Exercise peripheral oxygen saturation (SpO2) accurately reflects arterial oxygen saturation (SaO2) and predicts mortality in systemic sclerosis.

BACKGROUND: Measures of oxygenation have not been assessed for prognostic significance in systemic sclerosis-related interstitial lung disease (SSc-ILD). METHODS: 83 subjects with SSc-ILD performed a maximal cardiopulmonary exercise test with an arterial line. The agreement between peripheral oxygen saturation (SpO2) and arterial oxygen saturation (SaO2) was examined and survival differences between subgroups of subjects stratified on SpO2 were analysed. Cox proportional hazards analyses were used to examine the prognostic capabilities of SpO2. RESULTS: At maximal exercise the mean (SD) difference between SpO2 and SaO2 was 2.98 (2.98) and only 15 subjects had a difference of >4 points. The survival of subjects with SSc-ILD whose maximum exercise SpO2 (Spo(2)max) fell below 89% or whose SpO2max fell >4 points from baseline was worse than subjects in comparator groups (log rank p = 0.01 and 0.01, respectively). The hazard of death during the median 7.1 years of follow-up was 2.4 times greater for subjects whose SpO2max fell below 89% (hazard ratio 2.4, 95% CI 1.1 to 4.9, p = 0.02) or whose SpO2max fell >4 points from baseline (hazard ratio 2.4, 95% CI 1.1 to 5.0, p = 0.02). CONCLUSION: In patients with SSc-ILD, SpO2 is an adequate reflection of SaO2 and radial arterial lines need not be inserted during cardiopulmonary exercise tests in these patients. Given the ease of measurement and its prognostic value, SpO2 should be considered as a meaningful clinical and research outcome in patients with SSc-ILD.

Major life stress, coping styles, and social support in relation to psychological distress in patients with systemic lupus erythematosus.

The objective of this study was to examine psychological processes in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients in relation to measures of life stress, coping styles, social support and cognitive ability. Fifty-two SLE patients without overt neuropsychiatric symptoms, 29 RA patients and 27 healthy controls completed measures of depression, mood, disease activity, perceived health, stressful life events, coping, and social support. Variables entered into the multiple regression analysis following principal component analysis were: group, major difficult event, major life threatening event, disengaging coping, emotional coping, social support, and cognitive impairment. Depressive symptoms were associated with SLE group status (P < 0.001), major life-threatening events (P < 0.01), disengage coping (P < 0.001) and emotional coping (P < 0.05). SLE group status (P < 0.05), disengage coping (P < 0.05) and emotional coping (P < 0.05) were associated with current distressed mood. SLE patients without overt, major neuropsychiatric symptoms had greater psychological distress compared to RA and control subjects. Increased depressive symptoms and distressed mood state in SLE patients were related to use of disengaging and emotional coping styles. These findings are limited to SLE patients with no overt neuropsychiatric illness and low disease activity, suggesting the need for future studies with a greater variety of SLE patients. Interventions aimed at improving active coping and minimizing emotional response to stress may lower psychological distress in SLE patients with mild disease.

A parent-child relationship scale derived from the child and adolescent psychiatric assessment (CAPA).

OBJECTIVE: To examine a measure of children's perception of their relationships with parents. METHOD: The Child and Adolescent Psychiatric Assessment (CAPA) was administered to 114 inpatients (aged 9-18 years) at a tertiary asthma center from 1991 to 1994. Ten items from the CAPA were developed as a separate scale, the Parent-Child Relationship Scale (PCRS). Some subjects (82) were given family and child assessments. RESULTS: The PCRS had good internal reliability (Cronbach alpha = .72). Construct validity was demonstrated by correlations with child and parent report on the Family Assessment Device (r= 0.46 and 0.35; p < .001) and high expressed emotion of the parent (t= 2.89; p < .01). Divergent validity may be evidenced by the fact that the PCRS was not significantly related to high emotional over-involvement. Predictive validity was shown by significant correlations with the total problem scores of parents' (r = 0.28; p < .01) and children's (r = 0.41; p < .001) Achenbach reports, and prediction of CAPA psychiatric diagnosis (OR = 5.83; 95% CI 1.80-22.63). CONCLUSION: The PCRS can potentially be used to assess the child's perspective of the parent-child relationship for research or clinical purposes and deserves further study.

Improvement in health care utilization and pulmonary function with fluticasone propionate in patients with steroid-dependent asthma at a National Asthma Referral Center.

The impact of switching from other inhaled corticosteroids to fluticasone propionate was studied in patients with severe oral-steroid-dependent asthma over a 1-year period. In this open-label prospective study, patients on maintenance doses of oral and inhaled steroids were referred to a national asthma treatment center and were switchedfrom their previous inhaled corticosteroid to fluticasone propionate 880 microg BID. Compared with data collected from the year prior to enrollment, treatment with fluticasone propionate resulted in significant improvements in pulmonary function, oral steroid requirements, and health resource utilization. In addition, five patients were completely weaned off oral steroids.

Measurement of children's asthma medication adherence by self report, mother report, canister weight, and Doser CT.

BACKGROUND: Accurate assessment of medication adherence has been difficult to achieve but is essential to drug evaluation in clinical trials and improved outcomes in clinical care. OBJECTIVE: This study was conducted to compare four adherence assessment methods: child report, mother report, canister weight, and electronic measurements of metered dose inhaler (MDI) actuation. METHODS: Participants included 27 children with mild-to-moderate asthma who were followed prospectively for 6 months. All patients used an MDI equipped with an electronic Doser attached to their inhaled steroid. At each 2-month follow-up visit, Doser and canister weight data were recorded, while child and mother were interviewed separately regarding medication use. RESULTS: Children and mothers reported, on average, over 80% adherence with the prescribed inhaled steroid. Canister weight revealed, on average, adherence of 69%, significantly lower than self-report. When adherence recorded by the electronic Doser was truncated to no more than 100% of prescribed daily use, average adherence was 50%. Older children and adolescents, nonwhite children, and those from poorer functioning families were least adherent. CONCLUSIONS: Electronic adherence monitoring was significantly more accurate than self-report or canister weight measures. Such accuracy is an essential prerequisite to increasing understanding of the treatment, setting, and patient factors that influence adherence, and to the consequent design of effective intervention strategies.

The five minute speech sample in children with asthma: deconstructing the construct of expressed emotion.

OBJECTIVE: To use the Five Minute Speech Sample (FMSS) to assess Expressed Emotion (EE) in various samples of children with asthma in order to clarify (1) developmental and validity issues for the EE construct and (2) the use of the FMSS technique, specifically, in children with chronic medical illness. METHOD: Data were collected on a sample of 84 adolescents with severe, chronic asthma who had failed outpatient management. In addition, a sample of 30 children with asthma, ages 6-9. were recruited from an outpatient pediatric clinic. A comparison sample of 15 children without any chronic illness, ages 6 9, were recruited by notices posted in the community. The primary caregiver of each child was assessed using the FMSS. RESULTS: FMSS interviews were reliability coded in all samples. Rates of high Criticism (FMSS CRIT), Emotional Overinvolvement (FMSS EOI), and EE were comparable to rates previously reported in child and adolescent samples. Although the validity for ratings of FMSS CRIT was well supported, the validity of FMSS EOI ratings and the overall EE construct were more problematic. CONCLUSIONS: The FMSS is a useful and largely valid measure in children with asthma. Ratings of FMSS CRIT were found to have strong validity. There was little problem shifting the context of FMSS administration from chronic mental to chronic medical illness, but a variety of developmental considerations arose, especially regarding FMSS EOI ratings. Although we raise concerns about viewing EE as a valid construct, it may remain a useful predictive index.

Role of the family in the onset and outcome of childhood disorders: selected research findings.

OBJECTIVE: Three areas of basic family research were selected for review as being of special importance to the clinically oriented child and adolescent psychiatrist: behavioral genetics, expressed emotion, and the interaction of family dynamics and childhood illness. METHOD: Medline and PSYCINFO searches using appropriate keywords were obtained for each of the 3 major areas. All English-language articles published after 1989 that included empirical research pertaining to children or adolescents were reviewed. RESULTS: Behavioral genetics research indicates that the shared environment, including issues of parental monitoring and discipline, is important in the development and outcome of externalizing disorders. Differential parental treatments of one sibling are critical in internalizing disorders. Criticism (as measured by expressed emotion) is associated with poor outcome of many childhood medical and psychiatric disorders. Chronic illness in a child changes the family dynamics toward being more structured and less emotionally warm and communicative. The family's role in adherence to treatment is critical, and families with high levels of criticism have more difficulty. CONCLUSIONS: Families can cause problems, but many times the problems families have are in response to a child's problems. There is a continued need to empirically assess which family processes are important for specific childhood disorders.

Familial association between allergic disorders and depression in adult Finnish twins.

Clinical studies have shown a relationship between allergic disorders and depression, panic disorder, attention deficit/hyperactivity disorder, and social anxiety for a significant subset of patients with these disorders. The nature of the relationship, whether due to shared environmental or biologic vulnerabilities or as a result of the stress of chronic illness, has been less clear. By examining the covariance of atopic disorders and depressive symptoms in a community sample of monozygotic (MZ) and dizygotic (DZ) twins, the contribution of genetic and/or shared environmental etiological factors can be established. A Finnish sample of 1337 MZ and 2506 DZ twin pairs, ages 33-60 years, was sent questionnaires inquiring about history of asthma, eczema, and atopic rhinitis, as well as the Beck Depression Inventory (BDI). The nature of the covariation between twins of these symptoms was investigated by fitting competing genetic and environmental models. Within-person correlation between atopic symptoms and BDI was 0.103 (P < 0.001) for the total sample. Using the Mx statistical modeling program to fit the data to competing quantitative genetic models, the best fitting model estimated that 64% of the association between atopy and BDI was due to shared familial vulnerability, primarily additive genetic influences. Although the measures for allergic disorders and depression are crude, this study supports the hypothesis that there is a small shared genetic risk for atopic and depressive symptoms, and if replicated, may open research for common mechanisms between allergic and depressive disorders. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:146-153, 2000.

The parent-physician relationship in pediatric asthma care.

OBJECTIVE: To examine the feasibility of using a behavioral coding system, the Five Minute Speech Sample (FMSS), to estimate the prevalence of relationship difficulties between parents and physicians in a pediatric asthma care setting. METHOD: The FMSS was administered to 20 parents of children with severe, chronic asthma and to the physicians they worked with during a brief day program admission. RESULTS: Rates of relationship difficulties between parents and physicians ranged from 15% to 40%, comparable to those previously identified in patient-therapist relationships in psychiatric populations. CONCLUSIONS: Although further information is needed about validity and reliability, the FMSS appears to provide clinically relevant information about the parent-physician relationship in the context of pediatric chronic illness.

Clinical outcomes of steroid-insensitive asthma.

BACKGROUND: Steroid insensitivity increasingly is being recognized in patients with severe, chronic asthma. Virtually no data exist regarding the clinical outcomes of steroid insensitive (SI) asthma despite clear expectations of poorer longitudinal course for this condition. METHODS: We obtained 2-year follow-up data from 34 pediatric patients who had been evaluated for steroid insensitivity at a national asthma referral center. Outcomes evaluated included current oral glucocorticoid (GC) dose; number of GC bursts, emergency room visits, and hospitalizations for asthma in the prior 12 months; Asthma Functional Severity; Pediatric Asthma Quality of Life; and Pediatric Asthma Caregiver's Quality of Life. RESULTS: At follow-up, patients with SI asthma and their caregiving parent both reported poorer quality of life (QOL) compared with those with steroid sensitive (SS) asthma (adolescent: 4.6 +/- 0.4 versus 5.6 +/- 0.3; P < .05; caregiver: 5.1 +/- 0.4 versus 6.2 +/- 0.2; P < .05). Steroid-insensitive patients showed no significant difference in GC dose, number of GC bursts, emergency room visits or hospitalizations, or Asthma Functional Severity compared with SS patients. CONCLUSIONS: Steroid insensitivity was associated with significantly poorer QOL at 2-year follow-up. Steroid insensitive patients did not show poorer clinical outcomes compared with SS patients as assessed by current steroid requirements and health care utilization. Overall, the observed pattern of results suggests that SI asthma may be a worse form of asthma because a more fixed pattern of lung obstruction has developed. Further longitudinal study of the clinical and cellular outcomes of SI asthma is needed to more fully characterize the types and magnitude of risks associated with SI status.

Treatment alliance and its association with family functioning, adherence, and medical outcome in adolescents with severe, chronic asthma.

OBJECTIVE: To examine the concept of treatment alliance in the care of adolescents with asthma. METHODS: Measures of treatment alliance were obtained from 60 adolescents with severe, chronic asthma admitted to a tertiary care facility, their parents, and their asthma specialists at the referral center. Associations were examined between the alliance measures and multimeasure, multiagent data concerning family functioning and asthma treatment adherence and outcome. RESULTS: Physicians' reports of treatment alliance were associated with concurrent family functioning and asthma medication adherence, as well as with asthma treatment adherence and outcome in the year after the stay at the asthma center. CONCLUSIONS: As emphasized in the recently revised Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (NHLBI, 1997), the ability of children with asthma, their parents, and their physician to create a positive partnership, or treatment alliance, appears to have an important role in optimal asthma management.

Reliability of the model MC-311 MDI chronolog.

BACKGROUND: The Model MC-311 MDI Chronolog (Medtrac Technologies, Lakewood, Colo) is an electronic device for monitoring adherence to metered-dose inhalers (MDIs). It is a thermistor-actuated, microprocessor-equipped device that dispenses inhaled medication while recording the date and time of each canister activation. OBJECTIVE: We evaluated the reliability of the MC-311 MDI Chronolog to determine whether the model could accurately record and report the date, time, and number of MDI actuations. METHODS: Twenty-four of the MC-311 Chronologs were discharged at 8 hourly intervals across 8 days. Battery voltage was assessed before and after the experiment. The mouthpieces of 12 Chronologs were washed daily. RESULTS: By using generous criteria for acceptable reliability, only 10 of 24 (42%) were rated as acceptable. None of these 10 Chronologs recorded 320 or greater actuations (mean +/- SD, 293.9 +/- 13.3; range, 266 to 308); all reliable Chronologs underestimated MDI activation. An additional 6 devices had an initial signature of erroneous recordings dating from device initialization. After removing this signature, the remaining data showed acceptable reliability. All the remaining Chronologs judged to be unacceptable showed time series patterns of seizures (ie, bursts of clustered, erroneous records). Seizures were distributed across trial days, were associated with washing, and preceded all 4 cases of battery failure. Damage to the thermistor is the likely cause of seizure-pattern failures. CONCLUSIONS: In summary, because of a combination of a clear underreporting bias with frequent initialization and seizure-pattern failures, the Model MC-311 MDI Chronolog is not recommended for use in clinical care or research

Family-of-origin experiences and conflict resolution behaviors of young adult dating couples.

This study was conducted to explore the relationship among retrospective reports of family-of-origin functioning, reported perceptions of a laboratory-based conflict resolution discussion, and outsiders' ratings of communication behaviors between young adult dating couples, with a special focus on predicted gender differences. Sixty-three couples aged 18 to 24 participated in this study. A Revealed Differences task was used to elicit discussion about an issue identified as discordant for the couple on a Relationship Issue Questionnaire. Family-of-origin variables were related to both men's and women's perceptions of the conflict, as well as outsiders' ratings of their conflict resolution behaviors. However, the conflict resolution behaviors and perceptions of men and women were associated with distinctly different aspects of functioning in their families of origin. Further, women's families-of-origin factors were more prominent for the couples' communication behaviors because they indicated a greater number of significant correlations between the women's families of origin and: 1) perceptions of the conflict resolution discussion by both the men and women, and 2) the observed conflict resolution behaviors of both men and women. These findings are discussed in the context of both the relevant research and important social-political influences.

Psychiatric family history in adolescents with severe asthma.

OBJECTIVE: To examine the hypothesis that an association exists between severe asthma and familial affective and anxiety disorders. METHOD: A parent, usually the mother, of 62 adolescents admitted to a tertiary care asthma center was administered the Family History-Research Diagnostic Criteria Interview. Lifetime prevalence rates of psychiatric disorders in first-degree relatives were compared with previously reported rates. RESULTS: In relatives of asthmatic adolescents, rates for depression, mania (females only), substance abuse (males only), and antisocial personality disorder were significantly higher than the rates in the non-ill comparison sample. Rates for substance abuse (males only) and antisocial personality disorder were higher than the rates for relatives of the depressed comparison sample. Rates for anxiety disorders were not higher than rates in epidemiological samples. Rates of attention-deficit hyperactivity disorder (females only) and posttraumatic stress disorder in relatives were higher than in community samples. CONCLUSIONS: These results support the presence of a link between severe asthma and familial affective disorders, posttraumatic stress disorder, antisocial personality disorder, and substance abuse. Whether these disorders are genetically associated with asthma or represent an association with severe asthma because of environmental effects on the growing child is discussed.

Parental criticism and treatment outcome in adolescents hospitalized for severe, chronic asthma.

This pilot study investigated the relationship between parental criticism and medical treatment outcome across an inpatient hospitalization in 19 adolescents with severe, chronic asthma. Parental criticism toward their asthmatic adolescent was assessed using the Five Minute Speech Sample technique (FMSS) at the beginning of the adolescent's inpatient stay at a national asthma referral center. Those adolescents whose parents were rated as high in criticism on the FMSS were found to have greater improvement in their overall asthma severity, greater reduction in their steroid medication dose, and shorter lengths of stay in the hospital than those whose parents were rated as low in criticism. The adolescents whose parents were rated as high in criticism also showed lower compliance with their prescribed theophylline and oral steroid medication at admission than the low criticism group. These findings do not appear to be due to misdiagnosis secondary to the presence of vocal cord dysfunction or to the allergy status of the children. Clinical implications and possible causal mechanisms underlying these findings are discussed.

Marriages with children at medical risk: the transition to parenthood.

Prior studies suggest that the birth of a new baby causes a modest but reliable drop in marital satisfaction. The present study replicates and extends this finding in couples with children at medical risk and probes the mechanisms behind this effect. Longitudinal data on marital satisfaction, family structure, infant illness and temperament, and family life events were collected at prenatal, 6, 12, and 18 month periods. Family structural burdens and family stress burdens had a significant negative effect on marital satisfaction. Child-related burdens were less reliably related. Results are discussed in the context of stress and coping as well as developmental psychopathology.

Coping within couples: adjustment two years after forced geographic relocation.

Is our understanding of how individuals adjust to stressful life events increased when we analyze their adjustment in ways that recognize that these individuals are also married couples? The data used to answer this question came from a unique "natural experiment" occasioned by the forced evacuation of the Israeli settlement of Ophira under the terms of the Camp David Accords. We found that the adjustment of individuals within couples became more similar across the relocation, that is, couples adapted as a "family system." This occurred because the coping skills of one member of the couple "drove" the adjustment of both partners.

Defining a family heritage and a new relationship identity: two central tasks in the making of a marriage.

The roles of origin family environmental characteristics and couple consensus-building process within the development of marital relationships were examined prospectively in 16 premarital couples. Three important findings emerged. First, significant correlations were found between dimensions of origin family environment and the reported level of satisfaction within the couple's current relationship. Second, measures of the couple's ability to reach consensus concerning important interpersonal relationships appeared to be important mediators of the association between origin family environment and current relationship satisfaction. Third, important gender differences emerged that replicate and extend prior findings that portray women in the role of "relationship specialist" within their marriages. As a group, these findings were best explained by a developmental model of early marriage that envisions the young couple as facing two entwined tasks: to define both their family heritage and their new relationship identity. Overall, the importance of examining family-of-origin characteristics and consensus-building process as critical determinants of the fate of intimate relationships received strong support. The gender differences found in the literature reviewed, as well as the results of this study, have largely been overlooked by the theory and practice of family therapy. Efforts on both the research and theory construction fronts are needed to increase our understanding of the mechanisms whereby prior family experience is brought forward into current intimate relationships.

Short-term course of depressive symptoms in patients with eating disorders.

After inpatient treatment focused on aberrant eating behavior, six depressed normal-weight bulimic patients showed little improvement in depressive or eating symptoms. Four depressed anorexic patients with bulimic behavior improved in both areas, and five restricting anorexic patients had an intermediate response.