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1.  Patterns of Change in Symptom Clusters with HIV Disease Progression 
With better antiretroviral treatments (ART), persons living with HIV (PLWH) are living longer, healthier lives. Therefore, they also experience more medical comorbidities that come with normal aging, as well as side effects of multiple treatments and long-term sequelae of HIV. It can be hard to know whether symptoms reported by PLWH are related to comorbidities or are signs of HIV disease progression and possible treatment failure.
The current study was designed to disentangle these issues by examining within-person symptom changes in data collected from a cohort of PLWH before the advent of highly efficacious ART.
This study was a secondary analysis of symptom reports in longitudinal data collected from 246 PLWH in 1992–1994. Multilevel modeling was used to test for changes over time in HIV-related symptom clusters. Analyses also tested the effects of person-level demographic covariates and co-occurring mental health symptoms on HIV symptoms, and examined the magnitude of within-person versus between-person variations in reported symptom severity.
Two of six HIV-related symptom clusters, malaise/fatigue and nausea/vomiting, increased over time in the context of HIV disease progression, while the other four did not. Changes were independent of baseline disease severity or psychological covariates. There was substantial within-person variability in absolute symptom severity.
Relatively small but consistent changes in symptoms related to nausea or fatigue may suggest HIV disease progression, while changes in other HIV symptom clusters may instead be related to comorbidities or normal aging. Further research is recommended on symptom progression in PLWH.
PMCID: PMC3132274  PMID: 21429701
Aging; fatigue; HIV; nausea; symptom clusters
2.  Test–retest reliability of multidimensional dyspnea profile recall ratings in the emergency department: a prospective, longitudinal study 
Dyspnea is among the most common reasons for emergency department (ED) visits by patients with cardiopulmonary disease who are commonly asked to recall the symptoms that prompted them to come to the ED. The reliability of recalled dyspnea has not been systematically investigated in ED patients.
Patients with chronic or acute cardiopulmonary conditions who came to the ED with dyspnea (N = 154) completed the Multidimensional Dyspnea Profile (MDP) several times during the visit and in a follow-up visit 4 to 6 weeks later (n = 68). The MDP has 12 items with numerical ratings of intensity, unpleasantness, sensory qualities, and emotions associated with how breathing felt when participants decided to come to the ED (recall MDP) or at the time of administration (“now” MDP). The recall MDP was administered twice in the ED and once during the follow-up visit. Principal components analysis (PCA) with varimax rotation was used to assess domain structure of the recall MDP. Internal consistency reliability was assessed with Cronbach’s alpha. Test–retest reliability was assessed with intraclass correlation coefficients (ICCs) for absolute agreement for individual items and domains.
PCA of the recall MDP was consistent with two domains (Immediate Perception, 7 items, Cronbach’s alpha = .89 to .94; Emotional Response, 5 items; Cronbach’s alpha = .81 to .85). Test–retest ICCs for the recall MDP during the ED visit ranged from .70 to .87 for individual items and were .93 and .94 for the Immediate Perception and Emotional Response domains. ICCs were much lower for the interval between the ED visit and follow-up, both for individual items (.28 to .66) and for the Immediate Perception and Emotional Response domains (.72 and .78, respectively).
During an ED visit, recall MDP ratings of dyspnea at the time participants decided to seek care in the ED are reliable and sufficiently stable, both for individual items and the two domains, that a time lag between arrival and questionnaire administration does not critically affect recall of perceptual and emotional characteristics immediately prior to the visit. However, test–retest reliability of recall over a 4- to 6-week interval is poor for individual items and significantly attenuated for the two domains.
PMCID: PMC3464619  PMID: 22624887
Dyspnea; Recall; Test–retest reliability; Questionnaires; Emergency department visits
3.  Development and Validation of an Instrument for Rapidly Assessing Symptoms: The General Symptom Distress Scale 
Symptom assessment has increasingly focused on the evaluation of total symptom distress or burden rather than assessing only individual symptoms. The challenge for clinicians and researchers alike is to assess symptoms, determine the symptom distress associated with the symptoms, and the patient’s ability for symptom management without a lengthy and burdensome assessment process.
The objective of this article is to discuss the psychometric evaluation of a brief general symptom distress scale developed to assess specific symptoms and how they rank in relation to each other, the overall symptom distress associated with the symptom schema, and provide an assessment of how well or poorly that symptom schema is managed.
Results from a pilot study about the initial development of the General Symptom Distress Scale (GSDS) with 76 hospitalized patients are presented, followed by a more complete psychometric evaluation of the GSDS using three samples of cancer patients (n=190) and their social network members, called partners in these studies (n=94). Descriptive statistics were used to describe the GSDS symptoms, symptom distress and symptom management. Point biserial correlations indexed the associations between dichotomous symptoms and continuous measures, and conditional probabilities were used to illustrate the substantial comorbidities of this sample. Internal consistency was examined using the KR-20 coefficient, and test-retest reliability was examined. Construct validity and predictive validity were also examined.
The GSDS demonstrated satisfactory internal consistency and test-retest reliability, and good construct validity and predictive validity. The total score on the GSDS, symptom distress and symptom management correlated significantly with related constructs of depression, positive and negative affect and general health. The GSDS was able to demonstrate its ability to distinguish between those with or without chronic illness, and was able to significantly predict scores on criterion measures such as depression.
Collectively, these results suggest that the GSDS is a straightforward and useful instrument for rapidly assessing symptoms that can disrupt health-related quality of life.
PMCID: PMC3062688  PMID: 21131168
Symptoms; symptom distress; instrumentation; psychometric evaluation
4.  Wood Smoke Exposure and Gene Promoter Methylation Are Associated with Increased Risk for COPD in Smokers 
Rationale: Wood smoke–associated chronic obstructive pulmonary disease (COPD) is common in women in developing countries but has not been adequately described in developed countries.
Objectives: Our objective was to determine whether wood smoke exposure was a risk factor for COPD in a population of smokers in the United States and whether aberrant gene promoter methylation in sputum may modify this association.
Methods: For this cross-sectional study, 1,827 subjects were drawn from the Lovelace Smokers' Cohort, a predominantly female cohort of smokers. Wood smoke exposure was self-reported. Postbronchodilator spirometry was obtained, and COPD outcomes studied included percent predicted FEV1, airflow obstruction, and chronic bronchitis. Effect modification of wood smoke exposure with current cigarette smoke, ethnicity, sex, and promoter methylation of lung cancer-related genes in sputum on COPD outcomes were separately explored. Multivariable logistic and poisson regression models were used for binary and rate-based outcomes, respectively.
Measurements and Main Results: Self-reported wood smoke exposure was independently associated with a lower percent predicted FEV1 (point estimate [± SE] −0.03 ± 0.01) and a higher prevalence of airflow obstruction and chronic bronchitis (odds ratio, 1.96; 95% confidence interval, 1.52–2.52 and 1.64 (95% confidence interval, 1.31–2.06, respectively). These associations were stronger among current cigarette smokers, non-Hispanic whites, and men. Wood smoke exposure interacted in a multiplicative manner with aberrant promoter methylation of the p16 or GATA4 genes on lower percent predicted FEV1.
Conclusions: These studies identify a novel link between wood smoke exposure and gene promoter methylation that synergistically increases the risk for reduced lung function in cigarette smokers.
PMCID: PMC3001253  PMID: 20595226
wood smoke; cigarette smokers; airflow obstruction; gene promoter methylation in sputum DNA
5.  Development and validation of a new global well-being outcomes rating scale for integrative medicine research 
Researchers are finding limitations of currently available disease-focused questionnaire tools for outcome studies in complementary and alternative medicine/integrative medicine (CAM/IM).
Three substudies investigated the new one-item visual analogue Arizona Integrative Outcomes Scale (AIOS), which assesses self-rated global sense of spiritual, social, mental, emotional, and physical well-being over the past 24 hours and the past month. The first study tested the scale's ability to discriminate unhealthy individuals (n = 50) from healthy individuals (n = 50) in a rehabilitation outpatient clinic sample. The second study examined the concurrent validity of the AIOS by comparing ratings of global well-being to degree of psychological distress as measured by the Brief Symptom Inventory (BSI) in undergraduate college students (N = 458). The third study evaluated the relationships between the AIOS and positively- and negatively-valenced tools (Positive and Negative Affect Scale and the Positive States of Mind Scale) in a different sample of undergraduate students (N = 62).
Substudy (i) Rehabilitation patients scored significantly lower than the healthy controls on both forms of the AIOS and a current global health rating. The AIOS 24-hours correlated moderately and significantly with global health (patients r = 0.50; controls r = 0.45). AIOS 1-month correlations with global health were stronger within the controls (patients r = 0.36; controls r = 0.50). Controls (r = 0.64) had a higher correlation between the AIOS 24-hour and 1-month forms than did the patients (r = 0.33), which is consistent with the presumptive improvement in the patients' condition over the previous 30 days in rehabilitation. Substudy (ii) In undergraduate students, AIOS scores were inversely related to distress ratings, as measured by the global severity index on the BSI (rAIOS24h = -0.42, rAIOS1month = -0.40). Substudy (iii) AIOS scores were significantly correlated with positive affect (rAIOS24h = 0.56, rAIOS1month = 0.57) and positive states of mind (rAIOS24h = 0.42, rAIOS1month = 0.45), and inversely correlated with negative affect (rAIOS24h = -0.41, rAIOS1month = -0.59).
The AIOS is able to distinguish relatively sicker from relatively healthier individuals; and correlates in expected directions with a measure of distress and indicators of positive and negative affect and positive states of mind. The AIOS offers a tool for CAM/IM research that extends beyond a disease emphasis.
PMCID: PMC343287  PMID: 14725717
complementary and alternative medicine; well-being; global outcomes; questionnaire; validation; rehabilitation
6.  Development and validation of IMAQ: Integrative Medicine Attitude Questionnaire 
Complementary/alternative medicine and integrative medicine (CAM/IM) are increasingly used in the U.S. We set out to develop and validate a brief questionnaire measuring health care provider and medical student attitudes regarding these approaches to healthcare.
IMAQ is a 29-item, 7-point Likert scale rated instrument, developed from focus groups consisting of faculty, fellows, visiting residents, and medical students at a university based integrative medicine program. Respondents included 111 (of 574 contacted) internal medicine physicians on an academic medical center CME list and 85 healthcare providers (mostly physicians) attending an American Holistic Medical Association Annual Conference (296 attending). Cohorts were selected for expected differences in attitudes toward CAM/IM.
Factor analysis demonstrated that a 2 factor solution best explained the variance in responses (38%). Factor 1 ("openness to new ideas and paradigms") explained 26% of variance with loadings ranging from 0.79 to 0.3, with factor 2 ("value of both introspection and relationship to patient") contributing an additional 12% of the explained variance with loadings ranging from 0.69 to 0.42. Both factors demonstrated adequate reliability. Factor 1 had a Cronbach's alpha of 0.91, while factor 2 was 0.72. As expected, AHMA conference attendees scored higher (F = 120.00, p < 0.001) than the internists on the IMAQ, supporting the construct validity. Although 63% of the AHMA subjects, and only 32% of the internists were female, analysis revealed that gender did not explain the score differences (F = 2.6, p > 0.05).
Analysis of the IMAQ provided evidence of its reliability and validity in measuring attitudes toward CAM/IM, specifically openness to new ideas and paradigms, and the value of relationship to self and patient. Initial findings support use of the IMAQ in measuring attitudes of students and practitioners towards CAM/IM interventions as a first step in understanding willingness to use these approaches to healing. It is our desire that this preliminary instrument will continue to be refined as the field of CAM/IM matures.
PMCID: PMC200993  PMID: 12946276

Results 1-6 (6)