR (no guided imagery) and (4) laptop (no guided imagery). Patients allocated to VR groups will be trained to use a head-mounted display that immerses them in 3D audio-video content. The non-VR group will use a laptop displaying 2D video content. We will collect measures before and during the 3-week intervention as well as 3 weeks after the intervention ends. Measures will include patient-reported outcomes of pain, anxiety, depression and fatigue in addition to opioid use. The primary objective of the current study is to assess the efficacy of VRAGI on pain in the home setting. The secondary objective is to assess the efficacy of VRAGI on opioid use, anxiety, depression and fatigue. ETHICS AND DISSEMINATION: This study was approved by the Prisma Health Institutional Review Board (#Pro00114598) in November 2021. All participants enrolled in the study will provide written informed consent. Dissemination will be through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT05348174, clinicaltrials.gov.

Sleep, cardiovascular risk factors, and kidney function: The Multi-Ethnic Study of Atherosclerosis (MESA).

OBJECTIVES: Examine the associations of sleep measures with kidney function changes over time among individuals from a community-based study. METHODS: The sample includes 1657 participants (287 with chronic kidney disease [CKD]) in the Multi-Ethnic Study of Atherosclerosis Sleep Cohort (mean age: 57.7 years, male: 46.0%). We examined associations between a large set of sleep variables (polysomnography, actigraphy, and questionnaires) and cardiovascular disease risk factors and changes in estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio over approximately 5 years using high-dimensional regression. We investigated the modifying effect of sleep on the associations between cardiovascular disease risk factors and kidney function. RESULTS: Sleep metrics predicted kidney function decline only among individuals with baseline CKD. Among this group, eGFR decline was associated with decreased stage N3 sleep (0.32 mL/min/1.73 m2/y per 10% decrease in N3, p < .001); increased actigraphy napping frequency (beta: -0.20 [-0.30, -0.07]); and actigraphy sleep midpoint trajectory in early morning (ref: midnight, beta: -0.84 [-1.19, -0.50]). Urinary albumin-to-creatinine ratio increase was associated with high wake bouts trajectory (ref: low, beta: 0.97 [0.28, 1.67]) and increased sleep-related hypoxemia (oxygen saturation %time<90 [≥5%], beta: 2.17 [1.26, 3.08]). Sleep metrics--N3 sleep, naps, and midpoint trajectory--significantly modified associations between hemoglobin A1C and eGFR decline. CONCLUSIONS: Reduced deep sleep, daytime napping, increased wake bouts, delayed sleep rhythms, and overnight hypoxemia are associated with longitudinal kidney function decline, with effects most apparent in individuals with CKD. Deep sleep, napping, and sleep timing modified the association between hemoglobin A1C and kidney function.

Machine Learning-Based Models Incorporating Social Determinants of Health vs Traditional Models for Predicting In-Hospital Mortality in Patients With Heart Failure.

Importance: Traditional models for predicting in-hospital mortality for patients with heart failure (HF) have used logistic regression and do not account for social determinants of health (SDOH). Objective: To develop and validate novel machine learning (ML) models for HF mortality that incorporate SDOH. Design, Setting, and Participants: This retrospective study used the data from the Get With The Guidelines-Heart Failure (GWTG-HF) registry to identify HF hospitalizations between January 1, 2010, and December 31, 2020. The study included patients with acute decompensated HF who were hospitalized at the GWTG-HF participating centers during the study period. Data analysis was performed January 6, 2021, to April 26, 2022. External validation was performed in the hospitalization cohort from the Atherosclerosis Risk in Communities (ARIC) study between 2005 and 2014. Main Outcomes and Measures: Random forest-based ML approaches were used to develop race-specific and race-agnostic models for predicting in-hospital mortality. Performance was assessed using C index (discrimination), regression slopes for observed vs predicted mortality rates (calibration), and decision curves for prognostic utility. Results: The training data set included 123 634 hospitalized patients with HF who were enrolled in the GWTG-HF registry (mean [SD] age, 71 [13] years; 58 356 [47.2%] female individuals; 65 278 [52.8%] male individuals. Patients were analyzed in 2 categories: Black (23 453 [19.0%]) and non-Black (2121 [2.1%] Asian; 91 154 [91.0%] White, and 6906 [6.9%] other race and ethnicity). The ML models demonstrated excellent performance in the internal testing subset (n = 82 420) (C statistic, 0.81 for Black patients and 0.82 for non-Black patients) and in the real-world-like cohort with less than 50% missingness on covariates (n = 553 506; C statistic, 0.74 for Black patients and 0.75 for non-Black patients). In the external validation cohort (ARIC registry; n = 1205 Black patients and 2264 non-Black patients), ML models demonstrated high discrimination and adequate calibration (C statistic, 0.79 and 0.80, respectively). Furthermore, the performance of the ML models was superior to the traditional GWTG-HF risk score model (C index, 0.69 for both race groups) and other rederived logistic regression models using race as a covariate. The performance of the ML models was identical using the race-specific and race-agnostic approaches in the GWTG-HF and external validation cohorts. In the GWTG-HF cohort, the addition of zip code-level SDOH parameters to the ML model with clinical covariates only was associated with better discrimination, prognostic utility (assessed using decision curves), and model reclassification metrics in Black patients (net reclassification improvement, 0.22 [95% CI, 0.14-0.30]; P < .001) but not in non-Black patients. Conclusions and Relevance: ML models for HF mortality demonstrated superior performance to the traditional and rederived logistic regressions models using race as a covariate. The addition of SDOH parameters improved the prognostic utility of prediction models in Black patients but not non-Black patients in the GWTG-HF registry.

Allostatic load, unhealthy behaviors, and depressive symptoms in the Hispanic Community Health Study/Study of Latinos.

BACKGROUND: The Environmental Affordances Model (EAM) proposes that the effects of chronic stress on depression are moderated by unhealthy behaviors and race/ethnicity. The unique social structures and contexts of Hispanics/Latinos in the U.S. may influence such relationships. This study evaluated whether unhealthy behaviors weakened the relationship between allostatic load, a measure of chronic stress, and future elevated depressive symptoms among Hispanic Community Health Study/Study of Latinos participants. METHODS: Longitudinal data (2008-2011 and 2014-2017) from 11,623 participants were analyzed. The exposure was allostatic load, an index of twelve established biomarkers categorized using clinically relevant cut points, at Visit 1. Elevated depressive symptoms were operationalized as a score of ≥10 (out of 30) on the CES-D 10 at Visit 2. An index of unhealthy behaviors, with one point each for cigarette smoking, excessive/binge drinking, sedentary behavior, and poor diet quality at Visit 1, was examined as an effect modifier. Multivariable logistic regression, in the overall sample and among Mexicans specifically and adjusted for demographic characteristics and elevated depressive symptoms at Visit 1, was used to model allostatic load, unhealthy behavior index (range: 0-4), and their interaction in relation to elevated depressive symptoms at Visit 2. RESULTS: Overall, greater allostatic load was associated with higher odds of elevated depressive symptoms after at least 6 years (aOR = 1.06, 95% CI = 1.01, 1.10). Overall, individuals with greater allostatic load and an unhealthy behavior index = 1, compared to those with an unhealthy behavior index = 0, had lower odds of elevated depressive symptoms at follow-up (aß = -0.065, 95% CI = -0.12, -0.007). CONCLUSIONS: The relationship between chronic stress and depression was partially moderated among Hispanics/Latinos who engaged in unhealthy behavior, which may have reduced their risk of elevated depressive symptoms given more chronic stress.

Association of Subjective Social Status With Life's Simple 7s Cardiovascular Health Index Among Hispanic/Latino People: Results From the HCHS/SOL.

Background Evidence suggests that subjective (perceived) social status (SSS) may predict health outcomes more strongly than objective social status, but little is known about the relationship between SSS and cardiovascular health (CVH). This study focuses on this relationship among diverse Hispanic/Latino adults because while poor CVH profiles are prevalent in this population, immigration complicates attempts to measure their social status. Methods and Results We analyzed baseline HCHS/SOL (Hispanic Community Health Study/Study of Latinos) data on 15 374 Hispanic/Latino adults aged 18 to 74 years in 2008 to 2011. SSS was assessed using the McArthur Scale, a 10-rung "social ladder." CVH was based on levels of 7 metrics defined by the American Heart Association. Linear and logistic regressions were used to examine cross-sectional associations of SSS with CVH (overall and single metrics) after adjusting for objective social status, demographic, and health factors. Less than half of the population (46%) had Ideal scores in ≥4 metrics of CVH. In multivariable-adjusted models, an increase in SSS was associated with a higher overall CVH score (ß=0.04; 95% CI, 0.01-0.06) and greater likelihood of Ideal levels of body mass index, physical activity, and fasting blood glucose levels. Nativity and time in the United States modified the association between SSS and Ideal smoking. Conclusions Subjective measures of social status can enhance an understanding of CVH among Hispanic/Latino people. Future studies should explore the stability of SSS over time in comparison with objective social status and the mechanisms through which SSS may influence CVH.

Association of self-reported sleep disturbances with ideal cardiovascular health in Brazilian adults: A cross-sectional population-based study.

OBJECTIVE: To examine the association between sleep disturbances and cardiovascular health in Brazilian adults. METHODS: We analyzed cross-sectional data from a nationally representative sample of 36,480 Brazilian adults ages 18 and over. Multivariate Poisson regression models were used to assess the association between sleep disturbances (difficulty falling asleep, frequent interruptions in sleep, or sleeping more than usual) and Life's Simple 7 (LS7) cardiovascular health (CVH) scores through consideration of four behaviors (smoking, physical activity, body mass index, and diet) and three biological factors (hypercholesterolemia, hypertension, and diabetes). RESULTS: Adults with no sleep disturbances had better CVH, with higher mean LS7 CVH scores (4.2, 95% confidence interval [CI]: 4.1; 4.2) when compared to those experiencing some level of sleep disturbance within a 2-week timespan (3.8, 95% CI: 3.7; 3.8). Specifically, compared to those with no sleep disturbance, adults reporting sleep disturbances for half of the weekdays had significantly lower LS7 CVH mean scores (ß = -0.02, 95% CI: -0.04; 0.01). Adults who had disturbances more than half of the weekdays had even lower scores (ß = -0.06, 95% CI: -0.09; -0.02), followed by those who reported disturbances almost every day (ß = -0.08, 95% CI: -0.11; -0.04), even after adjusting for age, sex, education status, depressive symptoms, and night shift work. CONCLUSION: Brazilian adults with sleep disturbances are less likely to achieve ideal CVH. Given that sleep disturbances seem to be increasingly common in Brazil, recent gains in CVH mortality may be affected.

The Influence of Evidence-Based Exercise and Age Reattribution on Physical Function in Hispanic Older Adults: Results From the ¡Caminemos! Randomized Controlled Trial.

Older Hispanics routinely exhibit unhealthy beliefs about "normal" aging trajectories, particularly related to exercise and physical function. We evaluated the prospective effects of age reattribution on physical function in older Hispanics. Participants (n = 565, ≥60 years) were randomly assigned into (a) treatment group-attribution-retraining, or (b) control group-health education. Each group separately engaged in four weekly 1-hr group discussions and 1-hr exercise classes, followed by monthly maintenance sessions. The Short Physical Performance Battery (SPPB) measured physical function throughout the 24-month intervention. No significant difference in physical function between intervention arms was evident over time. However, both groups experienced significant improvements in physical function at 24 months (ß = 0.43, 95% confidence interval [CI] = [0.16, 0.70]). Participating in the exercise intervention was associated with improvements in physical function, although no additional gains were apparent for age attribution-retraining. Future research should consider strengthening or modifying intervention content for age reattribution or dosage received.

Mindfulness-based Virtual Reality Intervention in Hemodialysis Patients: A Pilot Study on End-user Perceptions and Safety.

Background: Virtual reality (VR) is an evolving technology that is becoming a common treatment for pain management and psychologic phobias. Although nonimmersive devices (e.g., the Nintendo Wii) have been previously tested with patients on hemodialysis, no studies to date have used fully immersive VR as a tool for intervention delivery. This pilot trial tests the initial safety, acceptability, and utility of VR during maintenance hemodialysis treatment sessions-particularly, whether VR triggers motion sickness that mimics or negatively effects treatment-related symptoms (e.g., nausea). Methods: Patients on hemodialysis (n=20) were enrolled in a phase 1 single-arm proof-of-concept trial. While undergoing hemodialysis, participants were exposed to our new Joviality VR program. This 25-minute program delivers mindfulness training and guided meditation using the Oculus Rift head-mounted display. Participants experienced the program on two separate occasions. Before and immediately after exposure, participants recorded motion-related symptoms and related discomfort on the Simulator Sickness Questionnaire. Utility measures included the end-user's ability to be fully immersed in the virtual space, interact with virtual objects, find hardware user friendly, and easily navigate the Joviality program with the System Usability Scale. Results: Mean age was 55.3 (±13.1) years; 80% male; 60% Black; and mean dialysis vintage was 3.56 (±3.75) years. At the first session, there were significant decreases in treatment and/or motion-related symptoms after VR exposure (22.6 versus 11.2; P=0.03); scores >20 indicate problematic immersion. Hemodialysis end-users reported high levels of immersion in the VR environment and rated the software easy to operate, with average System Usability Scale scores of 82.8 out of 100. Conclusions: Patients on hemodialysis routinely suffer from fatigue, nausea, lightheadedness, and headaches that often manifest during their dialysis sessions. Our Joviality VR program decreased symptom severity without adverse effects. VR programs may be a safe platform to improve the experience of patients on dialysis.

A Web-Based Positive Psychological Intervention to Improve Blood Pressure Control in Spanish-Speaking Hispanic/Latino Adults With Uncontrolled Hypertension: Protocol and Design for the ¡Alégrate! Randomized Controlled Trial.

BACKGROUND: Growing evidence links psychological well-being and resilience with superior cardiac health, but there remains a critical scientific gap about whether (or how) interventions that aim to cultivate psychological well-being reduce cardiac risk. Hispanic/Latino people in the United States have high cardiovascular disease risk and poorly controlled blood pressure (BP) compared with their peers of European ancestry, and they represent a population in need of new and innovative therapeutic approaches. As such, a focused intervention to boost psychological well-being holds promise as a novel therapeutic target for hypertension in Hispanic/Latino adults; to date, however, no research has explored whether a causal link is evident. OBJECTIVE: The aim of this paper is to detail the protocol for the ¡Alégrate! (Be Happy!) intervention, a Phase II randomized controlled trial testing initial efficacy in improving BP of a web-based positive psychological intervention designed to boost psychological well-being in Spanish-speaking Hispanic/Latino people with hypertension. METHODS: A total of 70 Hispanic/Latino people aged ≥18 years, fluent in Spanish, and with elevated BP (≥140/90 mm Hg) will be recruited in person from a single Federally Qualified Health Center in Chicago. Enrollees will be randomly assigned to 1 of 2 trial arms: (1) web-based positive psychological intervention or (2) an active control condition (eg, 3 times weekly emotion reporting). Our 5-week Spanish-language ¡Alégrate! intervention is web-based and delivers curricular content via didactic instruction, journaling, and assigned at-home practice-all accessed via our website using investigator-purchased tablet computers, with a unique username and password assigned to each enrollee. Targeted skills include noting daily positive events, positive reappraisal of stressful events, effective expression of gratitude, performing acts of kindness, and regular practice of mindfulness and meditation. The primary outcome is improvement in BP, both sitting values and 24-hour ambulatory readings, as measured at baseline and 5 and 12 weeks from baseline. Secondary outcomes include psychological well-being, engagement in healthy behaviors, and circulating levels of inflammatory markers. The outcomes of interest are collected by trained research staff through in-person interviews using the REDCap software. RESULTS: Activities of the ¡Alégrate! intervention were funded in August 2017, and data collection is ongoing. We expect to submit trial results for peer-reviewed publications in 2021, soon after recruitment has been concluded and statistical analyses are finalized. CONCLUSIONS: Findings will provide evidence on whether interventions to boost psychological well-being and resilience have downstream effects on BP control and cardiovascular health, particularly as they are deployed in the Spanish language with cultural tailoring and via a web-based platform. If effective, we will have an easily disseminatable application that can positively impact well-being profiles and BP control in Hispanic/Latino people, with the possibility of addressing health disparities of this US racial/ethnic minority group. TRIAL REGISTRATION: ClinicalTrials.gov NCT03892057; https://clinicaltrials.gov/ct2/show/NCT03892057. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/17721.

Optimism and Cardiovascular Health: Longitudinal Findings From the Coronary Artery Risk Development in Young Adults Study.

OBJECTIVE: Favorable cardiovascular health is associated with greater longevity free of cardiovascular disease. Although the prevalence of cardiovascular health decreases with age, less is known about protective factors that promote and preserve it over time. We investigated whether optimism was associated with better cardiovascular health over a 10-year period. METHODS: Participants included 3188 Black and White men and women from the Coronary Artery Risk Development in Young Adults study. Self-reported optimism was assessed in 2000 (this study's baseline) with the revised Life Orientation Test. Favorable cardiovascular health was defined by healthy status on five components of cardiovascular functioning that were repeatedly assessed through 2010 either clinically or via self-report (blood pressure, lipids, body mass index, diabetes, and smoking status). Linear mixed-effects models examined whether optimism predicted cardiovascular health over time, adjusting for covariates such as sociodemographic characteristics, health behaviors, health status, and depression diagnosis. RESULTS: In models adjusting for sociodemographic characteristics, optimism was associated with better cardiovascular health across all time points (ß = 0.08, 95% confidence interval = 0.04-0.11, p ≤ .001) but not with rate of change in cardiovascular health. Findings were similar when adjusting for additional covariates. Optimism did not interact significantly with race (p = .85) but did with sex, such that associations seemed stronger for women than for men (p = .03). CONCLUSIONS: Optimism may contribute to establishing future patterns of cardiovascular health in adulthood, but other factors may be more strongly related to how slowly or quickly cardiovascular health deteriorates over time.

Positive emotions and favorable cardiovascular health: A 20-year longitudinal study.

No studies have examined whether positive emotions lead to favorable cardiovascular health (CVH) early in the lifespan, before cardiovascular disease is diagnosed. Moreover, the direction of the association has not been thoroughly investigated. Among younger adults, we investigated whether baseline positive emotions were associated with better CVH over 20 years. We also considered whether baseline CVH was associated with subsequent positive emotions during the same period. Participants included 4196 Black and White men and women from the Coronary Artery Risk Development in Young Adults Study. Positive emotions and cardiovascular-related parameters were each assessed in 1990 (this study's baseline), with repeated assessment through 2010. CVH was defined by blood pressure, lipids, body mass index, diabetes, and smoking status. Primary analyses used linear mixed effects models adjusting for potential confounders; secondary analyses stratified by race and sex. Controlling for sociodemographic factors, greater baseline positive emotions were associated with better CVH across time (ß = 0.03, 95% confidence interval = 0.007-0.06). However, positive emotions were unrelated to rate of change in CVH across time. Baseline CVH was also associated with greater average positive emotions across time (ß = 0.09, 95% confidence interval = 0.02-0.15), but not rate of change. Positive emotions' association with CVH was stronger for women than men, but race did not modify associations. Positive emotions in early to middle adulthood were associated with better CVH across several decades. Baseline CVH was also associated with greater positive emotions during follow-up. Future research may be able to disentangle these relationships by assessing positive emotions and CVH earlier in life.

Differences of Quality in End-of-Life Care across Settings: Results from the U.S. National Health and Aging Trends Study of Medicare Beneficiaries.

Background: More than 2.5 million older Americans die each year. Place of residence in which dying patients receive care plays a crucial role in the quality of end-of-life (EOL) care. Objective: This study aimed to compare proxies' overall rating and ratings for 13 indicators across five major domains of EOL care by place of residence in the last month of decedents' lives. Design: We used data from the National Health and Aging Trends Study, a nationally representative study of Medicare beneficiaries at age 65 years and older in the United States. Setting/Subjects: Analyses included proxies (N = 1336) of Medicare beneficiaries who passed away between 2013 and 2016. Proxies were categorized into four groups, depending on place of residence in the last month of life and the involvement of hospice. Measurements: Quality of EOL care was assessed using questions modeled after quality of EOL care instruments. We adjusted for demographic data of decedents and proxies. Results: Hospice recipients, regardless of setting, were more likely to experience pain and talk about religion in the last month of life; families of patients without hospice in residential care settings were more likely to report not being kept informed; proxies of patients living in private residences with hospice care reported higher overall ratings. Among hospice recipients, those living in private residences were more likely to be treated with respect. Conclusions: Disparities exist across settings and in overall ratings for quality of EOL domains-particularly, the subdomains of symptom management, decision making, and spiritual needs.

Expressions of Gratitude and Positive Emotion among Hemodialysis Patients: Qualitative Findings.

Objectives: The current qualitative inquiry solicited hemodialysis (HD) patients to identify events or incidences that have gone well in their day-to-day life, things they consider to be blessings, and to further reflect on the contributors of such events. Methods: Hemodialysis patients kept an electronic journal using investigator-purchased tablet computers. Results: Multiple themes emerged for which HD patients expressed gratitude: 1) life itself, 2) positive or improving health 3) family interactions and social support, 4) clinic resources, favorable treatment therapy, and staff, and 5) other small events. Conclusions: Clinicians are urged to explore the psychological assets that HD patients possess with a focus on how these might be further cultivated and whether their amplification leads to improved quality of life.

The Association of Optimism with Sleep Duration and Quality: Findings from the Coronary Artery Risk and Development in Young Adults (CARDIA) Study.

Optimism is associated with better health outcomes with hypothesized effects due in part to optimism's association with restorative health processes. Limited work has examined whether optimism is associated with better quality sleep, a major restorative process. We test the hypothesis that greater optimism is associated with more favorable sleep quality and duration. Main analyses included adults aged 32-51 who participated in the Coronary Artery Risk Development in Young Adults (CARDIA) study (n = 3,548) during the fifth (Year 15: 2000-2001) and sixth (Year 20: 2005-2006) follow-up visits. Optimism was assessed using the revised Life-Orientation Test. Self-report measures of sleep quality and duration were obtained twice 5 years apart. A subset of CARDIA participants (2003-2005) additionally provided actigraphic data and completed the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Multivariate regression analyses were used to examine associations of optimism and sleep indicators. In cross-sectional analyses of 3548 participants, each standard deviation (SD) higher optimism score resulted in 78% higher odds of self-reporting very good sleep quality. Prospectively, a 1-SD higher optimism score was related to higher odds of reporting persistently good sleep quality across 5-years relative to those with persistently poor sleep [OR = 1.31; 95%CI:1.10,1.56]. In participant with supplementary data, each SD higher optimism score was marginally associated with 22% greater odds of favorable sleep quality [OR = 1.22; 95%CI:1.00,1.49] as measured by the PSQI, with possible mediation by depressive symptoms. Optimism was unrelated to objective actigraphic sleep data. Findings support a positive cross-sectional and prospective association between optimism and self-reported sleep behavior.

Psychosocial interventions for cancer survivors: A meta-analysis of effects on positive affect.

PURPOSE: Positive affect has demonstrated unique benefits in the context of health-related stress and is emerging as an important target for psychosocial interventions. The primary objective of this meta-analysis was to determine whether psychosocial interventions increase positive affect in cancer survivors. METHODS: We coded 28 randomized controlled trials of psychosocial interventions assessing 2082 cancer survivors from six electronic databases. We calculated 76 effect sizes for positive affect and conducted synthesis using random effects models with robust variance estimation. Tests for moderation included demographic, clinical, and intervention characteristics. RESULTS: Interventions had a modest effect on positive affect (g = 0.35, 95% CI [0.16, 0.54]) with substantial heterogeneity of effects across studies ([Formula: see text]; I2 = 78%). Three significant moderators were identified: in-person interventions outperformed remote interventions (P = .046), effects were larger when evaluated against standard of care or wait list control conditions versus attentional, educational, or component controls (P = .009), and trials with survivors of early-stage cancer diagnoses yielded larger effects than those with advanced-stage diagnoses (P = .046). We did not detect differential benefits of psychosocial interventions across samples varying in sex, age, on-treatment versus off-treatment status, or cancer type. Although no conclusive evidence suggested outcome reporting biases (P = .370), effects were smaller in studies with lower risk of bias. CONCLUSIONS: In-person interventions with survivors of early-stage cancers hold promise for enhancing positive affect, but more methodological rigor is needed. IMPLICATIONS FOR CANCER SURVIVORS: Positive affect strategies can be an explicit target in evidence-based medicine and have a role in patient-centered survivorship care, providing tools to uniquely mobilize human strengths.