Composite nerve conduction scores and signs for diagnosis and somatic staging of diabetic polyneuropathy: Mid North American ethnic cohort survey.

INTRODUCTION/AIMS: In the Diabetes Control and Complications Trial (DCCT), the minimal nerve conduction (NC) criterion for diabetic sensorimotor polyneuropathy (DSPN) was abnormality of NC in more than one peripheral nerve without specifying the attributes of NCs to be evaluated. In the present study, we assess individual and composite scores of NCs meeting the DCCT criterion and signs for improved diagnosis and assessment of DSPN severity. METHODS: Evaluated were 13 attributes and 6 composite NC scores and signs and symptoms in 395 healthy subjects (HS) and 388 persons with diabetes (DM). RESULTS: Percent abnormality between subjects with DM and HS was remarkably different among individual attributes and the six composite NC scores. For diagnosis of DSPN using the DCCT criterion, assessment of conduction velocities (CVs) and distal latencies (DLs) provided sensitive diagnoses of DSPN. NC amplitudes provided stronger measures of severity. In studied cohorts, DSPN was staged: N0, no NC abnormality using NC score 2 (CVs and DLs), 60.0%; N1, NC abnormality only, 18.4%; N2, NC abnormality and signs of feet or legs, 16.3%; and N3, NC abnormality and signs of thighs, 5.3%. DISCUSSION: For sensitive and standard diagnosis of DSPN using the DCCT NC criterion, specifically defined composite scores of CVs and DLs, e.g., score 2, is recommended. A composite score of amplitudes, e.g., score 4, provides a stronger measure of neuropathy severity. Also, provided are HS reference values of evaluated attributes of NCs and estimates of staged severity of DSPN of mid North American DM cohorts.

Postsurgical Remote Patient Monitoring Outcomes and Perceptions: A Mixed-Methods Assessment.

Objective: To determine how postsurgical remote patient monitoring (RPM) influences readmissions and emergency visits within 30 days of discharge after operation and to understand patient and surgeon perspectives on postsurgical RPM. Patients and Methods: This study was conducted at a US tertiary academic medical center between April 1, 2021, and December 31, 2021. This mixed-methods evaluation included a randomized controlled trial evaluation of RPM after operation and a qualitative assessment of patients' and surgeons' perceptions of RPM's acceptability, feasibility, and effectiveness. Results: A total of 292 patients participated in the RPM trial, and 147 were assigned to the RPM intervention. Despite a good balance between the groups, results indicated no difference in primary or secondary outcomes between the intervention and control groups. The qualitative component included 11 patients and 9 surgeons. The overarching theme for patients was that the program brought them peace of mind. Other main themes included technological issues and perceived benefits of the RPM platform. The major themes for surgeons included identifying the best patients to receive postsurgical RPM, actionable data collection and use, and improvements in data collection needed. Conclusion: Although quantitative results indicate no difference between the groups, postsurgical RPM appears well-accepted from the patient's perspective. However, technological issues could eliminate the benefits. Hospitals seeking to implement similar programs should carefully evaluate which populations to use the program in and seek to collect actionable data.

Assessment of the motivation to use artificial sweetener among individuals with an eating disorder.

Eating disorders are associated with a range of abnormalities in eating behavior. Some individuals consume large amounts of non-caloric artificial sweeteners, suggesting abnormalities in appetitive responding. The current study aimed to quantify hedonic and motivating effects of artificial sweetener in individuals with and without an eating disorder. Two laboratory studies were conducted. Hedonic preference was estimated using the number of artificial sweetener packets (0-10) added to unsweetened cherry flavored Kool-Aid (study 1). Motivation to obtain sweetener was assessed by a progressive ratio (PR) work task (study 2). Ninety-three participants (25 anorexia nervosa restricting type (AN-R), 23 AN binge/purge type (AN-B/P), 20 bulimia nervosa (BN), and 25 normal controls (NC)) completed the study. No significant difference in hedonic preference was found among participant groups. Work completed at the PR task ranged from 0 to 9500 key-board presses. The AN-B/P group had a significantly higher breakpoint and performed significantly more work for sweetener compared to the BN and NC groups. Among AN-B/P and AN-R participants, the preferred number of Equal packets was significantly correlated with the breakpoint and total work. The increased amount of work for sweetener among individuals with AN-B/P supports an enhanced reward value of sweet taste in this population, and suggests that the characteristic food avoidance in AN cannot be accounted for by decreased reward value of all taste-related stimuli. This study also supports the novel application of a PR ratio task to quantify the motivating effect of sweet taste among individuals with an eating disorder.

Measurement of fidgeting in patients with anorexia nervosa using a novel shoe-based monitor.

OBJECTIVE: To objectively assess seated non-exercise physical activity in patients with anorexia nervosa (AN) relative to healthy controls (HCs) and examine the associations between this physical activity, eating disorder pathology, and levels of anxiety and depression. METHOD: Eleven inpatients with AN and 10 HCs wore a shoe-based accelerometer (SmartShoe) at three time points: a) while eating lunch, b) filling out questionnaires, and c) watching television for 1h. RESULTS: Across all three tasks, patients with AN were significantly more active than HCs, thereby engaging in a greater degree of restless or fidgeting behavior. Degree of physical activity was positively correlated with eating disorder psychopathology in the sample with AN, and a trend towards a positive association between physical activity and levels of depression and anxiety was also found in this sample. Among individuals with AN, physical activity was not significantly correlated with BMI, duration of illness, or number of days since hospital admission. DISCUSSION: Use of a minimally invasive, shoe-based monitor revealed patients with AN engaged in a greater degree of fidgeting relative to HCs during quiet, seated tasks and this heightened activity was related to measures of pathology. Non-exercise physical activity, including fidgeting, may warrant further clinical attention in this patient population.

The reinforcing effect of exercise in anorexia nervosa: Clinical correlates and relationship to outcome.

The purpose of the current study was to examine the relative reinforcing effect of exercise compared to a non-monetary alternative reinforcer (leisure activity), and to money, before and after weight restoration in an inpatient population with anorexia nervosa (AN). Sixty-two inpatients with AN completed a progressive ratio (PR) task to earn exercise, leisure activities, or cash at low weight and after weight restoration. Measures of pathology and motivation to exercise were completed and post-treatment discharge weights were collected. Patients worked harder for exercise at low weight than after weight restoration (df = 46, t = 5.50, p < .001). PR task performance was weakly associated with a measure of commitment to exercise (low weight: r = 0.31, weight restored: r = 0.36, p < .05), but not with other clinical measures or follow-up weights. Contrary to prior suggestions, measurement of the reinforcing value of exercise among individuals with AN via a PR task does not appear valuable in assessing clinical severity or outcome. Other, simpler, self-report measures of commitment to exercise may have greater value in assessing these outcomes.

Physical activity and post-treatment weight trajectory in anorexia nervosa.

OBJECTIVE: This study compared an objective measurement of physical activity (PA) in individuals with anorexia nervosa (AN) at low-weight, weight-restored, and post-treatment time points, and also compared PA in AN with that of healthy controls (HC). METHOD: Sixty-one female inpatients with AN wore a novel accelerometer (the IDEEA) which measured PA at three time points: a) low-weight, b) weight-restored, and c) one month post-hospital discharge. Twenty-four HCs wore the IDEEA at one time point. RESULTS: Inpatients with AN became more physically active than they were at low-weight at weight restoration and following treatment discharge. Post-treatment patients with AN were more physically active than HCs during the day and less active at night, which was primarily accounted for by amount of time spent on feet, including standing and walking. Greater time spent on feet during the weight-restoration time point of inpatient treatment was associated with more rapid decrease in BMI over the 12 months following treatment discharge. Fidgeting did not differ between patients and controls, did not change with weight restoration, and did not predict post-treatment weight change. DISCUSSION: Use of a novel accelerometer demonstrated greater PA in AN than in HC. PA following weight restoration in AN, particularly time spent in standing postures, may contribute to weight loss in the year following hospitalization. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:482-489).

Exercise reinforcement, stress, and ß-endorphins: an initial examination of exercise in anabolic-androgenic steroid dependence.

BACKGROUND: Anabolic-androgenic steroids (AASs) are abused primarily in the context of intense exercise and for the purposes of increasing muscle mass as opposed to drug-induced euphoria. AASs also modulate the HPA axis and may increase the reinforcing value of exercise through changes to stress hormone and endorphin release. To test this hypothesis, 26 adult males drawn from a larger study on AAS use completed a progressive ratio task designed to examine the reinforcing value of exercise relative to financial reinforcer. METHOD: Sixteen experienced and current users (8 on-cycle, 8 off-cycle) and 10 controls matched on quantity×frequency of exercise, age, and education abstained from exercise for 24 h prior to testing and provided 24-h cortisol, plasma cortisol, ACTH, ß-endorphin samples, and measures of mood, compulsive exercise, and body image. RESULTS: Between group differences indicated that on-cycle AAS users had the highest ß-endorphin levels, lowest cortisol levels, higher ACTH levels than controls. Conversely, off-cycle AAS users had the highest cortisol and ACTH levels, but the lowest ß-endorphin levels. Exercise value was positively correlated with ß-endorphin and symptoms of AAS dependence. CONCLUSION: The HPA response to AASs may explain why AASs are reinforcing in humans and exercise may play a key role in the development of AAS dependence.

Comparison of three immunoassays for detection of antibodies to Strongyloides stercoralis.

Due to the limited sensitivities of stool-based microscopy and/or culture techniques for Strongyloides stercoralis, the detection of antibodies to this intestinal nematode is relied upon as a surrogate for determining exposure status or making a diagnosis of S. stercoralis infection. Here, we evaluated three immunoassays, including the recently released InBios Strongy Detect IgG enzyme-linked immunosorbent assay (ELISA) (InBios International, Inc., Seattle, WA), the SciMedx Strongyloides serology microwell ELISA (SciMedx Corporation, Denville, NJ), and the luciferase immunoprecipitation system (LIPS) assay performed at the National Institutes of Health (NIH), for their detection of IgG antibodies to S. stercoralis. A total of 101 retrospective serum samples, previously submitted for routine S. stercoralis antibody detection using the SciMedx assay, were also evaluated by the InBios and LIPS assays. The qualitative results from each assay were compared using a Venn diagram analysis, to the consensus result among the three assays, and each ELISA was also evaluated using the LIPS assay as the reference standard. By Venn diagram analysis, 65% (66/101) of the samples demonstrated perfect agreement by all three assays. Also, the numbers of samples considered positive or negative by a single method were similar. Compared to the consensus result, the overall percent agreement of the InBios, SciMedx, and LIPS assays were comparable at 87.1%, 84.2%, and 89.1%, respectively. Finally, the two ELISAs performed analogously but demonstrated only moderate agreement (kappa coefficient for the two assays, 0.53) with the LIPS assay. Collectively, while the two commercially available ELISAs perform equivalently, neither should be used independently of clinical evaluation to diagnose strongyloidiasis.

Assessment of fat taste in individuals with and without anorexia nervosa.

OBJECTIVE: Avoidance of dietary fat is a highly characteristic eating behavior of individuals with anorexia nervosa (AN). To date, no study has determined whether these individuals are better able to perceive the fat content of foods than individuals without AN. The goal of this study was to compare blinded taste ratings of fat-free, low fat, and regular cream cheese in patients with AN and in normal controls (NC). METHOD: AN (n = 25) and control (NC; n = 25) participants were presented with a series of nine cream cheese samples of three differing fat contents and asked to taste and rate each sample from very low to very high fat. RESULTS: Repeated measures ANOVA found no significant main effect of fat content and no interaction between fat content and diagnosis; however, a significant three-way interaction between fat content, diagnosis, and trial was observed. Post hoc analysis revealed a significant fat content by trial interaction within the AN group, suggesting a significant trial effect for the fat-free samples only with improving ability to detect fat-free samples over repeated trials. DISCUSSION: The current study suggests that individuals with AN do not have a markedly greater ability to taste fat than NC, and that; therefore, fat avoidance is likely primarily based on cognitive factors.

Validation of two novel monitoring devices to measure physical activity in healthy women.

Measurement of physical activity is increasingly important in health research. We sought to determine the accuracy and sensitivity to non-exercise activity of three activity monitors worn simultaneously by healthy adult women participating in a structured activity protocol. Ten normal-weight women wore the Intelligent Device for Energy Expenditure and Activity (IDEEA), the SmartShoe, and the SenseWear Armband, during activities that included standing, sitting still, sitting and fidgeting, lying down, and walking at varying speeds. Percentage of time postures correctly identified was determined for the IDEEA and the SmartShoe, and activity counts collected from all three devices were compared. Posture was detected with high accuracy by both the IDEEA and the SmartShoe (97.4% and 94.2% accuracy, respectively). The SmartShoe showed superior sensitivity to movement while seated ("fidgeting") compared with the IDEEA (p=0.004 and 0.049 difference between postures, respectively); all three devices distinguished between fast and slow walking. Data support the ability of the IDEEA and the SmartShoe to recognize basic postures in healthy normal-weight women, as well as to detect fidgeting within the seated position.

Behavioral assessment of the reinforcing effect of exercise in women with anorexia nervosa: further paradigm development and data.

OBJECTIVE: To use a Progressive Ratio (PR) computerized "work" paradigm to measure course and correlates of exercise motivation in in-patients with Anorexia Nervosa (AN). METHOD: Sixteen inpatients with AN participated in a PR task assessing the relative reinforcing effect of two different increments of cash versus the opportunity to exercise for upto 30 min, twice; at low weight, and, for n = 10 participants, after weight restoration. RESULTS: There was a trend toward a higher work for exercise with 2 versus 5 increments of cash as the alternative reinforcer. Exercise breakpoint did not differ between low and normal-weight states. Exercise breakpoint at each time point was correlated with prehospitalization exercise "commitment" (Commitment to Exercise Scale, r = .613, p = .012 at T1; r = .634, p = .049 at T2). DISCUSSION: Patients with AN will work at a PR task for access to even a small amount of exercise. Exercise motivation during hospitalization is correlated with prehospital exercise commitment and does not appear to change consistently with weight restoration.

Adipose tissue distribution after weight restoration and weight maintenance in women with anorexia nervosa.

BACKGROUND: Body image distortions are a core feature of anorexia nervosa (AN). We, and others, previously reported abnormalities in adipose tissue distribution after acute weight restoration in adult women with AN compared with body mass index-matched healthy control women. Whether these abnormalities persist over time remains unknown. OBJECTIVES: We aimed to 1) replicate previous findings that showed preferential central accumulation of adipose tissue in recently weight-restored AN women compared with control subjects, 2) describe the change within patients with longer-term (1-y) weight maintenance, and 3) compare adipose tissue distribution after 1-y maintenance with that of control subjects. DESIGN: Body composition and adipose tissue distribution were assessed by whole-body magnetic resonance imaging in women with AN shortly after weight normalization (n = 30) and again 1 y after hospital discharge (n = 16) and in 8 female control subjects at 2 time points. RESULTS: With acute weight restoration, AN patients had significantly greater visceral and intermuscular adipose tissue compared with control women [visceral: 0.75 +/- 0.26 compared with 0.51 +/- 0.26 kg in AN patients and controls, respectively (P = 0.02); intermuscular: 0.46 +/- 0.17 compared with 0.29 +/- 0.13 kg in AN patients and controls, respectively (P = 0.01)]. With maintenance of normal weight for approximately 1 y, visceral adipose tissue distribution in AN patients was not different from that in healthy control subjects. CONCLUSIONS: In adult women with AN, normalization of weight in the short term is associated with a distribution of adipose tissue that is consistent with a central adiposity phenotype. This abnormal distribution appears to normalize within a 1-y period of weight maintenance. This research was registered at clinicaltrials.gov as NCT 00271921 and NCT 00368667.

Screening mammography utilization in Tennessee women: the association with residence.

CONTEXT: Approximately 70% of US women over age 40 report mammography screening within 2 years. However, rates are likely to vary by age, income, educational level, and residence. PURPOSE: To describe the prevalence of screening mammography and associated factors in women living in rural and urban areas of Tennessee. METHODS: Using pooled data from the Tennessee Behavioral Risk Factor Surveillance System (BRFSS; 2001 and 2003), utilization of screening mammography within a 2-year period was examined for a sample of 1,922 women, 40 years and older. Demographic, behavior, and health-related variables were used to examine associations with utilization. FINDINGS: The prevalence of screening mammography utilization (71.3% 95% CI 67.4-75.2) in women living in rural areas of Tennessee was significantly lower than utilization among women living in urban areas (78.3% 95% CI 75.9-80.7). Higher utilization was associated with having attained at least a high school education, having health insurance, identifying a personal health care provider, being a nonsmoker, recent use of alcohol, having had a recent clinical breast exam or Papanicolau (Pap) test done, and meeting the Healthy People 2010 (HP 2010) recommendation for physical activity. After controlling for all other factors, rural residence was not associated with utilization. For rural women, identifying a personal health care provider was significantly associated with increased likelihood of utilization. CONCLUSIONS: Lower income and lower education, each associated with lower screening utilization, were more common in rural Tennessee women. The significance of a personal health care provider for utilization in rural women is meaningful for service providers.

SEPT9 mutations and a conserved 17q25 sequence in sporadic and hereditary brachial plexus neuropathy.

BACKGROUND: The clinical characteristics of sporadic brachial plexus neuropathy (S-BPN) and hereditary brachial plexus neuropathy (H-BPN) are similar. During attacks, inflammation of the brachial plexus nerves has been identified in both conditions. SEPT9 mutations (Arg88Trp, Ser93Phe, 5'UTR c.-131G>C) occur in some families with H-BPN. These mutations were not found in North American kindreds with H-BPN with a conserved 500-kilobase sequence of DNA at the 17q25 chromosomal region (where SEPT9 localizes) where a founder mutation has been suggested. OBJECTIVE: To study the 17q25 sequence and SEPT9 in S-BPN (56 individuals) and H-BPN (13 kindreds). METHODS: Allele analysis at 17q25, SEPT9 DNA sequencing, and messenger RNA analysis from lymphoblast cultures were performed. RESULTS: A conserved 17q25 sequence was found in 5 of 13 kindreds with H-BPN and 1 individual with S-BPN. This conserved sequence was not found in the family with a SEPT9 mutation (Arg88Trp) or in 182 control subjects. SEPT9 messenger RNA expression levels did not differ between forms of H-BPN and control subjects. No known mutations of SEPT9 were found in S-BPN. CONCLUSIONS: Rarely, individuals with S-BPN may have the same conserved 17q25 sequence found in many North American kindreds with H-BPN. Individuals with BPN with this conserved sequence do not seem to have SEPT9 mutations or alterations of messenger RNA expression levels in lymphoblast cultures and are predicted to have the most common genetic cause in North America by a founder-effect mutation.

Validity of 2 devices for measuring steps taken by older adults in assisted-living facilities.

BACKGROUND: This 2-part study examined validity of selected motion sensors for assessing physical activity in older adults residing in assisted-living communities. METHODS: Twenty-one older adults (mean age = 78.6 +/- 13.1 years) wore the StepWatch 3 Step Activity Monitor (SW3) and the Yamax Digi-Walker SW-200 pedometer (DW). Part I compared accuracy of these devices for measuring steps taken over 161 m. Part II compared devices over a 1-day (24-hour) period. RESULTS: In part I, the DW recorded 51.9% (r2 = -.08, P = .75) and the SW3 recorded 102.6% (r2 = .99, P < .001) of steps. In part II, the DW measured significantly fewer steps (1587 +/- 1057 steps) than did the SW3 (6420 +/- 3180 steps). CONCLUSIONS: The SW3 pedometer was more accurate in counting steps and recorded higher 24-hour step counts than the DW pedometer. Thus, the SW3 is a valid research instrument for monitoring activity in the assisted-living population.

Ageism revisited: a study measuring ageism in East Tennessee, USA.

Research literature over the past 50 years has addressed ageism, but few studies have examined the measurement of ageism or how to combat it. This study utilized Palmore's Ageism Survey to measure the frequency of occurrence of ageism and to examine the types of ageism reported by older adults in the East Tennessee region of the USA. A convenience sample of 247 community-dwelling older adults was recruited from eight senior centers and nutrition sites. The participants ranged in age from 60-92 years. Eighty-four percent of the participants indicated an experience with at least one type of ageism. The forms of ageism frequently reported were jokes and birthday cards that poked fun at older people. Events showing disrespect also were reported. Differences in urban/suburban and rural reporting were noted. The findings from this and similar studies might provide guidance for the measurement of ageism and how to combat it.

Relative reinforcing value of exercise in inpatients with anorexia nervosa: model development and pilot data.

OBJECTIVE: This study sought to quantify, among patients hospitalized for the treatment of anorexia nervosa (AN), the reinforcing value of exercise, defined as the amount of work a patient would expend for the opportunity to exercise. METHOD: Sixteen inpatients with AN performed a computerized progressive ratio (PR) task for the opportunity to exercise for either 15 or 30 min, or a monetary voucher. Exercise "breakpoint" was calculated and compared with clinical measures. RESULTS: Patients performed an average of 1134.4 (+/-751.2) button presses for exercise. Exercise breakpoint was significantly correlated with the Beck Depression Inventory (BDI; r = .728, p = .001), and there was a trend toward a correlation with the Commitment to Exercise Scale (CES; Davis, 1993; r = .490, p = .054). CONCLUSION: Results support the feasibility and potential utility of this novel application of the PR task to quantify the reinforcing value of exercise in AN. The association between exercise and depression is consistent with some prior studies in AN. The trend toward an association with CES scores suggests that breakpoint captures an aspect of the motivation for exercise in this population.

Physical activity and cortisol in anorexia nervosa.

Elevated physical activity is commonly observed among patients with Anorexia Nervosa (AN) and can manifest in several forms. While elevated physical activity may play a key role in the pathophysiology of this disorder, much remains unknown about it, including the relationship among its various manifestations, and their underlying mechanism(s). The purposes of the current study were to (1) quantify locomotor activity in inpatients with AN using an accelerometer, (2) determine the association between locomotor activity and exercise history and (3) determine the association between urinary cortisol and physical activity. Thirty-six women hospitalized with AN wore activity armbands for 48 h during the first 2 weeks of hospitalization, collected 24-h urine to measure cortisol, and completed rating forms. Activity counts varied more than four-fold among individuals but were consistent within individuals over the 2 monitoring days (p<0.001). Averaged 24-h activity counts were positively correlated with pre-hospitalization attitude towards exercise as measured by the Commitment to Exercise Scale (CES; p=0.032). Forty-two percent of women reported "high" exercise in the 3 months before hospitalization; compared to non-high-exercising patients, these women demonstrated a higher CES score (p<0.001) and a trend toward greater activity counts (p=0.059). Urinary cortisol was positively associated with activity counts (p=0.044) and CES score (p=0.018). These data suggest that some women with AN have a higher "drive" for physical activity that persists into early hospitalization. HPA axis abnormalities may be associated with this state.

Artificial sweetener use among individuals with eating disorders.

UNLABELLED: Women with eating disorders report using large quantities of artificially sweetened products, but this has not been quantified. OBJECTIVE: The authors assessed the use of selected artificially sweetened low-calorie products among women with eating disorders compared with controls. METHOD: Thirty women with anorexia nervosa (18 with the restricting subtype [AN-R] and 12 with the binge/purge subtype [AN-B/P]), 48 women with bulimia nervosa (BN), and 32 healthy control women completed a survey of frequency and amount of consumption of chewing gum, artificially sweetened low-calorie beverages, and packets of artificial sweetener in the previous month. RESULTS: A greater proportion of women with AN-B/P and BN reported use of each product, compared with women with AN-R and control participants. Among product users, patients with eating disorders reported using greater amounts than controls. Among patients who reported binge eating and/or purging, the quantity of each product used was inversely correlated with body mass index (BMI). CONCLUSION: These data suggest an increased drive for sweet orosensory stimulation in women with AN and BN.

Depressive symptoms predict hospitalization for adolescents with type 1 diabetes mellitus.

OBJECTIVE: To examine the role of self-reported depressive symptoms in predicting hospitalization for complications of diabetes mellitus over a period of up to 2 years. STUDY DESIGN: Two hundred thirty-one adolescent outpatients (age range: 11-18 years) with type 1 diabetes completed the Center for Epidemiological Studies Depression Scale, a self-report measure of depressive symptoms. Glycosylated hemoglobin levels were also assessed, to account for this known predictor of hospitalization. With survival analysis methods, hospitalizations for medical complications that occurred up to 2 years after this assessment were recorded. RESULTS: After controlling for age, gender, socioeconomic status, and glycosylated hemoglobin levels at baseline, the odds ratio for prediction offered by Center for Epidemiological Studies Depression Scale scores above the cutoff point (12 for boys and 22 for girls) was 2.58 (95% confidence interval: 1.12-5.98). CONCLUSIONS: Young people with type 1 diabetes who show high levels of depressive symptoms are at increased risk for hospitalization for disease complications. Interventions aimed at improving their depressive symptoms may result in positive health outcomes, as well as improved quality of life.