Children's emerging receptive, positive orientation toward their parents in the network of early attachment relationships.

Early security plays a major role in inaugurating the child's receptive, positive orientation - a foundation for cooperative parent-child relationships and successful socialization. However, few studies have considered the association between children's attachments with both mothers and fathers and multiple aspects of children's receptive, positive orientation, or compared all four attachment groups (secure, avoidant, resistant, and disorganized). In 192 mother-child and 186 father-child dyads from community families, children's attachment was assessed at 15-17 months in Strange Situation Paradigm. Aspects of receptive, positive orientation toward each parent - positive affect, committed compliance, empathic concern, and restraint in response to parental prohibition - were observed in naturalistic laboratory contexts. Generally, securely attached children were more receptive and positive than insecure, although specific effects depended on the measure, comparison group (avoidant, resistant, disorganized), and the relationship (mother- or father-child). For positive orientation in the father-child dyads, being secure with both parents conferred a modest additional benefit.

Usefulness of improvement in walking distance versus peak oxygen uptake in predicting prognosis after myocardial infarction and/or coronary artery bypass grafting in men.

Information is limited on the influence of a change in fitness and/or physical activity on mortality in cardiac patients who undergo exercise rehabilitation. This was studied in 6,956 men (4,713 with myocardial infarctions, 2,243 who underwent coronary bypass surgery) completing a 12-month walking-based training regimen and followed for a median of 9 years (range 4 to 26; 67,820 patient-years). Peak oxygen uptake (VO2peak) was measured at the beginning and the end of the program, and walking distance and pace were recorded weekly. These and other pertinent data were entered into a Cox proportional-hazards model and tested for associations with time to cardiac and all-cause death. In total, 2,016 deaths were recorded (737 cardiac, 1,279 all-cause). The mean increase in VO2peak was 4.9 ml/kg/min (95% confidence interval [CI] 4.7 to 5.0, p <0.0001), and the mean increase in distance walked was 2.1 mi (95% CI 2.0 to 2.1, p <0.0001). Increase in VO2peak was significant on univariate analysis (hazard ratio [HR] 0.98) but not on multivariate analysis. Distance increase was a significant predictor of cardiac and all-cause death on multivariate analysis, with each 1-mi improvement conferring a 20% reduction in cardiac death (HR 0.80, 95% CI 0.71 to 0.87, p <0.0001). When categorized into groups of <1.3 (referent), 1.3 to 2.8, and >2.8 mi, increased walking distance of 1.3 to 2.8 and of >2.8 mi yielded 24% (HR 0.76, 95% CI 0.62 to 0.92, p = 0.005) and 48% (HR 0.52, 95% CI 0.40 to 0.68, p <0.0001) reductions in cardiac death, respectively. In conclusion, in men who underwent an exercise rehabilitation program, improvement in walking distance was a strong independent predictor, and a greater guide to prognosis, than gains in VO2peak.

Informed consent for research participation in frail older persons.

Informed consent has been the most scrutinized and controversial aspect of clinical research ethics. Institutional review boards (IRBs), government regulatory agencies, and the threat of litigation have all contributed to increasingly detailed consent documents that hope to ensure that subjects are not misled or coerced. Unfortunately, the growing regulatory burden on researchers has not succeeded in protecting subjects, but has rather made the consent process less effective and has discouraged research on vulnerable populations. As a matter of fact, investigators and ethicists continue to identify failures of the consenting process, particularly concerning participation in research of older individuals. The challenges involved in ensuring appropriate consent from the elderly include physical frailty, reduced autonomy and privacy, and impaired decision-making capacity due to dementia, delirium, or other neuropsychiatric illnesses. Ageism among investigators also contributes to failure of informed consent. The evaluation and continuing re-evaluation of an individual's decision-making capacity is critical but difficult. In the most extreme cases, the older adult's ability to participate in the consent process is clearly impaired. However, in many instances, the decision-making capacity is only partially impaired but declines during the course of a research project. Implementing methods of effective communication may enable many frail elderly individuals to make informed decisions. Special challenges are posed by research on end-of-life care, which typically involves frail, older subjects who are uniquely vulnerable, and research is conducted in institutional settings where subtle violations of autonomy are routine. Clearly, the frail elderly represent a vulnerable population that deserves special attention when developing and evaluating an informed consent process. Two important ethical conflicts should be kept in mind. First, although vulnerable older patients must be protected, protection should not prevent research on this important population. Similarly, because informed consent documents are often written to prevent legal jeopardy, these technical documents, expressed in language sometimes difficult to understand, can prevent comprehension of basic issues, defeating the ethical purpose of human protection.

Timeline for peak improvements during 52 weeks of outpatient cardiac rehabilitation.

PURPOSE: Cardiac rehabilitation is an integral component of comprehensive care for patients with coronary heart disease. Although the typical programmatic delivery of outpatient cardiac rehabilitation services often involves 36 sessions over 12 weeks, that format is based more on historical practice than on outcome data. This study aimed to determine the point at which during 52 weeks of outpatient cardiac rehabilitation, patients achieved peak values for selected outcomes, and whether the number of supervised exercise sessions had any effect on these outcomes. METHODS: In this study, 623 male patients with coronary heart disease admitted to an outpatient cardiac rehabilitation program were randomized to one of two 52-week program formats. One format (CR1) used one supervised exercise session per week over 52 weeks, and the second format (CR2) used weekly supervised sessions for 26 weeks followed by one supervised session per month for the remaining 26 weeks. Both formats used four unsupervised, documented exercise sessions per week. Selected clinical, physiologic, and psychological variables were measured at baseline, then at 4, 12, 26, 38, and 52 weeks. The program costs for both the CR1 and CR2 formats were calculated from known expenses. RESULTS: Because there were no significant intercohort differences between CR1 and CR2 and no significant interaction (time x group), data from the two cohorts were pooled for statistical analysis. Peak oxygen intake (VO(2peak)) significantly increased by 4.4 mL/kg per minute at 38 weeks, and the greatest percentage of patients (30.1%) also achieved their highest VO(2peak) at this time. The largest gain in Medical Outcomes Survey Short Form 36 role physical scores was from baseline to 38 weeks (52.4 versus 85.2), and the highest percentage of patients (72%) with role physical scores in the excellent category occurred at 38 weeks. Clinical depression at baseline (Beck Depression Inventory score > 10) had no significant effect on the dropout rate or the gain in VO(2peak) with exercise training. Program costs for these alternative formats of service were similar to the cost for a standard program format of 36 sessions. CONCLUSIONS: Patients achieved their highest functional capacity after 38 weeks of outpatient cardiac rehabilitation using a program format of only 29 to 38 supervised exercise sessions. The results of this study show that an outpatient cardiac rehabilitation program combining supervised with unsupervised exercise sessions and continuing for 38 weeks results in the greatest improvement in these selected outcomes.

Long-term cardiorespiratory results of exercise training following cardiac transplantation.

The long-term influence of exercise training after heart transplantation remains unclear. Accordingly, we performed a 12-year follow-up study of 36 patients who underwent heart transplantation. Findings for survivors were compared with those of age-matched controls over the same period. Comparisons were also made between survivors and deceased patients. The sample comprised 36 men (aged 47 +/- 9 years) and a group of healthy age-matched controls. The patients received 16 months of outpatient exercise training; physiologic data were collected initially and at discharge. At 12 years, further data were collected on 20 of 23 survivors and their controls; 3 of the survivors were unavailable for final assessment, and 13 patients had died in the interim. The survivors' peak oxygen intake (V*O(2peak)) increased 26% after training and decreased 0.39 mlkg(-1)min(-1) per year (27.9 +/- 7 to 23.7 +/- 6), which was a similar rate as the controls (0.37 mlkg(-1)min(-1) per year; 33.7 +/- 7 to 29.2 +/- 7). Lean body mass (LBM) increased 3 kg by 16 months and a further 2.5 kg by 12 years, but ultimately was 3 kg below the controls. Although there was no difference in entry data between deceased patients and survivors, the latter attained greater gains in V*O(2peak) and LBM over the 16 months of training. Thus, in heart transplantation patients who undergo training, gains in exercise capacity are lost over 12 years at a rate commensurate with normal aging. A reduced training response in V*O(2peak) and LBM contributes to a poorer prognosis.