Background: The recent hype in yoga practice is concomitant with the fact that it helps the practitioner to achieve radiant health and serene mind. The science of yoga has also become a powerful stream of knowledge. It has increased the number of scientific studies on different yogic interventions, but has also been performed to evaluate its effects on brain wave activity, particularly in neural oscillations. Objectives: In this systematic analysis, we reviewed studies investigating the effect of integrated yoga, meditation, and pranayama on brain wave activity that affects overall cognitive functions. Methods: Broad search strategy was practiced using several online databases: PubMed, Google Scholar, Web of Science, Embase, Medline, PsycINFO, Europe PMC, Scopus, and IndMED. Studies were included in integrated yoga, meditation, and pranayama with brain wave activity, and the entire relevant articles were critically analyzed according to the nature of this study. Results: Several studies examined yogic interventions for restoring brain functions, nerve diseases, and cognitive impairment and suggested that integrated yoga, meditation, and pranayama practices improve verbal skills, reaction time, hand–eye coordination, speed accuracy, and neural activity. Yogic intervention increases overall brain wave (delta, theta, alpha, beta, and gamma) activity, which increases overall cognitive functions with greater perceived cognition, working memory, attention, better switching ability, focusing ability, positive mind, and perception. It has also been reported that yogic intervention activates dormant areas of brain while downgrading memories not of interest and upgrading useful ones.Conclusions: There is emerging evidence from randomized controlled trials to support yoga practice, which significantly improves brain wave activity resulting in better cognitive functions.

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Purpose: Many childhood cancer survivors are not engaging in sufficient physical activity despite high chronic disease incidence. We assessed satisfaction and acceptability of attending an exercise physiology consultation. Methods: An 8–18-year-old cancer survivor >1-year posttherapy were assessed by an exercise physiologist (T₀). We assessed parents' and survivors' satisfaction and acceptability with the consultation and information received 1-month later (T₁). Parents and survivors were asked whether they would see an exercise physiologist again and whether other survivors should be assessed. Results: We recruited 102 participants, with 70 unique families retained. Parents were more satisfied with information received about exercise from T₀to T₁ (43.4 ± 33.2 vs. 81.5 ± 17.6/100,P < 0.001). Parents reported high satisfaction from the consultation (94.7 ± 10.2/100). Most parents (96.6%) and survivors (95.9%) recommended other survivors see an exercise physiologist. Some parents (37.0%) wanted their child to be more active, while 47.8% of survivors wanted to be more active. Conclusions: There was support for an exercise physiology consultation from parents and survivors. Guidance from an exercise physiologist may be important to alter lifestyle behaviors, which can be potentially beneficial to cardiovascular and psychological well-being.

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The association of cardiovascular disease (CVD) and psychosocial stress (PSS) is a bidirectional function, whereby the two conditions create a self-reinforcing feedback loop. Either can incite and/or magnify the other, prognosis consequently deteriorates and spontaneous remission is unlikely. Several studies show that even subclinical PSS increases mortality. Recent evidence suggests that stress exhibits a strong dose–response toxicity on cardiovascular health with increased levels of PSS directly correlating to additional morbidity and mortality. As such, it will be important that future research considers PSS as a continuous variable capable of causing a spectrum of disease. This article proposes targeted exercise routines as the most efficient therapy for both arms of the feedback loop. A consistent body of data indicates that regular physical activity eases the PSS burden while simultaneously lowering CVD risk. Exercise therapy, mindfulness training, and interventions targeting positive psychological well-being stress management are indispensable therapies, particularly for at-risk and already established cardiovascular patients. Indeed, comprehensive cardiac rehabilitation and exercise training programs inclusive of education, lifestyle, and psychological measures in addition to fitness training are a potent multifaceted therapy for improving quality of life and overall prognosis.

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Objectives: Fatigue is a common complaint in the community. The twofold aims of the present study were (a) to estimate the prevalence rate of reported chronic fatigue syndrome-like (CFS-like) complains, and (b) to explore the sex-related differences in it. Methods: A probability non-clinical sample of 3,465 Kuwaiti volunteer undergraduate men (n = 1,745) and women (n = 1,720) was recruited. Their ages ranged between 16 and 43 years. They responded to the Arabic Scale of Chronic Fatigue (ASCF). It has good internal consistency, temporal stability, criterion-related validity, and factorial validity (its loading on a CFS factor = 0.81). Principal component analysis disclosed 2 factors: Mental fatigue and Physical fatigue. The prevalence rate was computed based on 2 criteria, i.e., the percentage of persons which have total scores greater than (a) the M + 1 SD, and (b) greater than the M + 2 SD. Results: Based on criterion (a), prevalence rates were 13.47% for men and 20.98% for women. As to criterion (b), the rates were 2.35% for men and 5.76 % for women. These rates lie in the rage of the international studies on CFS-like complaints (from 1.2% to 30.5%). Women obtained significantly higher mean score and prevalence rates than did their male counterparts. Conclusion: It is highly probable that the participants obtained the higher scores than did their M + 2 SD are in need of therapeutic intervention. It was concluded that psychological scales may be useful in screening disorders to detect the cases.

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Evolocumab is a proprotein convertase subtilisin/kexin type 9 inhibitor drug which has shown great treatment effects in the treatment of uncontrolled hypercholesterolemia, particularly elevated low-density lipoprotein cholesterol levels. Due to its significant costs, several health technology assessment agencies (HTA) worldwide have exercised caution in issuing its recommendation across different patient groups. This study attempts to review the processes and compare the approach adopted by the HTA agencies in England (National Institute for Care and Health Excellence [NICE]), Canada (Canadian Agency for Drugs and Technologies in Health [CADTH] Common Drug Review), and Australia (Pharmaceutical Benefits Advisory Committee [PBAC]) in the evaluation of evolocumab. Between July and August 2018, the websites of CADTH, the NICE in England, and the PBAC of the Pharmaceutical Benefits Scheme in Australia were searched for technology appraisal documents pertaining to evolocumab. The search included the initial appraisal, resubmissions, as well as the final recommendation made between 2015 and 2018. Significant variability exists between the recommendations and clinical and economic assessment processes in the evaluation of evolocumab across the three selected HTAs. More collaborative efforts may be required to align the interagency HTAs.

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Tobacco regulatory science seeks in part to reduce harm of new tobacco products. Part of this interest is to help chronic adult smokers switch to potentially less harmful products, while not facilitating use of these modified risk tobacco products by nonusers (particularly teens). Studies to discern a lack of interest in reduced harm products are conducted on emerging adults as a proxy for teens. The present empirical review explores the topography and etiology of tobacco use among emerging adults compared to teens to discern whether they might be a reasonable proxy for such reduced harm studies. Both teens and emerging adults view combustible and e-cigarette smoking as disapproved of by peers and are likely to process tobacco marketing information similarly. I conclude that while some differences do exist (e.g., emerging adults are in a period of escalating use and dependence, whereas teens are relatively likely to be initiating use), emerging adults may indeed be a reasonable proxy, at least for current reduced harm studies.

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The definition of a psychosocial stressor and reactions to it is discussed in relation to individual and environmental factors. The relation of this model to psychophysiological stress reactions and regeneration, as well as its significance for cardiovascular diseases, is described. Three classes of psychosocial stressors (life changes, work conditions, and family conflicts) are then described in relation to cardiovascular illness and risk factors. Particular emphasis is on longitudinal studies of patients. Heart contractility and urinary adrenaline excretion are discussed in detail. Epidemiological data on psychosocial stressors and cardiovascular disease outcomes (mainly myocardial infarction) are also discussed.

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The present study was conducted to explore the role of Withania somnifera in posttraumatic stress disorder (PTSD) in mice. Swiss albino mice were subjected to a 2-day electric foot-shock stress of 5 min, which included 15 alternating inescapable foot shocks of 0.8 mA intensity with 10-s duration and 10-s intershock interval on the electrified grid floor. It was followed by 3 week re-exposures (on day 3, 7, and 14) in the same context (as situational reminders) for 5 min without delivering any foot-shocks. Trauma and situational reminders results a significant development of behavioral deficits and reduced serum corticosterone levels, as assessed on the 21^st day. A significant development of freezing behavior was also observed in response to situational reminders on 3^rd, 7^th and 14^th days. Repeated administration (for 21 days) of W. somnifera (50 mg/kg and 100 mg/kg) considerably restored the behavioral changes and normalized the corticosterone levels. W. somnifera led to significant reduction in the freezing behavior in response to situational reminders suggesting the inhibition of formation of aversive fear memory. It may be concluded that W. somnifera may be beneficial in preventing the PTSD symptoms in response to a traumatic event.

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Background: Mood disorders have been associated with a variety of cardiovascular disease (CVD) risk factors, including inflammation and large arterial stiffness, particularly while depressed, although longitudinal studies have been limited. Materials and Methods: With measurements at baseline and 8 weeks, the researchers prospectively assessed mood, levels of inflammatory markers (high-sensitivity C-reactive protein and tumor necrosis factor-alpha [TNF-α]), serum lipids, and large arterial stiffness in a cohort of 26 participants with a diagnosis of a mood disorder, enriched for current depression. Depressive symptoms were measured using the Montgomery–Šsberg Depression Rating Scale (MADRS) at baseline and 8 weeks. Associations between depressive symptoms and other measures were assessed using linear mixed models, unadjusted and adjusted for age and body mass index. Results: The mean age of the participants (n = 26) was 41.6 (standard deviation [SD] 12.8) years, and 81% were female. During the study, there was a mean (SD) MADRS score improvement of 9.5 (9.4) from baseline to 8 weeks. Reductions in the primary outcome of tumor necrosis factor-α with improvement in depression fell short of statistical significance (P = 0.076). In secondary analyses, there was a statistically significant association between improved cholesterol ratio (P = 0.038) and triglycerides (P = 0.042) with improvement in depression. There was no statistically significant change in large arterial stiffness during the study. Conclusion: Improved depressive symptoms were associated with improved cholesterol ratios even after adjustment, suggesting a possible mechanism by which acute mood states may influence CVD risk. Future longitudinal studies with extended and intensive follow-up investigating CVD risk related to acute changes and persistence of mood symptoms are warranted.

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There is rapidly accumulating literature regarding the hypercoagulable state associated with patients diagnosed with COVID-19 infection. Pulmonary, cardiac, and visceral involvement has been described. We describe a middle-aged male, with a background of diabetes and hypertension, diagnosed with severe COVID-19, who passed away despite maximum support. He had concomitant aortic and pulmonary thrombus. This is a devastating, poorly understood complication of severe COVID-19, adding to the body of medical literature related to severe COVID-19. COVID-19 is a hypercoagulable disease, and multi-organ involvement should be considered. Aortic imaging during a computed tomography pulmonary angiography can add additional information to the risk stratification and clinical implications in a patient diagnosed with COVID-19, with a suspected hypercoagulable state and possible multi-organ involvement.

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Spontaneous coronary artery dissection (SCAD) is the acute development of a false lumen within the coronary artery wall by the spontaneous formation of an intramural hematoma which may compromise coronary (blood) flow by compression of the true lumen. Psychological factors have been implicated in its pathophysiology, but a synthesis of available data has not been previously undertaken. A literature search was conducted with the terms coronary artery dissection or spontaneous coronary artery dissection AND the terms psychological stress, anxiety, or depression. Initial studies in the field reported that psychological stress, anxiety, or depression was associated with SCAD and that acute stress may have a role in producing the SCAD. Recent studies with control groups of either acute coronary syndromes or acute myocardial infarction have produced discordant results. A meta-analysis of these studies, in this review, using a fixed effects model, showed that there was no significant association between SCAD and either moderate-to-high psychological stress or moderate-to-severe depression. However, one study reported that patients with SCAD were two-fold more likely to have experienced an emotional precipitant in the 24 h prior to the event. Assessment of patients with SCAD found long-term psychological consequences, and in some cases similar to posttraumatic stress disorder. In conclusion, chronic psychological stress, anxiety, or depression is not associated with the development of SCAD, however acute emotional stress may be a factor precipitating SCAD in some patients. Further research is necessary to examine the biological basis for SCAD and how acute stress might play a role in its pathogenesis.

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We review the aspects of obstructive sleep apnea (OSA), which is the most common respiratory disorder of sleep in China. Approximately 176 million people in China have apnea/hypopnea index ≥5/h, ranking first among the ten countries with the highest prevalence rates. Two-thirds of patients do not receive treatment at all or withdraw after only brief treatment in a survey nested in two centers in China. Drowsiness and progressive cognitive impairment related to OSA decrease work performance and add to workplace errors and accidents. Many patients with OSA remain undiagnosed. Untreated OSA increases the risk of developing cardiovascular diseases and metabolic diseases. Undiagnosed and untreated OSA patients place a great burden on healthcare costs and services, and thus enormous economic burdens across most countries across the world, due to the global epidemic of obesity, an important contributor to OSA. Continuous positive airway pressure is the first-line treatment for OSA in China; however, adherence levels are poor. Effective and less labor-intensive methods that improve adherence need to be further investigated. Traditional Chinese medicine and acupuncture are promising treatments but with unproven efficacy.

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We are exposed to noise on a daily basis, and noise pollution is increasingly becoming more intense, especially with more people living in the urban areas. Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide and of global public health concern. Preventing and treating CVDs requires a better understanding of the associated risk factors. There is emerging evidence that noise pollution, especially related to the various forms of transport, is likely a contributor to the pathogenesis and aggravation of CVDs. We review key epidemiological data that address the link between excessive noise exposure and CVDs in humans and present proposed pathophysiological mechanisms underlying this association.

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Importance: Coronavirus disease 2019 is associated with a variety of arrhythmias. However, there are limited data regarding bradyarrhythmias and cardiac pauses in COVID-19. Objective: The objective was to characterize significant cardiac pauses in critically ill COVID-19 patients. Design: This was a case series of 26 consecutive patients with confirmed COVID-19 at an academic medical center in Shreveport, Louisiana. Setting: The study was conducted in the intensive care unit (ICU) and step-down ICU. Participants: Patients were either on mechanical ventilation or high-flow oxygen by nasal cannula. Main Outcomes and Measures: Demographic, clinical, laboratory, and medication data were analyzed. Continuous telemetry monitoring was utilized to record number, type, and duration of bradyarrhythmic events as well as their risk determinants. Results: The median age of the 26 patients was 49.5 years (range 33–78). Fifteen (57.7%) were men. Incidence of significant bradycardia and cardiac pauses, defined as an event, occurred in 11 (42.3%) patients. The median age of patients with an event was 57 years (range 33–66) and 5 (45.5%) were men. The average pause duration was 6.77 s with a range of 1.6–30 s. Five of 11 (45.5%) patients had high-grade atrioventricular (AV) nodal block. One patient required temporary pacemaker insertion for complete heart block and recurrent asystole arrests. A trend toward higher troponin I level in bradyarrhythmia patients was noted (mean troponin I was 2.72 ng/mL, [standard deviation] 4.48) compared to patients without event(s) (mean 0.42 ng/mL 0.52, P = 0.07). Conclusions and Relevance: Significant bradycardic events in critically ill patients with COVID-19 occurred in 42.3% of patients. This is the first case series of such events in COVID-19 patients. Increased awareness of these findings could affect management techniques and call for enhanced monitoring of such patients.

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Our appreciation and understanding of the interrelationships between disrupted metabolic function and depression have increased significantly over the last few decades. This review focuses still more specifically on the intersections between cardiovascular disease (CVD) and major depressive disorder (MDD). General pathophysiological mechanisms implicated in both diseases include inflammation, cytokine and hypothalamic–pituitary–adrenal axis dysregulation, oxidative stress, neurotransmitter disruptions, neuroplasticity, and the microbiome. Here, we explore these mechanistic overlaps of depression and CVD, including some discussion of related and frequently comorbid disorders, such as obesity and diabetes, and the closely related “metabolic syndrome.” Finally, we discuss integrated therapeutic strategies for treating MDD comorbid with CVD.

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Background: Within the field of cardiology, telehealth has been advocated by many as important benefits have been demonstrated regarding disease management and survival. Both patient- and physician-related barriers have hampered the uptake of telehealth in the clinical practice. The COVID-19 pandemic has pushed the upscaling of telehealth modalities. Objective: The current study will examine patients' preferences, needs, and recommendations regarding the use of telehealth at the cardiology outpatient clinic during the pandemic. Methods: Semi-structured focus groups were organized covering two themes: (1) patients' experiences with telehealth and (2) patients' needs and recommendations regarding the use of telehealth. Focus groups were held online using Microsoft Teams, and audio recordings were made. After transcribing the recordings, thematic analysis was applied to code the answers that were given. Results: A total of n = 19 patients were recruited; the mean age was 62.4 (7.7) and 10 (52.6%) were female. The majority of the patients (15/19) indicated to be positive regarding telehealth use mainly due to its time-saving character. Four patients were negative toward telehealth as they did not receive appropriate care in their perception due to telehealth use. Patients recommend using blended care where teleconsultation, and face-to-face appointments are provided in accordance with patients' preferences. Conclusions: This is the first study to examine, in-depth, cardiac patients' experiences, needs, and recommendations regarding telehealth use in the clinical practice. Learning from current experiences with the COVID-19 pandemic where upscaling of telehealth emerged will give us a foundation to further increase the uptake of telehealth in the clinical practice.

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Loneliness has been associated with different health outcomes in the following domains: general health, well-being, physical health, mental health, sleep, and cognitive function. However, the most significant associations fall into mental health- and well-being-related outcomes. Moreover, loneliness is an identified risk factor for all-cause mortality. This article overviews the systematic and meta-analytic studies, which have investigated epidemiology and etiology, associated medical and neuropsychiatric conditions, and interventions for loneliness. Meta-analyses have associated higher levels/prevalence of loneliness with pathological conditions, including physical (cardiovascular diseases, obesity, and cancer) and mental health conditions (dementia, cognitive impairment, depression, anxiety, suicide, substance abuse, frailty, and addiction). Furthermore, loneliness commonly occurs to people during particular physiological conditions, for example, childhood, adulthood, elderly, pregnancy, and taking care of others. Moreover, young adults commonly experience transient loneliness. For all these pathological/physiological conditions, COVID-19 has been confirmed as a loneliness-worsening condition. Genetic background, in addition to environmental factors, plays a role in the etiology of loneliness. Biomarkers mainly include neural correlates, including aberrations in the structure/function of cognitive or emotional control-related brain regions, inflammatory correlates, and anthropometric measures. The current interventions for loneliness alleviation are mostly focused on older people, for whom the evidence derived from systematic or meta-analytic studies shows none-to-moderate benefits and substantial heterogeneity across studies. The evidence is not adequate to conclude about the effectiveness of interventions in youth. In addition to the need for pathology- and population-specific interventions for loneliness reduction/prevention, there is a need to survey loneliness longitudinally to examine the causality of loneliness-health associations.

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Background: Depression is an established predictor of coronary artery disease (CAD) progression and mortality. “Somatic” symptoms of depression such as fatigue and sleep impairment overlap with symptoms of CAD and independently predict CAD events. Differentiating between “somatic” and “cognitive” depressive symptoms in at-risk patients may improve our understanding of the relationship between depression and CAD. Methods: The study utilized data from the Women's Ischemia Syndrome Evaluation. Participants (N = 641; mean age = 58.0 [11.4] years) were enrolled to evaluate chest pain or suspected myocardial ischemia. They completed a battery of symptom and psychological questionnaires (including the Beck Depression Inventory [BDI]) at baseline, along with quantitative coronary angiography and other CAD diagnostic procedures. The BDI provided scores for total depression and for cognitive and somatic depressive symptom subscales. Results: Two hundred and fourteen (33.4%) women met criteria for obstructive CAD. Logistic regression models were used to examine relationships between depression symptoms and obstructive CAD. Neither BDI total scores (odds ratio [OR] =1.02, 95% confidence interval [CI], 0.99–1.05, P = 0.053) nor BDI cognitive scores (OR = 1.02, 95% CI, 1.00–1.04, P = 0.15) predicted CAD status. BDI somatic symptom scores, however, significantly predicted CAD status and remained statistically significant after controlling for age, race, and education (OR = 1.06, 95% CI, 1.01–1.12, P = 0.02). Conclusion: Among women with suspected myocardial ischemia, somatic but not cognitive depressive symptoms predicted an increased risk of obstructive CAD determined by coronary angiography. Consistent with prior reports, these results suggest a focus on somatic rather than cognitive depressive symptoms could offer additional diagnostic information.

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Background: Perceived stress plays an important role in the pathogenesis of cardiovascular diseases (CVDs). Their associations with CVDs in the Chinese population are less investigated. The present study aims to investigate the associations of perceived stress with well-defined CVDs in a population-based survey in Shenzhen, China. Methods: In the community-based survey, we recruited 2,287 participants aged 18 years and over from 8 communities in Shenzhen, China. Perceived stress was assessed using the modified Chinese version of the Perceived Stress Scale with 14 items and a five-point Likert scale. CVDs including coronary heart disease, heart failure, and atrial fibrillation were ascertained from electronic health records and confirmed by family physicians. Potential confounders included age, sex, educational attainment, occupation, smoking, and alcohol-drinking habits. Multivariable logistic regression models were employed to estimate the magnitude of the associations. Results: Overall, the average perceived stress score was 37.2 (standard error: 7.2 and range: 14–70) among the participants. The prevalence of CVDs was 2.7%. After controlling for age, sex, educational attainment, occupation, smoking, and alcohol-drinking habits, a higher perceived stress score was significantly associated with higher risks of CVDs (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.01–1.55). The associations were comparable among men (OR: 1.20, 95% CI: 1.01–1.43) and women (OR: 1.29, 95% CI: 1.02–1.63). We also examined the potential nonlinear relationship using restricted cubic spines and found that the relationship was almost linear. Conclusions: Our analysis showed that higher perceived stress was associated with higher risks of CVDs among adults. Future studies are warranted to clarify the biological mechanisms and shed light on these associations.

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Background: Ischemic heart disease (IHD) risk in women includes biomedical, behavioral, and psychosocial contributors. The purpose of this study was to build upon previous research suggesting that in women, somatic symptoms (SS) of depression may be important to the development of IHD risk factors and major adverse cardiovascular events (MACE). Based on previous findings, we hypothesized that: (1) SS would be associated with robust biomedical predictors of heart disease and functional capacity, while cognitive symptoms (CS) of depression would not, and (2) SS would independently predict adverse health outcomes while CS would not. Methods: We examined the relationships between symptoms of depression (SS/CS), metabolic syndrome (MetS), inflammatory markers (IM), coronary artery disease (CAD) severity, and functional capacity in two independent cohorts of women with suspected IHD. In the Women's Ischemia Syndrome Evaluation (WISE), we also examined these variables as predictors of all-cause mortality (ACM) + MACE over a median 9.3-year follow-up. The WISE sample included 641 women with suspected ischemia with or without obstructive CAD. The WISE-Coronary Vascular Dysfunction (WISE-CVD) sample consisted of 359 women with suspected ischemia and no obstructive CAD. All study measures were collected uniformly at baseline. Depressive symptoms were measured via the Beck Depression Inventory. MetS was assessed according to Adult Treatment Panel III (ATP-III) criteria. Results: In both studies, SS was associated with MetS (Cohen's d = 0.18, 0.26, P < 0.05, respectively), while CS was not. Within WISE, using Cox Proportional Hazard Regression, SS (Hazard ratio [HR] = 1.08, 95% confidence interval [CI] = 1.01–1.15; HR = 1.07, 95% CI = 1.00–1.13) and MetS (HR = 1.89, 95% CI = 1.16–3.08; HR = 1.74, 95% CI=1.07–2.84) were independent predictors of ACM + MACE after controlling for demographics, IM, and CAD severity, while CS was not. Conclusions: In two independent samples of women undergoing coronary angiography due to suspected ischemia, SS but not CS of depression were associated with MetS, and both SS and MetS independently predicted ACM and MACE. These results add to previous studies suggesting that SS of depression may warrant specific attention in women with elevated cardiovascular disease (CVD) risk. Future research evaluating the biobehavioral basis of the relationship between depression, MetS, and CVD is needed.

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Background: Abusive relationships are highly prevalent in our society, but often go unnoticed. Research showed that dating violence continues to escalate in college student populations. Purpose: The purpose of this study is to determine the effectiveness of the video as a chosen method of education in raising the college students' awareness regarding warning signs of an abusive relationship. Design: This study used a descriptive qualitative design. Sample/Data Collection: Five focus groups of college students' participants (freshmen to seniors) were recruited to participate in the “Escalation” workshop. To facilitate discussion, each focus group originally had 15 college students for a total of 75 college students' participants. Five participants dropped of the study the last minute due to conflicting schedules and personal situations. Each focus group lasted for 90 min and consisted of watching a 38 min “Escalation” video that depicts scenarios of abusive relationships and a pre- and a post-qualitative discussion. Results: The results of the study and the identified themes illustrate the broadened perspectives participants gained through participating in the workshop. Insights from participants became less focused on physical abuse and began to include more mental and emotional effects of abuse in their responses. This study showed that most participants were not previously aware of the progression and scope of violent relationships. Discussion/Conclusion: By recognizing the early signs of an abusive relationship, it is more likely for victims and/or peers to intervene in a safe manner rather than continuing to allow an abusive relationship to escalate to its full potential of violence and physical harm.

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Purpose: The Medical Maximizer-Minimizer Scale (MMS) has been validated to predict preferences for health-care service use on hypothetical vignettes in nonclinical cohorts. Using mixed methods, we sought to determine whether it would predict preferences for cardiac stress testing in a cohort of emergency department (ED) patients with low-risk chest pain within the context of the Health Belief Model (HBM). Design: Patients who met the definition for low-risk chest pain and who were eligible to take a cardiac stress test before being discharged from the hospital were recruited to participate. Each participant provided demographic information and completed the MMS-10 paper-and-pencil scale. They then watched a 7-min informational video on an iPad tablet that provided information about the condition of “low-risk chest pain” and the probabilities of results and outcomes following a cardiac stress test. After the video, participants answered a one-question survey on their intention-to-take (ITT) a cardiac stress test or not and were then interviewed about factors that influenced their decision-making. Interviews were interpreted using a HBM lens. Results: Sixty participants were enrolled in the study who were between the ages of 29 and 80 years with a mean age of 53 (± 10.8); 58% were women and 90% were white. The mean MMS score was 4.6 (± 0.8) and ranged from 2.6 to 6.8. Minimizers accounted for 25% (n = 15) of the cohort while maximizers accounted for 75% (n = 45). MMS scores followed a normal distribution and were found to be mildly correlated with ITT scores (r = 0.25; P = 0.051). The mean ITT scores for individuals with MMS scores in the 1^st and 4^th quartiles were 3.9 ± 2.2 and 5.9 ± 1.7, respectively. After watching the informational video, individuals' perceptions related to the: (1) low threat posed by the condition, (2) low utility (low benefits + significant barriers) of taking a cardiac stress test, and (3) high benefits of taking a cardiac stress test were all strongly associated with ITT scores in a directional manner. No direct connection was found between minimizer-maximizer preferences and health beliefs after watching the informational video. This may have been due to sample size and underrepresentation of minimizers in the cohort. Conclusions: MMS and health beliefs predicted preferences for cardiac stress testing in ED patients with low-risk chest pain after viewing an informational video on the topic. However, we did not find direct evidence that the relationship between MMS and decision-making is mediated through the formation of perceptions of threat and utility consistent with the HBM. More research is needed to establish this connection and understand how framing of information in the health-care space may interact with stable personality traits to influence decision-making.

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This article explores the relationship of existential suffering and moral distress by examining life-threatening medical situations and the distress on persons engaged in medical ethics decision-making. The aim and focus are to articulate how existential suffering experienced by the patient and family generates moral distress in the health-care team as they perceive ongoing treatments as futile. Suffering and existential suffering pose a challenge ethically and therapeutically on a number of levels, first in terms of determining what a patient wants to be addressed or what a substitute decision-maker needs to consider in fulfilling the best interests of the patient who is suffering. Second, when there are unrelenting and intolerable sufferings, a difficult medical assessment is sometimes made that any further treatments are “futile,” which leads to conflict with the family and moral distress for the medical team. Moral distress and mental stress have physiological, psychological, social/behavioral, and existential-spiritual dimensions. Existential suffering consists of a constellation of factors, not only severe pain but also the inclusion of harms from the illness, which are irreversible, irremediable, and unrelenting, adding to the total suffering. This article argues that the existential suffering of the patient and family has a special moral status that significantly and legitimately guides decisions at the end of life, and addressing the existential suffering of the patient/family can relieve levels of moral distress for the health-care team.

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