Particulate air pollutants, APOE alleles and their contributions to cognitive impairment in older women and to amyloidogenesis in experimental models

Exposure to particulate matter (PM) in the ambient air and its interactions with APOE alleles may contribute to the acceleration of brain aging and the pathogenesis of Alzheimer's disease (AD). Neurodegenerative effects of particulate air pollutants were examined in a US-wide cohort of older women from the Women's Health Initiative Memory Study (WHIMS) and in experimental mouse models. Residing in places with fine PM exceeding EPA standards increased the risks for global cognitive decline and all-cause dementia respectively by 81 and 92%, with stronger adverse effects in APOE ɛ4/4 carriers. Female EFAD transgenic mice (5xFAD+/-/human APOE ɛ3 or ɛ4+/+) with 225 h exposure to urban nanosized PM (nPM) over 15 weeks showed increased cerebral β-amyloid by thioflavin S for fibrillary amyloid and by immunocytochemistry for Aβ deposits, both exacerbated by APOE ɛ4. Moreover, nPM exposure increased Aβ oligomers, caused selective atrophy of hippocampal CA1 neurites, and decreased the glutamate GluR1 subunit. Wildtype C57BL/6 female mice also showed nPM-induced CA1 atrophy and GluR1 decrease. In vitro nPM exposure of neuroblastoma cells (N2a-APP/swe) increased the pro-amyloidogenic processing of the amyloid precursor protein (APP). We suggest that airborne PM exposure promotes pathological brain aging in older women, with potentially a greater impact in ɛ4 carriers. The underlying mechanisms may involve increased cerebral Aβ production and selective changes in hippocampal CA1 neurons and glutamate receptor subunits.

Cognitive function and retinal and ischemic brain changes: the Women's Health Initiative

OBJECTIVE

To examine the association between retinopathy and cognitive decline or brain lesions and volumes in older women.

METHODS

This study included 511 women aged 65 and older who were simultaneously enrolled in the Women's Health Initiative Memory Study and the Sight Examination Study. In this analysis, we examined the link between retinopathy, assessed using fundus photography (2000-2002), cognitive performance over time assessed by the modified Mini-Mental State Examination (3MSE) (1996-2007), and white matter hyperintensities and lacunar infarcts in the basal ganglia.

RESULTS

Presence of retinopathy was associated with poorer 3MSE scores (mean difference = 1.01, SE: 0.43) (p = 0.019) over a 10-year follow-up period and greater ischemic volumes in the total brain (47% larger, p = 0.04) and the parietal lobe (68% larger, p = 0.01) but not with measures of regional brain atrophy.

CONCLUSIONS

The correspondence we found between retinopathy and cognitive impairment, along with larger ischemic lesion volumes, strengthens existing evidence that retinopathy as a marker of small vessel disease is a risk factor for cerebrovascular disease that may influence cognitive performance and related brain changes. Retinopathy may be useful as a clinical tool if it can be shown to be an early marker related to neurologic outcomes.

Postmenopausal hormone therapy and subclinical cerebrovascular disease: the WHIMS-MRI Study

OBJECTIVE

The Women's Health Initiative Memory Study (WHIMS) hormone therapy (HT) trials reported that conjugated equine estrogen (CEE) with or without medroxyprogesterone acetate (MPA) increases risk for all-cause dementia and global cognitive decline. WHIMS MRI measured subclinical cerebrovascular disease as a possible mechanism to explain cognitive decline reported in WHIMS.

METHODS

We contacted 2,345 women at 14 WHIMS sites; scans were completed on 1,424 (61%) and 1,403 were accepted for analysis. The primary outcome measure was total ischemic lesion volume on brain MRI. Mean duration of on-trial HT or placebo was 4 (CEE+MPA) or 5.6 years (CEE-Alone) and scans were conducted an average of 3 (CEE+MPA) or 1.4 years (CEE-Alone) post-trial termination. Cross-sectional analysis of MRI lesions was conducted; general linear models were fitted to assess treatment group differences using analysis of covariance. A (two-tailed) critical value of alpha = 0.05 was used.

RESULTS

In women evenly matched within trials at baseline, increased lesion volumes were significantly related to age, smoking, history of cardiovascular disease, hypertension, lower post-trial global cognition scores, and increased incident cases of on- or post-trial mild cognitive impairment or probable dementia. Mean ischemic lesion volumes were slightly larger for the CEE+MPA group vs placebo, except for the basal ganglia, but the differences were not significant. Women assigned to CEE-Alone had similar mean ischemic lesion volumes compared to placebo.

CONCLUSIONS

Conjugated equine estrogen-based hormone therapy was not associated with a significant increase in ischemic brain lesion volume relative to placebo. This finding was consistent within each trial and in pooled analyses across trials.

Predictors of adherence in the Women's Health Initiative Calcium and Vitamin D Trial

The authors analyzed data from the Women's Health Initiative (WHI) Calcium and Vitamin D Supplementation Trial (CaD) to learn more about factors affecting adherence to clinical trial study pills (both active and placebo). Most participants (36,282 postmenopausal women aged 50-79 years) enrolled in CaD 1 year after joining either a hormone trial or the dietary modification trial of WHI. The WHI researchers measured adherence to study pills by weighing the amount of remaining pills at an annual study visit; adherence was primarily defined as taking > or = 80% of the pills. The authors in this study examined a number of behavioral, demographic, procedural, and treatment variables for association with study pill adherence. They found that relatively simple procedures (ie, phone contact early in the study [4 weeks post randomization] and direct social contact) later in the trial may improve adherence. Also, at baseline, past pill-use experiences, personal supplement use, and relevant symptoms may be predictive of adherence in a supplement trial.

No effect of HRT on health-related quality of life in postmenopausal women with heart disease

AIM

Previous clinical studies suggest hormone replacement therapy (HRT) alleviates menopausal symptoms and may improve health-related quality of life (HRQL). Most studies on HRT and HRQL were limited in duration (12 months or less) and scope (few and non-standard HRQL measures). The aim of this paper is to assess HRQL in the Estrogen Replacement and Atherosclerosis (ERA) trial.

METHODS

A subset of women within a randomized, blinded, placebo-controlled secondary prevention trial has been studied in outpatient and community settings at 5 US sites. A total of 246 postmenopausal women with angiographically documented heart disease (mean age 66 years, 83% Caucasian) were enrolled in the ERA trial. Participants received either 0.625 mg/day conjugated equine estrogen only, estrogen plus 2.5 mg/day medroxyprogesterone acetate, or placebo. HRQL was assessed using validated questionnaire instruments at baseline and follow-up (mean 3.2 years of trial). Physical and mental functioning, life satisfaction, depressive symptoms, urinary incontinence, sleep disturbance, and frequency and intensity of physical symptoms were evaluated.

RESULTS

In this group of women with established coronary disease, active therapy was not significantly associated with more favorable outcomes for any HRQL. The estrogen-only group reported more urinary incontinence than the placebo group (p<0.05). Analyses restricted to adherent women (those who took > or = 80% of pills) showed a similar pattern of results, showing that the estrogen only group reported significantly higher urinary incontinence compared to placebo (p<0.01).

CONCLUSION

The hormone replacement regimens in the ERA trial did not improve HRQL of postmenopausal women with heart disease.

The health-related quality of life and survival of small-cell lung cancer patients: results of a companion study to CALGB 9033

The purposes of this study were 2-fold: to evaluate the impact of the schedule dependency of etoposide (3-day IV short course vs. a 21-day oral prolonged course) with cisplatin on the quality of life of small-cell lung cancer (SCLC) patients; and to examine the effect of baseline quality of life variables on long-term survival, after adjustment for known demographic and clinical prognostic factors. Participants were 70 patients enrolled in the cancer and leukemia group B (CALGB) protocol 9033. Quality of life was assessed at baseline, 6 and 12 weeks by: the EORTC QLQ-30, the Centers for epidemiology studies--Depression short form, the medical outcomes study (MOS) social support questionnaire, and a scale of sleep quality. Contrary to expectations, study results suggested no significant differences in the patients' life quality and treatment response based on whether they received etoposide in a 3-day IV vs. a 21-day oral regimen. The use of the baseline variables in predicting overall survival indicated that patients who were non-white and with liver involvement had decreased survival. Brain involvement, being male, and higher depressive symptoms were also found to be borderline significant in predicting decreased survival in this patient population.

Promoting adherence and retention to clinical trials in special populations: a women's health initiative workshop

This paper describes a Women's Health Initiative workshop on promoting adherence and retention in randomized clinical trials among ethnic minority women, participants of lower socioeconomic status, and older women. Workshop objectives were: (1) to increase knowledge of demographic and cultural characteristics of diverse groups, (2) to increase awareness of how diversity can affect interactions in clinical research, (3) to explore how research staff behavior can influence adherence and retention, and (4) to increase knowledge of strategies to enhance adherence and retention in special populations. The workshop emphasized the importance of understanding beliefs, values, and experiences that are common in diverse groups of individuals, while at the same time recognizing and respecting individual differences that result from varying life circumstances and experiences. We discuss strategies to increase cultural competence, reduce stereotypes and discrimination, and create a culturally relevant and sensitive research environment.

Enhancing adherence in randomized controlled clinical trials

This paper identifies individual and systematic primary, secondary, and tertiary prevention approaches that can be used to enhance adherence in randomized controlled trials. Specifically, strategies such as these are discussed: careful screening during enrollment, use of a run-in period, fully informing participants of the study burden, explaining randomization, determining the participant's prior history with treatment interventions, establishing and using a tracking system, clearly specifying adherence measures, and staff training in communication and negotiation. These strategies have been gathered over time from our experiences working in multiple randomized controlled trials. Research on factors that promote or detract from adherence should be a standard part of randomized controlled trials. Control Clin Trials 2000;21:226S-232S

Factors related to sleep disturbance in older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis

OBJECTIVES

To describe the types and frequencies of sleep complaints and the biopsychosocial factors associated with sleep disturbance in a large community sample of older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis (OA).

DESIGN

Baseline analyses of an observational prospective study.

SETTING AND PARTICIPANTS

Participants were 429 men and women aged 65 years and older experiencing knee pain or knee pain with radiographic evidence of OA enrolled in the Observational Arthritis Study in Seniors (OASIS).

MEASUREMENTS

Demographic variables (age, gender, ethnicity, education), health (X-rays of knee rated for OA severity, medical conditions, medication use, smoking status, body mass index, self-rated health), physical functioning (self-rated physical functioning, physical performance), knee pain, and psychosocial functioning (social support, depression) were measured.

RESULTS

Problems with sleep onset, sleep maintenance, and early morning awakenings occurred at least weekly among 31%, 81%, and 51% of participants, respectively. Bivariate correlates of greater sleep disturbance in those with OA were less education, cardiovascular disease, more arthritic joints, poorer self-rated health, poorer physical functioning, poorer physical performance, knee pain, depression, and less social support. In regression analyses, each set of variables representing the domains of health, physical functioning, pain, and psychosocial functioning contributed to the prediction of sleep disturbance beyond the demographic set. Finally, in a simultaneous model, white race (trend, P = .06), poorer self-rated health, poorer physical functioning, and depressive symptoms were predictive of sleep disturbance.

CONCLUSIONS

Sleep disturbance is common in older adults experiencing knee pain or knee pain with radiographic evidence of OA and is best understood through the consideration of demographic, physical health, physical functioning, pain, and psychosocial variables. Interventions that take into account the multidetermined nature of sleep disturbance in knee pain or knee OA are most likely to be successful.

Effects of estrogen replacement on the progression of coronary-artery atherosclerosis

BACKGROUND

Heart disease is a major cause of illness and death in women. To understand better the role of estrogen in the treatment and prevention of heart disease, more information is needed about its effects on coronary atherosclerosis and the extent to which concomitant progestin therapy may modify these effects.

METHODS

We randomly assigned a total of 309 women with angiographically verified coronary disease to receive 0.625 mg of conjugated estrogen per day, 0.625 mg of conjugated estrogen plus 2.5 mg of medroxyprogesterone acetate per day, or placebo. The women were followed for a mean (+/-SD) of 3.2+/-0.6 years. Base-line and follow-up coronary angiograms were analyzed by quantitative coronary angiography.

RESULTS

Estrogen and estrogen plus medroxyprogesterone acetate produced significant reductions in low-density lipoprotein cholesterol levels (9.4 percent and 16.5 percent, respectively) and significant increases in high-density lipoprotein cholesterol levels (18.8 percent and 14.2 percent, respectively); however, neither treatment altered the progression of coronary atherosclerosis. After adjustment for measurements at base line, the mean (+/-SE) minimal coronary-artery diameters at follow-up were 1.87+/-0.02 mm, 1.84+/-0.02 mm, and 1.87+/-0.02 mm in women assigned to estrogen, estrogen plus medroxyprogesterone acetate, and placebo, respectively. The differences between the values for the two active-treatment groups and the value for the placebo group were not significant. Analyses of several secondary angiographic outcomes and subgroups of women produced similar results. The rates of clinical cardiovascular events were also similar among the treatment groups.

CONCLUSIONS

Neither estrogen alone nor estrogen plus medroxyprogesterone acetate affected the progression of coronary atherosclerosis in women with established disease. These results suggest that such women should not use estrogen replacement with an expectation of cardiovascular benefit.

The estrogen replacement and atherosclerosis (ERA) study: study design and baseline characteristics of the cohort

The Estrogen Replacement and Atherosclerosis (ERA) trial is a three-arm, randomized, placebo-controlled, double-blind trial to evaluate the effects of estrogen replacement therapy (0.625 mg/day oral conjugated estrogen) with or without continuous low-dose progestin (2.5 mg oral medroxyprogesterone acetate/day) versus placebo on progression of atherosclerosis. A total of 309 postmenopausal women at five sites underwent baseline coronary angiography and were randomized. Participants will have repeat coronary angiography after an average of 3.25 years of treatment. The primary outcome of interest will be change in minimum diameter of the major epicardial segments, as assessed by quantitative coronary angiography. The primary aim is to test the hypothesis that either form of hormone therapy will slow the progression or induce regression of coronary atherosclerosis compared to placebo. The secondary aims are to assess the effects of the two treatments versus placebo on endothelial function (measured using flow-mediated vasodilator responses), on several presumed mediators of estrogen's effect on atherosclerosis (i.e., plasma lipids and lipoproteins, blood pressure, glucose metabolism, hemostatic factors, and antioxidant activity), on other factors that influence the development of coronary heart disease (i.e., diet, smoking status, exercise, weight, and health-related quality of life issues), and on clinical cardiovascular events. The ERA trial is the first angiographic endpoint clinical trial to examine the effects of postmenopausal hormone replacement on coronary atherosclerosis in women. It will provide an unparalleled opportunity to determine if either regimen of hormone therapy is effective in slowing the progress of angiographically defined coronary atherosclerosis. This study will complement other estrogen replacement trials, such as the PEPI, HERS, and Women's Health Initiative studies, to provide a more comprehensive examination of the effects of estrogen replacement on cardiovascular risk factors, anatomic and functional manifestations of atherosclerosis, and risk for coronary heart disease in postmenopausal women. Control Clin Trials 2000;21:257-285

Profile of men randomized to the prostate cancer prevention trial: baseline health-related quality of life, urinary and sexual functioning, and health behaviors

PURPOSE

To describe men who agreed to be randomized to the Prostate Cancer Prevention Trial (PCPT), a 7-year, double-blind placebo-controlled study of the efficacy of finasteride in preventing prostate cancer.

METHODS

Comprehensive health-related quality-of-life data are presented for 18,882 randomized PCPT participants.

RESULTS

PCPT participants are highly educated, middle to upper income, and primarily white (92%). Participants reported healthy lifestyles. The mean American Urological Association Symptom Index score was well below the maximum entry score of less than 19; existing urinary symptoms were generally not bothersome. The scores for two sexual functioning scales could range from 0 to 100, with higher scores reflecting worse sexual functioning. The mean score for the Sexual Problem Scale was 19.2 out of 100, and the mean Sexual Activities Scale was 44.1 out of 100. Scores for seven of the eight Medical Outcomes Study 36-item Short-Form Health Survey scales (higher scores are better) were 10 to 20 points higher than those reported by a general population sample and differed minimally by race but not by age. Previously reported associations between sexual dysfunction and hypertension, diabetes, and depression were also observed. Men who never smoked reported less sexual dysfunction than did those who either had quit or still smoked.

CONCLUSION

Individuals who are likely to enroll in primary prevention trials have a high socioeconomic status, healthy lifestyle behaviors, and better health than the general population. These data help oncologists design chemoprevention trials with respect to the selection of health-related quality-of-life assessments and recruitment strategies.

The Women's Health Initiative Memory Study (WHIMS): a trial of the effect of estrogen therapy in preventing and slowing the progression of dementia

Evidence from animal, human cross-sectional, case-control, and prospective studies indicate that hormone replacement therapy (HRT) is a promising treatment to delay the onset of symptoms of dementia. The Women's Health Initiative Memory Study (WHIMS) is the first double-masked, randomized, placebo-controlled, long-term clinical trial designed to test the hypothesis that HRT reduces the incidence of all-cause dementia in women aged 65 and older. WHIMS, an ancillary study to the Women's Health Initiative (WHI) funded by the National Institutes of Health, will recruit a subgroup of women aged 65 and older from among those enrolling in the HRT trial of the WHI. The WHI clinical centers and 10 affiliated satellites plan to enroll approximately 8300 women into WHIMS over a 2-year period. Participants will be followed annually for 6 years, receiving cognitive assessments via the Modified Mini-Mental State (3MS) Examination. Women who screen positively for cognitive impairment on the basis of an educational and age-adjusted 3MS cutpoint proceed to more extensive neuropsychological testing and neurologic evaluation. Each woman suspected to have dementia then undergoes a series of laboratory tests that confirm the clinical diagnosis and classify the type of dementia. WHIMS is designed to provide more than 80% statistical power to detect a 40% reduction in the rate of all-cause dementia, an effect that could have profound public health implications for older women's health and functioning.

The Kidney Outcomes Prediction and Evaluation (KOPE) study: a prospective cohort investigation of patients undergoing hemodialysis. Study design and baseline characteristics

PURPOSE

The purpose of the Kidney Outcomes Prediction and Evaluation (KOPE) study, was to more fully characterize the end-stage renal disease (ESRD) population with respect to social, psychological, and clinical characteristics, and to prospectively study the biomedical, social, and psychological factors that influence a range of ESRD outcomes in a large observational study of black and white patients on hemodialysis. This paper focuses on the KOPE study design as well as characteristics of patients at baseline.

METHODS

KOPE was a prospective cohort investigation of patients treated at four dialysis centers in Forsyth County, North Carolina. Participants were interviewed at the dialysis centers, semi-annually over a 3 1/2 year period. Prevalent cases who were being treated with hemodialysis at the initiation of the study were enrolled into KOPE. Incident cases were subsequently enrolled as they presented to the participating units for hemodialysis. A total of 304 prevalent and 162 incident cases were enrolled into the study. The baseline health and sociodemographic characteristics of KOPE participants reported in this paper were obtained from medical records and Southeast Kidney Council data. Laboratory values taken within a 30-day interval around the baseline interview are also reported.

RESULTS

KOPE participants differ from national statistics on race, age, and gender. Differences between KOPE participants and patients living in the region, but who did not participate in the study, can be explained by our recruitment criteria.

CONCLUSIONS

KOPE will enable the characterization of the ESRD population, identification of factors related to poor outcomes, and identification of opportunities for interventions to prevent death and morbidity.

Baseline correlates with quality of life among men and women with medication-controlled hypertension. The trial of nonpharmacologic interventions in the elderly (TONE)

OBJECTIVES

To examine Quality of Life (QOL) and its correlates among older adults with medication-controlled hypertension.

DESIGN

Baseline data from the TONE clinical trial.

MEASUREMENTS

Demographic variables (age, race, income), hypertension treatment (medication class, years treated), health status (obesity, physical symptoms), and QOL status (MOS-Short-Form 36, Jenkins Sleep Disturbance, and CES-D Depression).

PARTICIPANTS

A total of 975 men and women, aged 60 to 81 years and free of major diseases and disability, with a screening blood pressure (BP) of < or = 145/85 mm Hg, treated medically for hypertension with antihypertensive medication.

RESULTS

On average, TONE participants reported a QOL level on the SF-36 that was similar to or better than that reported by older adults in the general population. However, there was a strikingly high prevalence of physical complaints or symptoms: 90.3% of men and 93.3% of women experienced one or more physical symptoms or complaints, and nearly 50% reported that such symptoms had disrupted their daily functioning. Among variables-considered, only the physical symptoms index score, number of severe symptoms, and obesity status were correlated consistently with QOL among TONE men and women. Lower QOL scores were associated with higher symptom scores and with obesity. Neither medication class nor age were appreciably associated with QOL status.

CONCLUSIONS

Physical symptoms, rather than medication class and age, were the strongest correlates of QOL in TONE. This underscores the importance of identifying the etiology of symptoms as a means to improve the QOL of order hypertensive persons rather than substituting medication. The association of poorer physical well-being with obesity suggests that weight reduction to manage BP may also improve QOL for some individuals.

Assessing health-related quality of life in HIV disease: key measurement issues

The reliable and valid assessment of health-related quality of life (HRQoL) in human immunodeficiency virus (HIV) clinical research presents both familiar and unique challenges. Consistent with HRQoL research in general, measures of HRQoL in HIV disease must meet a set of standard psychometric properties, produce interpretable results, and be responsive to relatively small treatment effects. Furthermore, as clinical research for a range of diseases and conditions becomes increasingly global, HRQoL investigators are confronted with the formidable task of developing measures that are applicable across a range of cultures and languages within and across national boundaries. In this paper, we present a model of HRQoL to be applied across disease and conditions, with a discussion of the key measurement issues. We then briefly consider the natural history and treatment aspects of HIV that are relevant to HRQoL research. In the final sections of the paper, we describe the elements needed in an 'ideal' HRQoL/HIV instrument and propose a method for evaluating the degree to which current HRQoL measures address the challenges posed by HIV clinical research.

Hormone replacement therapy and other potential treatments for dementias

The past decade has seen a substantial increase in the number of individuals affected by dementia. Dementia places a tremendous personal and economic burden on millions of patients and caregivers annually. Consequently, many scientists have been searching for a treatment for dementia to avoid the imminent public health crisis that will occur if this trend continues. Primary and secondary prevention studies, as well as animal research, demonstrate the potential for hormone replacement therapy (HRT) as an efficacious treatment for dementia. Recently, the Women's Health Initiative-Memory Study began the first randomized, longterm clinical trial to test the hypothesized role of HRT at the onset and in the progression of dementia in women. Researchers also are investigating the potential of other treatments for dementias, such as nonsteroidal anti-inflammatory drugs and free radical scavengers.

Women's health initiative. Why now? What is it? What's new?

Studies collectively named the Women's Health Initiative (WHI) are currently enrolling 164,500 postmenopausal women in several overlapping clinical trials and an observational study. The overall goals of WHI are to understand the determinants of postmenopausal women's health and to evaluate the efficacy of practical interventions in preventing the major causes of morbidity and mortality in older women. This article reviews the research leading to the WHI studies; describes the study designs and protocols, with an emphasis on what's new about WHI from a psychological perspective; and outlines the major psychosocial hypotheses under investigation and the major challenges WHI presents to psychological science.

Comparison of preoperative characteristics of men and women undergoing coronary artery bypass grafting (the Post Coronary Artery Bypass Graft [CABG] Biobehavioral Study)

A cohort of 759 coronary artery bypass grafting (CABG) patients (269 women and 490 men) was enrolled in the prospective POST CABG Biobehavioral Study at 5 clinical centers in the United States and Canada. Sociodemographic and medical data were obtained by interview and from medical charts. Health-related quality of life and psychosocial data were ascertained preoperatively by interview and questionnaire for those patients whose condition allowed preoperative assessment and was compared among patients from hospitals enrolling both male and female patients (143 women and 267 men). Women enrolled in the Biobehavioral Study were older than men (65.4 +/- 9.0 vs 61.8 +/- 9.7 years, p < 0.001) and more likely to have a preoperative medical condition which precluded biobehavioral evaluation (47% vs 34%, p < 0.001). Women were less likely to be high school graduates (59% vs 74%, p < 0.001), were less likely to be earning > or = $25,000 per year (39% vs 69%, p < 0.001), and were married less often at the time of surgery (59% vs 85%, p < 0.001). Fewer women than men were able to perform basic self-care activities (p < 0.001) and social activities (p < 0.001). Women were also less able to perform the more demanding activities required for independent living, recreation, and maintaining a household (p < 0.001). Women were also more anxious (p = 0.01) and reported more depressive symptoms (p < 0.001) than men. These data suggest that plans for perioperative and convalescent care for women undergoing CABG should take into account their less favorable medical and psychosocial status relative to men.

Gender differences in health-related quality of life among postmyocardial infarction patients: brief report. CAST Investigators. Cardiac Arrhythmia Suppression Trials

Heart disease is the leading cause of death among women in the United States. The prognosis for heart disease is worse for women than for men. Also, although women are less likely than men to initially present with a myocardial infarction (MI), they are more likely to die following an MI. A number of factors have been identified that partially account for the gender difference in post-MI morbidity and mortality. However, limited data are available on the sex differences in clinical, psychosocial, and demographic factors that may combine to explain the poorer prognosis for women following an acute MI. The Cardiac Arrhythmia Suppression Trials collected detailed demographic, clinical, and psychosocial data on 2,043 men and 448 women following acute MIs. Analyses indicate that women had a worse clinical, socioeconomic, and psychosocial profile than did men. In addition, significant differences in psychosocial profiles persisted after controlling for demographic and clinical data, suggesting that women presenting with MIs have a cluster of complex factors that put them at high risk for morbidity and mortality following an MI. Future longitudinal studies that include adequate numbers of women as well as reliable assessments of both clinical and psychological variables are needed to better understand the factors that influence the poor prognosis for women with coronary heart disease.

Assessment of health-related quality of life in orthopaedic outcomes' studies

The assessment of health-related quality of life is becoming increasingly important in evaluating the effectiveness of orthopaedic interventions. This report provides an overview of issues related to the assessment of quality of life in orthopaedic populations. Discussed are the definition and dimensions of health-related quality of life: the usefulness of collecting quality of life data; methodological considerations in designing outcomes' studies; the selection of quality of life instruments; modes of instrument administration; and scoring.

Women's health initiative. Why now? What is it? What's new?

Studies collectively named the Women's Health Initiative (WHI) are currently enrolling 164,500 postmenopausal women in several overlapping clinical trials and an observational study. The overall goals of WHI are to understand the determinants of postmenopausal women's health and to evaluate the efficacy of practical interventions in preventing the major causes of morbidity and mortality in older women. This article reviews the research leading to the WHI studies; describes the study designs and protocols, with an emphasis on what's new about WHI from a psychological perspective; and outlines the major psychosocial hypotheses under investigation and the major challenges WHI presents to psychological science.

Relation of sociodemographic, clinical, and quality-of-life variables to adherence in the cardiac arrhythmia suppression trial

Clearly, age and education are important factors for predicting adherence in CAST, given that they appear in all three regressions. Moreover, the 4-month and 1-year results indicate that mental health and presence of a spouse are important predictors. Physical function, stress, angina, and history of MI may also provide additional information regarding adherence levels. It is interesting to note that although adherence was higher for patients who have "good" social characteristics, such as having a spouse, support, integration, perceived good health, good mental health, low stress, and education, it was also better for those patients who had "poor" physical characteristics such as a history of angina, a history of MI, and low physical function. In the multivariate analysis, older age was also associated with good adherence. These observations are not necessarily intuitive and support the need for further research in this area. If patients at risk for poor adherence can be identified prospectively, strategies may be developed to improve their subsequent medical care in such a way to favorably affect and improve their outcomes.

Social support and health-related quality of life in black and white dialysis patients

OBJECTIVES

To identify factors associated with health-related quality of life (HRQoL) in end stage renal disease (ESRD) patients treated with dialysis, and to identify potential racial differences in HRQoL.

DESIGN

Cross-sectional study. SAMPLE/SETTINGS: 256 dialysis patients; 72 black women, 59 black men, 61 white women, and 64 white men at Piedmont Dialysis Center, a university-affiliated dialysis center in northwest North Carolina.

METHODS

Information was obtained on perceived social support, social networks, blood chemistries, blood pressure, cause of renal failure, treatment-related factors, and socioeconomic factors. HRQoL indicators included two measures of life satisfaction, limitations in leisure-time activities, and Karnofsky's Physical Functioning Scale.

RESULTS

On all HRQoL indicators, blacks consistently rated their HRQoL better than whites. In univariate analyses, lack of social support was consistently related to poorer HRQoL. In multivariate regression analyses, good social support and black race were the two strongest predictors of more positive responses to each of the HRQoL indicators, after controlling for the effects of the other investigated factors. With respect to the Karnofsky scale, younger age and fewer medications taken were additional significant predictors of better functioning.

CONCLUSIONS

HRQoL was consistently rated better among blacks than among whites. In addition, perceived social support exerted a strong, independent influence on objectively and subjectively measured HRQoL of ESRD patients.

Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group

This article describes short form versions of the Incontinence Impact Questionnaire (IIQ) and the Urogenital Distress Inventory (UDI). These instruments assess life impact and symptom distress, respectively, of urinary incontinence and related conditions for women. All subsets regression analysis was used to find item subsets that best approximated scores of the long form versions. The approach succeeded in reducing the 30-item IIQ and the 19-item UDI to 7- and 6-item short forms, respectively. The short form versions may be more useful than the long form versions in many clinical and research applications.

Health-related quality of life measures for women with urinary incontinence: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group

Urinary incontinence (UI) is a relatively common condition in middle-aged and older women. Traditional measures of symptoms do not adequately capture the impact that UI has on individuals' lives. Further, severe morbidity and mortality are not associated with this condition. Rather, UI's impact is primarily on the health status and health-related quality of life (HRQOL) of women. Generic measures of HRQOL inadequately address the impact of the condition on the day-to-day lives of women with UI. The current paper presents data on two new condition-specific instruments designed to assess the HRQOL of UI in women: the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Used in conjunction with one another, these two measures provide detailed information on how UI affects the lives of women. The measures provide data on the more traditional view of HRQOL by assessing the impact of UI on various activities, roles and emotional states (IIQ), as well as data on the less traditional but critical issue of the degree to which symptoms associated with UI are troubling to women (UDI). Data on the reliability, validity and sensitivity to change of these measures demonstrate that they are psychometrically strong. Further, they have been developed for simple, self-administration.

Quality of life among 5,025 patients with left ventricular dysfunction randomized between placebo and enalapril: the Studies of Left Ventricular Dysfunction. The SOLVD Investigators

OBJECTIVES

This study was performed to assess the quality of life of patients with left ventricular dysfunction for up to 2 years after randomization to enalapril or placebo.

BACKGROUND

Previous reports have documented that survival of patients with congestive heart failure can be extended by the angiotensin-converting enzyme inhibitor enalapril. However, it is unknown whether enalapril has a long-term favorable impact on the quality of life in patients with heart failure.

METHODS

A brief quality of life questionnaire assessing the quality of life was administered at baseline and at 6 weeks, 1 year and 2 years of follow-up to patients randomized to placebo or enalapril in the Studies of Left Ventricular Dysfunction (SOLVD). Participants had an ejection fraction < or = 0.35, no other serious illnesses and either symptomatic heart failure (treatment trial, n = 2,465) or asymptomatic left ventricular dysfunction (prevention trial, n = 2,560).

RESULTS

Among the 14 scales of quality of life, better scores at one or more follow-up intervals were noted in 6 scales in the treatment trial and in 1 scale in the prevention trial among patients assigned to enalapril. Consistent superiority with enalapril at two consecutive follow-up intervals was noted in the treatment trial for social functioning and dyspnea but for no scale in the prevention trial. However, an average of 40% of quality of life responses were missing at 2 years of follow-up because of death or failure to complete the questionnaire. In the treatment trial, survivors with more severe heart failure were less likely to complete the questionnaire.

CONCLUSIONS

Modest benefits in quality of life for > or = 1 year occurred when patients with left ventricular dysfunction and symptomatic heart failure were treated with enalapril. No apparent beneficial or adverse effect on quality of life was observed with enalapril in asymptomatic patients with left ventricular dysfunction.

Integrating health-related quality of life into cross-national clinical trials

When planning to implement health-related quality of life (HRQL) assessment in a multinational clinical trial, there are at least four general considerations: the natural history of the disease or condition, the characteristics of the population, the treatment under consideration, and the structure and function of the clinical trial organization. Each of these considerations must be addressed simultaneously when planning, implementing and analysing a cross-national clinical trial. There are five relevant polar components of the natural history of a given disease or condition: (1) time frame (acute versus chronic); (2) life threat (yes versus no); (3) symptomatology (present versus absent); (4) symptom expression (episodic versus constant); and (5) functional impact (present versus absent). Differences in population characteristics, (e.g., age, conditions, co-morbidity), embedded within any cross-national trial, must be addressed conceptually prior to initiating the trial, methodologically when planning implementation, and statistically after the collection of the data. In terms of treatment, issues such as adverse and positive effects and timing of effects must be considered. The methods entailed in planning, implementing and analysing HRQL data will depend upon the degree of centralization of personnel and resources within any given clinical trial. The range of possibilities runs from complete centralization, in which all planning and coordination of data collection and transmittal is done by one office, to complete decentralization, in which the work is distributed to participating sites and interested investigators. Finally, successful implementation of HRQL data collection is enhanced by heightening awareness of the importance of, and value in, assessing HRQL in clinical trials.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of quality of life as observed from the baseline data of the Studies of Left Ventricular Dysfunction (SOLVD) trial quality-of-life substudy

The improvement of aspects of a patient's quality of life may be as important as prolonging survival in evaluating clinical trials of heart failure. The purpose of this study was to analyze the psychometric properties of the baseline measures from the quality-of-life substudy from the Studies of Left Ventricular Dysfunction (SOLVD) trial. The measures included the 6-Minute Walk Test, Dyspnea Scale, Living with Heart Failure, Physical Limitations, Psychologic Distress and Health Perceptions, as reported by both patients and staff. Cognitive functioning, such as Vocabulary, Digit Span and Trails Making, was also assessed. Patients were classified as New York Heart Association class I (n = 158) versus II or III (n = 150). The internal consistencies (i.e., reliabilities) of the self-report measures were high, except for the Health Perceptions of Class II or III patients. Reliability of the SOLVD quality-of-life battery was confirmed by significantly better life quality among New York Heart Association class I patients versus class II or III patients combined on the Walk Test, Physical Limitations, Dyspnea, Living with Heart Failure, Psychologic Distress and staff perceptions of patient health. In accordance with prior studies, the measures were uncorrelated with left ventricular ejection fraction. By demonstrating strong internal consistencies, reliability based on physician reports, and independence of ejection fraction levels, use of this quality-of-life assessment battery in this and other clinical trials of compromised ventricular functioning is supported.

Psychosocial interventions in adult patients with coronary heart disease and cancer. A literature review

A growing body of evidence suggests that chronic medical illness is associated with an increased prevalence and incidence of psychiatric and psychological disturbances. The present literature review is based on two theses: first, that chronic illness is viewed as a stressor and is associated with increased psychological distress, and secondly, that interventions can minimize the distress. A review of the studies conducted with adult patients diagnosed either with coronary heart disease or cancer suggests that psychosocial interventions are, in general, efficacious in relieving self-reported psychological distress. The review also recommends psychosocial interventions for high-risk patients rather than all patients, and that researchers need to identify other outcomes such as health care costs, disability, days in hospital, morbidity, and mortality in order to convince policy makers that these interventions are worthwhile. Recommendations for future research are also discussed.

The integration of health quality of life in clinical research: experiences from cardiovascular clinical trials

Health Quality of Life (HQL) assessment in clinical trial and epidemiological research is necessary to determine the efficacy of treatments and interventions. A definition of HQL is presented with the following dimensions of HQL identified: social, physical, and neuropsychological functioning; emotional stability; personal productivity; and intimacy. A strategy for selecting HQL dimensions and measures is discussed and includes consideration of the study population, the intervention(s), and the clinical trial design. Examples from NHLBI-sponsored clinical trials illustrate how HQL measures are selected as well as the goals that HQL assessment can address. That is, the authors discuss how HQL data can be used to characterize the study populations, determine the effects of HQL on critical outcomes, and assess how treatment affects overall HQL and specific dimensions of HQL.

Gender differences in social support and physical health

A large body of prospective data has accumulated linking social support to health, and most social scientists agree that low levels of support are associated with poor physical and mental health. Unfortunately, most of the research has been limited to White men. When women and people of color are included in the designs, the relationships between social support and physical health are more complicated. Prospective population-based studies provide evidence that low support is associated with increased risk of mortality in women. However, in several studies, results indicated that, for specific age groups, women with high social support have increased risk of mortality. Factors that may contribute to the observed gender differences in the social support-physical health relationship are discussed. Future research should include adequate numbers of women and more sophisticated measures of social support to move the field forward.

Gender differences in social support and physical health

A large body of prospective data has accumulated linking social support to health, and most social scientists agree that low levels of support are associated with poor physical and mental health. Unfortunately, most of the research has been limited to White men. When women and people of color are included in the designs, the relationships between social support and physical health are more complicated. Prospective population-based studies provide evidence that low support is associated with increased risk of mortality in women. However, in several studies, results indicated that, for specific age groups, women with high social support have increased risk of mortality. Factors that may contribute to the observed gender differences in the social support-physical health relationship are discussed. Future research should include adequate numbers of women and more sophisticated measures of social support to move the field forward.