Uncovering undernutrition in chronic obstructive pulmonary disease: Beyond body mass index.

BACKGROUND: Undernutrition, a common but treatable complication of chronic obstructive pulmonary disease (COPD), contributes to poor outcomes but is under-detected. Improved detection could prompt dietary intervention which may improve outcomes. We investigated whether adding a measure of muscle mass (fat-free mass index, FFMI) or a malnutrition screening tool (Mini Nutritional Assessment, MNA®) to the commonly used measure of body mass index (BMI), helps detect undernutrition in COPD. METHODS: We conducted a retrospective chart review of 86 outpatients with COPD. Demographic and disease severity data were collected, and nutritional status assessed using BMI, FFMI and MNA®. RESULTS: Patients comprised 55% males with median age 71.5 years, severe COPD (median FEV1 = 0.74 (30.5% predicted)) and high symptom impact (median COPD Assessment Test (CAT) = 23). Twenty-eight percent of patients had low BMI, 27% had low FFMI, 22% were MNA®-classified malnourished and 43% were MNA®-classified at risk of malnutrition. MNA® correlated moderately with BMI and classified 55% of patients with healthy/high BMI as either malnourished or at risk of malnutrition. FFMI and BMI correlated strongly, and low FFMI was present in 5% of patients with healthy/high BMI. The undernutrition measures also showed weak to moderate correlations with disease severity (spirometry data) and MNA® weakly correlated with symptom impact (CAT). CONCLUSION: The MNA® identified more undernourished patients than FFMI or BMI. It also correlated with disease severity and broader symptom burden. The MNA® appears to be a simple tool for earlier detection of patients who may benefit from dietary intervention, potentially enhancing their quality of life.

Maintenance of non-pharmacological strategies 6 months after patients with chronic obstructive pulmonary disease (COPD) attend a breathlessness service: a qualitative study.

OBJECTIVES: This study aimed to explore the degree to which non-pharmacological strategies for chronic breathlessness are sustained 6 months after completing a breathlessness service in patients with chronic obstructive pulmonary disease (COPD), and patient perceptions regarding the need for ongoing support. DESIGN: A qualitative approach was taken using semistructured telephone interviews. Thematic analysis used an integrative approach. SETTING: The Westmead Breathlessness Service (WBS) trains patients with COPD to self-manage chronic breathlessness over an 8-week programme with multidisciplinary input and home visits. PARTICIPANTS: Patients with moderate to very severe COPD who had completed the WBS programme 6 months earlier. RESULTS: Thirty-two participants were interviewed. One or more breathlessness self-management strategies were sustained by most participants, including breathing techniques (n=22; 69%), the hand-held fan (n=17; 53%), planning/pacing and exercise (n=14 for each; 44%) and strategic use of a four-wheeled walker (n=8; 25%). However, almost a third of participants appeared to be struggling psychologically, including some who had refused psychological intervention. A 'chaos narrative' appeared to be prevalent, and many participants had poor recall of the programme. CONCLUSIONS: Self-management strategies taught by breathlessness services to patients with moderate to very severe COPD have potential to be sustained 6 months later. However, psychological coping may be more challenging to maintain. Research is needed on ways to improve resilience to set-backs and uptake of psychological interventions, as well as to understand and address the implications of poor recall for self-management. TRIAL REGISTRATION NUMBER: ACTRN12617000499381.

Protocol for a Single-Blind, Randomized, Parallel-Group Study of a Nonpharmacological Integrated Care Intervention to Reduce the Impact of Breathlessness in Patients with Chronic Obstructive Pulmonary Disease.

Background: Patients with chronic obstructive pulmonary disease (COPD) frequently experience breathlessness despite maximal medical therapy. Nonpharmacological management is effective in studies enrolling patients with a variety of respiratory diseases; however, the impact on patients with COPD is unclear. Methods: A protocol for a mixed-methods, single-center, observer-blinded, fast-track randomized-controlled, parallel-group trial comparing an immediate eight-week nonpharmacological Westmead Breathlessness Service (WBS) to a standard care control group is described. Population: At least moderate COPD (FEV1:FVC ≤0.7; FEV1%predicted ≤60%) and persistent disabling breathlessness (modified Medical Research Council ≥2). Intervention: Individualized prescription of nonpharmacological breathlessness interventions, including a handheld fan, breathing techniques, postures to relieve breathlessness, relaxation, nutritional advice, energy conservation, and exercise advice delivered by a team including doctors, nurses, a physiotherapist, an occupational therapist, a dietitian, and speech pathologist. Control: Participants who receive the WBS intervention after an eight-week period while receiving usual care (standard care group). Outcome: Primary outcome-Chronic Respiratory Questionnaire (CRQ) Mastery subscale. Secondary outcomes include numerical rating scale of breathlessness intensity, unpleasantness, and confidence managing breathlessness; quality of life as measured by other CRQ subscales; Hospital Anxiety and Depression Scale score; daily step count; health resource utilization 12 months pre- and postintervention; and cost-effectiveness. Qualitative analysis of participant interviews will provide additional context for interpreting the quantitative results. Discussion: This study aims to establish the efficacy and cost-effectiveness of an eight-week nonpharmacological breathlessness intervention in patients with COPD. Trial Registration: The Australian New Zealand Clinical Trial Registry ACTRN12617000499381 (06/04/17).

Adverse events reported by anxious school refusing adolescents receiving cognitive behavioral therapy with and without fluoxetine.

BACKGROUND: Investigating adverse events associated with antidepressant treatments in adolescents is important given the concerns about increased risk of suicidal ideation and behavior in this age group. The aim of this study is to investigate adverse and serious adverse events associated with the treatment of anxiety (cognitive behavioral therapy (CBT)-only, CBT-plus-placebo, and CBT-plus-fluoxetine) in anxious school-refusing adolescents. METHODS: A side-effect symptom checklist was completed by participants prior to commencing treatment and during treatment (weekly/fortnightly). RESULTS: CBT-plus-fluoxetine was well tolerated and not associated with higher levels of adverse events than the other treatments. Adverse events in all groups decreased over time, and the only adverse event distinct to fluoxetine was nausea. Baseline anxiety predicted higher levels of adverse events. There was one suicide attempt in the CBT-plus-placebo group but no statistically significant difference in suicide attempts between groups. Participants with a comorbid depressive disorder were more likely to report self-injury ideation but not suicidal ideation compared with those who did not have comorbid depressive disorder. Frequency of suicidal ideation and non-suicidal self-injury was significantly lower in the CBT-plus-fluoxetine group compared with the CBT-only group. Frequency of self-injury ideation was significantly lower in the CBT-plus-fluoxetine group compared with both other groups. CONCLUSIONS: Overall, the treatments were well tolerated and fluoxetine plus CBT appeared to be protective against suicidal ideation, non-suicidal self-injury, and self-injury ideation in this sample.

The Cranky Thermometers: Visual analogue scales measuring irritability in youth.

This study assessed the psychometric properties of two visual analogue scales of irritability, known as the Cranky Thermometers (CT), in both an Australian community secondary-school sample (N = 164) and a sample of adolescents with a depressive disorder (N = 127). The first scale Cranky Now measures current irritability, and the second, Cranky Two Weeks, measures peak irritability within the last two weeks. CT scores were significantly higher in adolescents with major depressive disorder than in the school sample and showed improvement following treatment for depression. Positive associations were found between CT and irritability scores as determined by Kiddie Schedule for Affective Disorders and Schizophrenia (not irritable, sub-threshold, threshold irritability) and Affective Reactivity Index scores. Results suggest that the CTs are rapidly administered, have promising psychometric properties and demonstrate utility in measuring irritability in clinical and community settings.

Augmenting Cognitive Behavior Therapy for School Refusal with Fluoxetine: A Randomized Controlled Trial.

This study investigates whether the augmentation of cognitive behavior therapy (CBT) with fluoxetine improves outcomes in anxious school refusing adolescents (11-16.5 years). Sixty-two participants were randomly allocated to CBT alone, CBT + fluoxetine or CBT + placebo. All treatments were well tolerated; with one suicide-attempt in the CBT + placebo group. All groups improved significantly on primary (school attendance) and secondary outcome measures (anxiety, depression, self-efficacy and clinician-rated global functioning); with gains largely maintained at 6-months and 1-year. Few participants were anxiety disorder free after acute treatment. During the follow-up period anxiety and depressive disorders continued to decline whilst school attendance remained stable, at around 54 %. The only significant between-group difference was greater adolescent-reported treatment satisfaction in the CBT + fluoxetine group than the CBT alone group. These results indicate the chronicity of school refusal, and the need for future research into how to best improve school attendance rates.

Neuropsychological deficits in adolescent unipolar depression.

Although neuropsychological deficits in adult depression are relatively well established, findings in children/adolescents have been inconsistent and thus require further investigation. The current study investigated verbal fluency (VF), cognitive speed, motor speed, and executive functions in adolescents with unipolar depression. Results indicated that adolescents with minor depression showed working memory deficits and poorer VF (letter task). Adolescents with major depression showed working memory deficits and processing speed deficits from the early stages of information processing to the later stages of motor output. Executive function deficits of set-shifting and response inhibition that are well established in adults were not found, but may reflect task differences. Thus, it appears that depression subtype or severity of symptoms may impact on neuropsychological functioning and may in part explain previous inconsistent results.

Driving ability in Parkinson's disease: current status of research.

Guidelines for assessing fitness to drive in individuals with neurodegenerative disorders, such as Parkinson's disease (PD), are subjective. It is therefore timely to review the current status of the literature not only for health professionals who are required to assess fitness to drive, but also for the development of future research directions. This review, in the context of PD, outlines the complex changes in driving behaviours, motor vehicle crash rates, driving simulator and on-road driving ability assessments, the relationship between disease severity, duration, medication dose and driving performance, the relationship between driving and neuropsychological test performance, and the effect of dopaminergic medications on driving. While it provides a current overview of the ongoing research, more comprehensive research is required for the full and proper development of policies and guidelines for assessing fitness to drive in PD.

Children should be seen and heard: self-report of feelings and behaviors in primary-school-age children with ADHD.

OBJECTIVE: The belief that children with externalizing disorders have difficulties with self-awareness raises the question of whether children with externalizing disorders are good informants of their own behavior. METHOD: This study investigates how children with ADHD rate their behaviors compared to children without ADHD on a new rating scale (the Self-Evaluation Scale for Children). RESULTS: Preliminary results indicate that this rating scale has acceptable reliability and validity. Furthermore, children with ADHD are found to provide useful information about their feelings and behaviors. Compared to children without ADHD, children with ADHD report more disorganized, disruptive, and impulsive behaviors; poorer self-perception; and poorer social and communication skills. They do not report any less interest in school activities nor more anxiety than the children without ADHD. CONCLUSION: These findings suggest that children with ADHD are more self-aware than previously thought, and this information should inform our clinical and research practice.

A comparison of cognitive-behavioral therapy, sertraline, and their combination for adolescent depression.

OBJECTIVE: To evaluate cognitive-behavioral therapy, antidepressant medication alone, and combined CBT and antidepressant medication in the treatment of depressive disorders in adolescents. METHOD: Seventy-three adolescents (ages 12-18 years) with a primary diagnosis of DSM-IV major depressive disorder, dysthymic disorder, or depressive disorder not otherwise specified were randomly allocated to one of three treatments. Treatment outcome measures were administered before and after acute treatment, and at a 6-month follow-up. Depression diagnosis was the primary outcome measure; secondary measures were self- and other report and clinician rating of global functioning. The trial was conducted at three community-based clinics between July 2000 and December 2002. Data analyses used an intent-to-treat strategy. RESULTS: Following acute treatment, all treatment groups demonstrated statistically significant improvement on outcome measures (depressive diagnosis, Reynolds Adolescent Depression Scale, Revised Children's Manifest Anxiety Scale, Suicidal Ideation Questionnaire), and improvement was maintained at follow-up. Combined cognitive-behavioral therapy and antidepressant medication was not found to be superior to either treatment alone. Compared with antidepressant medication alone, participants receiving cognitive-behavioral therapy alone demonstrated a superior acute treatment response (odds ratio = 6.86; 95% confidence interval 1.12-41.82). Although cognitive-behavioral therapy was found to be superior to antidepressant medication alone for the acute treatment of mild to moderate depression among youth, this may have stemmed from the relatively low dose of sertraline used. CONCLUSIONS: All treatments led to a reduction in depression, but the advantages of a combined approach were not evident.

The Self-Efficacy Questionnaire for Depression in Adolescents (SEQ-DA). Development and psychometric evaluation.

The 12-item clinician or self-administered Self-Efficacy Questionnaire for Depression in Adolescents (SEQ-DA) was developed as a measure of perceived ability to cope with depressive symptomatology. This study examined the reliability and validity of the SEQ-DA in a clinical population of 130 adolescents that were receiving treatment for depression. Psychometric evaluation revealed good internal consistency and test-retest reliability. Results indicated that higher SEQ-DA scores were associated with lower self-rated depression scores (Reynolds Adolescent Depression Scale), which is evidence of good construct validity. Further, higher SEQ-DA scores prior to treatment predicted better outcome at the end of the 3 months of treatment and at 6 months post-treatment. Therefore, the SEQ-DA has a potentially useful role in clinical work and research with depressed young people.

Motor preparation, motor execution, attention, and executive functions in attention deficit/hyperactivity disorder (ADHD).

Attention and executive functions were investigated in medicated and unmedicated children with ADHD combined type using a novel selective reaching task. This task involved responding as rapidly as possible to a target while at times having to ignore a distractor. Results indicated that unmedicated children with ADHD showed slow and inaccurate responding. Slow responding reflected problems at the stage of movement preparation but not movement execution. An attentional impairment, rather than a motor planning problem per se, appeared to underlie the slow movement preparation. Inaccurate responding reflected problems with response inhibition and selective attention, impulsivity, set-shifting, and difficulties in maintaining vigilance. Although medicated children with ADHD did not show slow movement preparation, they did show some response inaccuracy, resulting especially from impulsive responding. These findings suggest that ADHD is characterized by slow motor preparation (but not motor execution), and deficits in selective attention, vigilance, and executive functions. Preliminary results suggest that stimulant medication may resolve some of these motor, attentional and executive function deficits.

Bimanual coordination deficits in attention deficit/hyperactivity disorder (ADHD).

Although motor difficulties have been implicated in ADHD, studies investigating bimanual coordination have been few and their results inconsistent. This study examined the performance of 12 boys with ADHD combined type and their matched controls on a simple in-phase bimanual movement task (requiring symmetrical hand movements) and a complex out-of-phase bimanual movement task (requiring asymmetrical hand movements), at different designated speeds (1 and 2 Hz). Compared to controls, ADHD children were significantly more variable in both velocity and coordination, and less accurate in coordination, with the in-phase movements. For out-of-phase movements, the ADHD children were significantly more variable in velocity and coordination. These findings suggest a problem of bimanual coordination in the syndrome.

Examining the development of attention and executive functions in children with a novel paradigm.

The development of attention and executive functions in normal children (7-12 years) was investigated using a novel selective reaching task, which involved reaching as rapidly as possible towards a target, while at times having to ignore a distractor. The information processing paradigm allowed the measurement of various distinct dimensions of behaviour within a single task. The largest improvements in vigilance, set-shifting, response inhibition, selective attention, and impulsive responding were observed to occur between the ages of 8 and 10, with a plateau in performance between 10 and 12 years of age. These findings, consistent with a step-wise model of development, coincide with the observed developmental spurt in frontal brain functions between 7 and 10 years of age, and indicate that attention and executive functions develop in parallel. This task appears to be a useful research tool in the assessment of attention and executive functions, within a single task. Thus it may have a role in determining which cognitive functions are most affected in different childhood disorders.

Perceptual asymmetries in normal children and children with attention deficit/hyperactivity disorder.

Perceptual asymmetries in normal right-handed children (7-12 years of age) and children with attention deficit/hyperactivity disorder (ADHD), combined type, were investigated using various chimeric stimuli in free-viewing conditions. In the face-matching task, participants indicated which of two symmetrical face chimeras more closely resembled the original; in the chimeric faces task, participants indicated which of a pair of faces appeared happier; and in the grey scales task participants indicated which of two shaded rectangles appeared to be darker overall. Leftward biases were found for normal children with no effects of age. Contrary to expectations, normal leftward biases were also found for ADHD children in the face-matching and the chimeric faces tasks; however, a significant leftward bias was not observed in the grey scales task. The absence of anomalous perceptual bias in ADHD children on these purely perceptual tasks, suggests that anomalous perceptual asymmetries observed in other tasks (line bisection and cancellation tasks) may have been confounded by the motor response, and/or the explicit spatial components of those tasks.