Qualitative study of the views of people living with cardiovascular disease, and healthcare professionals, towards the use of a digital platform to support cardiovascular disease self-management.

OBJECTIVES: This paper focuses on formative research as part of a broader study to develop and evaluate an innovative digital health platform for the self-management of cardiovascular disease (CVD). The primary objective is to better understand the perceptions of key stakeholders towards the proposed platform (Salvio) and to identify the development considerations they may prioritise based on their own experiences of CVD management. DESIGN: A qualitative research study using thematic analysis to explore patterns and themes within the various participant contributions. SETTING: Triangulation of data collection methods were used to generate data, including focus group discussions, semistructured interviews and guided conversations. PARTICIPANTS: Participants (n=26) were people with a diagnosis of CVD (n=18) and relevant healthcare professionals (n=8). RESULTS: Findings indicate that the proposed platform would be a beneficial solution for certain groups whose health behaviour change is not currently supported by discrete solutions. Both participant groups perceive the digital health platform more trustworthy than accessing multiple interventions through unsupported digital repositories. Healthcare professionals agreed that they would endorse an evidence-based platform that had been rigorously developed and evaluated. CVD participants prioritised a decision support tool to guide them through the platform, as they perceive an unstructured approach as overly complex. Both participant groups perceived data sharing with certain self-selected individuals (eg, spouse) to be a useful method for gaining support with their health behaviour change. CONCLUSIONS: A digital health platform offering a variety of existing, evidence-based interventions would provide users with suitable self-management solution(s) based on their own individual needs and preferences. Salvio could be enhanced by providing adequate support to platform users, guiding the diverse CVD population through a host of digital solutions, ensuring that Salvio is endorsed by trusted healthcare professionals and maintaining connections with usual care. Such a platform would augment existing self-management and secondary prevention services.

Toward a Digital Platform for the Self-Management of Noncommunicable Disease: Systematic Review of Platform-Like Interventions.

BACKGROUND: Digital interventions are effective for health behavior change, as they enable the self-management of chronic, noncommunicable diseases (NCDs). However, they often fail to facilitate the specific or current needs and preferences of the individual. A proposed alternative is a digital platform that hosts a suite of discrete, already existing digital health interventions. A platform architecture would allow users to explore a range of evidence-based solutions over time to optimize their self-management and health behavior change. OBJECTIVE: This review aims to identify digital platform-like interventions and examine their potential for supporting self-management of NCDs and health behavior change. METHODS: A literature search was conducted in January 2020 using EBSCOhost, PubMed, Scopus, and EMBASE. No digital platforms were identified, so criteria were broadened to include digital platform-like interventions. Eligible platform-like interventions offered a suite of discrete, evidence-based health behavior change features to optimize self-management of NCDs in an adult population and provided digitally supported guidance for the user toward the features best suited to their needs and preferences. Data collected on interventions were guided by the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) checklist, including evaluation data on effectiveness and process outcomes. The quality of the included literature was assessed using the Mixed Methods Appraisal Tool. RESULTS: A total of 7 studies were included for review. Targeted NCDs included cardiovascular diseases (CVD; n=3), diabetes (n=3), and chronic obstructive pulmonary disease (n=1). The mean adherence (based on the number of follow-up responders) was 69% (SD 20%). Of the 7 studies, 4 with the highest adherence rates (80%) were also guided by behavior change theories and took an iterative, user-centered approach to development, optimizing intervention relevance. All 7 interventions presented algorithm-supported user guidance tools, including electronic decision support, smart features that interact with patterns of use, and behavior change stage-matching tools. Of the 7 studies, 6 assessed changes in behavior. Significant effects in moderate-to-vigorous physical activity were reported, but for no other specific health behaviors. However, positive behavior change was observed in studies that focused on comprehensive behavior change measures, such as self-care and self-management, each of which addresses several key lifestyle risk factors (eg, medication adherence). No significant difference was found for psychosocial outcomes (eg, quality of life). Significant changes in clinical outcomes were predominately related to disease-specific, multifaceted measures such as clinical disease control and cardiovascular risk score. CONCLUSIONS: Iterative, user-centered development of digital platform structures could optimize user engagement with self-management support through existing, evidence-based digital interventions. Offering a palette of interventions with an appropriate degree of guidance has the potential to facilitate disease-specific health behavior change and effective self-management among a myriad of users, conditions, or stages of care.

The influence of fatigue on decision-making in athletes: a systematic review.

A potential challenge associated with sports is that athletes must often perform the cognitive processing associated with decision-making (i.e., movement selection) when fatigued. The purpose of this systematic review was to summarise studies that have analysed the extent to which fatigue influences the effects of decision-making on lower extremity mechanics during execution of common sports manoeuvres. We specifically focused on mechanics associated with ACL injury risk. Reviewers searched the PubMed, SPORTDiscus, CINAHL and Web of Science databases. The search identified 183 unique articles. Five of these articles met our eligibility criteria. Two of the studies incorporated fatigue protocols where athletes progressed to exhaustion and found that the effects of decision-making on mechanics were more pronounced with fatigue. The nature of the results appears to indicate that fatigue may compromise an athlete's cognitive processing in a manner that diminishes their ability to control movement when rapid decision-making is required. However, three subsequent studies utilised fatigue protocols designed to mimic sports participation and found that fatigue did not influence the effects of decision-making on mechanics. In general, these findings appear to indicate that fatigue may only affect the cognitive processing associated with decision-making when athletes approach a state of exhaustion.

mHealth Interventions for Exercise and Risk Factor Modification in Cardiovascular Disease.

Exercise and lifestyle risk factor management are critical for the secondary prevention of cardiovascular disease but are poorly adhered to. Mobile health interventions could enhance engagement; however, a one-size intervention approach cannot meet the needs of all people. We hypothesize a unifying digital platform that enables choice from a suite of evidence-based programs will enhance access, delivery, and engagement.

Brain imaging in the differential diagnosis of young-onset dementias.

Young-onset dementia is a broad category of diseases that affect adults before the age of 65, with devastating effects on individuals and families. Neuroimaging plays a clear and ever-expanding role in the workup of these diseases. MRI demonstrates classic patterns of atrophy that help to confirm the clinical diagnosis and may predict the underlying disease. Functional nuclear imaging, such as PET, demonstrates areas of brain dysfunction even in the absence of visible atrophy. These techniques can inform important aspects of the care of young-onset dementia, such as the underlying pathologic condition, treatment, and prognosis.

Test-retest reliability of a new questionnaire for the retrospective assessment of long-term lithium use in bipolar disorder.

BACKGROUND: The identification of predictors of treatment response holds tremendous potential for the improvement of clinical outcomes in bipolar disorder (BP). The goal of this project is to evaluate the test-retest reliability of a new clinical tool, the Lithium Questionnaire (LQ), for the retrospective assessment of long-term lithium use in research participants with BP. METHODS: Twenty-nine individuals with BP-I (n=27), major depression (n=1), or schizoaffective disorder (n=1) were recruited for participation. The LQ was administered to all participants at two time-points, spaced 17 months apart on average, and used to determine each subject׳s score on the Retrospective Criteria of Long-Term Treatment Response in Research Subjects with Bipolar Disorder Scale, or the Alda Scale. Scores were confirmed through a best-estimate procedure, and test-retest reliability (intra-class correlation coefficient [ICC]) of the LQ was calculated. RESULTS: The correlation between the total Alda Scale scores at the two time-points was in the moderate range (ICC=0.60). Relevant clinical factors such as age or presence of Axis I psychiatric comorbidity did not influence the reliability. LIMITATIONS: The validity of the LQ was not examined. Inclusion of two participants with non-BP diagnoses may have affected the LQ׳s reliability, but re-analysis of our data after exclusion of these participants did not influence the reliability. The absence of measures of mood and cognition at time of LQ may be a limitation of this work. CONCLUSIONS: The LQ holds promise for the standardization of the retrospective assessment of long-term treatment in BP.

Pattern separation of emotional information in hippocampal dentate and CA3.

Emotional arousal, mediated by the amygdala, is known to modulate episodic memories stored by the hippocampus, a region involved in pattern separation (the process by which similar representations are independently stored). While emotional modulation and pattern separation have been examined independently, this study attempts to link the two areas of research to propose an alternative account for how emotion modulates episodic memory. We used an emotional discrimination task designed to tax pattern separation of emotional information by concurrently varying emotional valence and similarity of stimuli. To examine emotional modulation of memory at the level of hippocampal subfields, we used high-resolution fMRI (1.5 mm isotropic) of the medial temporal lobe. Consistent with prior reports, we observed engagement of the hippocampal dentate gyrus (DG) and CA3 during accurate discrimination of highly similar items (behavioral correlate of pattern separation). Furthermore, we observed an emotional modulation of this signal (negative > neutral) specific to trials on which participants accurately discriminated similar emotional items. The amygdala was also modulated by emotion, regardless of the accuracy of discrimination. Additionally, we found aberrant amygdala-hippocampal network activity in a sample of adults with depressive symptoms. In this sample, amygdala activation was enhanced and DG/CA3 activation was diminished during emotional discrimination compared to those without depressive symptoms. Depressive symptom severity was also negatively correlated with DG/CA3 activity. This study suggests a novel mechanistic account for how emotional information is processed by hippocampal subfields as well as how this network may be altered in mood disorders.

Asymmetric effects of emotion on mnemonic interference.

Emotional experiences can strengthen memories so that they can be used to guide future behavior. Emotional arousal, mediated by the amygdala, is thought to modulate storage by the hippocampus, which may encode unique episodic memories via pattern separation--the process by which similar memories are stored using non-overlapping representations. While prior work has examined mnemonic interference due to similarity and emotional modulation of memory independently, examining the mechanisms by which emotion influences mnemonic interference has not been previously accomplished in humans. To this end, we developed an emotional memory task where emotional content and stimulus similarity were varied to examine the effect of emotion on fine mnemonic discrimination (a putative behavioral correlate of hippocampal pattern separation). When tested immediately after encoding, discrimination was reduced for similar emotional items compared to similar neutral items, consistent with a reduced bias towards pattern separation. After 24h, recognition of emotional target items was preserved compared to neutral items, whereas similar emotional item discrimination was further diminished. This suggests a potential mechanism for the emotional modulation of memory with a selective remembering of gist, as well as a selective forgetting of detail, indicating an emotion-induced reduction in pattern separation. This can potentially increase the effective signal-to-noise ratio in any given situation to promote survival. Furthermore, we found that individuals with depressive symptoms hyper-discriminate negative items, which correlated with their symptom severity. This suggests that utilizing mnemonic discrimination paradigms allows us to tease apart the nuances of disorders with aberrant emotional mnemonic processing.

Diffusion tensor imaging of neuropsychiatric symptoms in mild cognitive impairment and Alzheimer's dementia.

Neuropsychiatric symptoms (NPS) occur frequently in mild cognitive impairment (MCI) and Alzheimer's dementia (AD). The authors examined the relationship between NPS and white-matter integrity in these conditions. Twenty-two individuals with MCI and 23 with mild AD underwent clinical assessments including the Neuropsychiatric Inventory Questionnaire and 3.0-tesla magnetic resonance scans. Fractional anisotropy (FA) was measured in the following manually-drawn regions of interest (ROI): fornix, cingulum bundle, splenium, and cerebral peduncles (control region). The probability of having NPS by tertile of ROI FA was assessed by logistic regression. Because associations were similar within MCI and AD groups, the two groups were combined. Compared with those in the highest tertile, participants within the lowest anterior cingulum (AC) FA tertile were more likely to exhibit irritability, agitation, dysphoria, apathy, and nighttime behavioral disturbances. After adjusting for Mini-Mental State Exam status, participants in the lowest versus highest tertile of AC FA were more likely to report irritability. Using DTI, low AC FA was associated with increased odds of irritability in mild AD and MCI participants. Further imaging studies are necessary to elucidate the role of the AC in the pathophysiology of neuropsychiatric symptoms in AD and MCI.

Total white matter hyperintensity volume in bipolar disorder patients and their healthy relatives.

OBJECTIVES: White matter hyperintensities (WMH) are more common in subjects with bipolar disorder (BP) than in healthy subjects (HS). Few studies have examined the effect of the diagnostic type of bipolar illness on WMH burden, and none have approached this question through a direct measurement of the volume of affected white matter in relationship to familiality. In this pilot study, we utilized a volumetric measurement of WMH to investigate the relationship between the total volume of WMH and the familiality and type of BP. METHODS: Forty-five individuals with bipolar I disorder (BP-I) with psychotic features, BP-I without psychotic features, or bipolar II disorder (BP-II), seven of their unaffected relatives, and 32 HS were recruited for participation. T-2 weighted magnetic resonance imaging scans were obtained on all subjects, and the total volume of all WMH for each subject was measured in cubic centimeters. The significance of difference between groups was tested using ANOVA with post-hoc adjustment for multiple comparisons. Further, we used logistic regression to test for trends between symptom load and total WMH volume. RESULTS: The mean total volume of WMH in BP-I patients with psychotic features was significantly higher (p < 0.05) than that of HS. Further, we observed a positive linear trend by familiality and type of affectedness when comparing mean total WMH volume of HS, unaffected family members, subjects with BP-II, and BP-I with and without a history of psychosis (p < 0.05). CONCLUSIONS: Based on a quantitative technique, WMH burden appears to be associated with familiality and type of BP. The significance of these findings remains to be fully elucidated.

Fornix integrity and hippocampal volume predict memory decline and progression to Alzheimer's disease.

BACKGROUND: The fornix is the predominant outflow tract of the hippocampus, a brain region known to be affected early in the course of Alzheimer's disease (AD). The aims of the present study were to: (1) examine the cross-sectional relationship between fornix diffusion tensor imaging (DTI) measurements (fractional anisotropy [FA], mean diffusivity [MD], axial diffusivity, and radial diffusivity), hippocampal volume, and memory performance, and (2) compare fornix DTI measures with hippocampal volumes as predictors of progression and transition from amnestic mild cognitive impairment to AD dementia. METHODS: Twenty-three mild cognitive impairment participants for whom hippocampal volumetry and DTI were conducted at baseline received detailed evaluations at baseline; 3, 6, and 12 months; and 2.5 years. Six participants converted to AD over the follow-up period. Fornix and posterior cingulum DTI measurements and hippocampal volumes were ascertained using manual measures. Random effects models assessed each of the neuroimaging measures as predictors of decline on the Mini-Mental State Examination, Clinical Dementia Rating-sum of boxes, and memory z scores; receiver operating characteristic analyses examined the predictive value for conversion to AD. RESULTS: There was a significant correlation between fornix FA and hippocampal volumes. However, only the fornix measurements (FA, MD, radial diffusivity, and axial diffusivity) were cross-sectionally correlated with memory z scores. Both fornix FA and hippocampal volumes were predictive of memory decline. Individually, fornix FA and MD and hippocampal volumes were very good predictors of progression, with likelihood ratios >83, and better than 90% accuracy. CONCLUSION: Fornix FA both cross-sectionally correlated with and longitudinally predicted memory decline and progression to AD. Manually drawn region of interest within the fornix shows promise comparable with hippocampal volume as a predictive biomarker of progression, and this finding warrants replication in a larger study.

Predictors of lithium response in bipolar disorder.

While lithium is generally regarded as the first-line agent for patients with bipolar disorder, it does not work for everyone, which raises the question: can we predict who will be most likely to respond? In this paper, we review the most compelling clinical, biologic, and genetic predictors of lithium response in bipolar disorder. Among clinical factors, the strongest predictors of good response are fewer hospitalizations preceding treatment, an episodic course characterized by an illness pattern of mania followed by depression, and a later age at onset of bipolar disorder. While several biologic predictors have been studied, the results are preliminary and require replication with studies of larger patient samples over longer observation periods. Neuroimaging is a particularly promising method given that it might concurrently illuminate pathophysiologic underpinnings of bipolar disorder, the mechanism of action of lithium, and potential predictors of lithium response. The first genome-wide association study of lithium response was recently completed. No definitive results emerged, perhaps because the study was underpowered. With major new initiatives in progress aiming to identify genes and genetic variations associated with lithium response, there is much reason to be hopeful that clinically useful information might be generated within the next several years. This could ultimately translate into tests that could guide the choice of mood-stabilizing medication for patients. In addition, it might facilitate pharmacologic research aimed at developing newer, more effective medications that might act more quickly and yield fewer side effects.

The association between activity participation and time to discharge in the assisted living setting.

OBJECTIVES: Given recent evidence that activity participation may reduce functional decline, the effect of activity on resident ability to remain in assisted living (AL) is of interest. This study examines the relationship between participation in activities and the length of time residents remain in AL. METHODS: The data reported here were gathered in the initial phase of the Maryland Assisted Living Study (MDAL), an epidemiologic study of psychiatric disorders in AL. A stratified, random sample of 198 residents of 22 AL facilities in central Maryland was evaluated using a number of cognitive, behavioral, general health, and functional assessments. The total amount of time each resident spent in group and solitary activity in the prior month was quantified. The dependent variable, time to discharge (TTD), was the number of days between the date of initial assessment by the study team and the date of death in AL, discharge, or administrative censoring. RESULTS: Greater levels of activity participation at baseline are associated with longer TTD in an univariate Cox proportional hazards model. After adjustment for global cognitive functioning, general medical health, and mobility, greater activity participation remained associated with longer TTD in AL (p=0.017). CONCLUSIONS: Higher levels of activity are associated with longer retention in the AL setting. This effect appeared to be independent of other potentially confounding factors such as general health, cognitive impairment, and mobility. This finding is consistent with the hypothesis that engagement in activities delays functional decline, but further longitudinal research is needed to understand this finding.