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This study examined the dynamic, real-time associations between partner involvement in diabetes self-care and continuous glucose monitor (CGM) metrics in adults with type 2 diabetes.For 1 week, 63 participants wore Dexcom G4 CGMs and provided momentary reports of partner involvement in diabetes self-care five times per day. Dynamic structural equation models were used to estimate the reciprocal lagged effects of partner involvement on next-hour CGM metrics (and vice versa).Partner involvement predicted improved next-hour glucose control for five of six CGM metrics in analyses adjusted for time-varying covariates. The hour after partner involvement, the model predicted a 26.34 mg/dl decrease in glucose level (standardized β = -0.19), 30% greater odds of meeting target time in target range ( β = 0.07), 48% higher odds of target time below target range (TBR; β = 0.04; the only nonsignificant effect), 47% greater odds of target time above target range (β = 0.11), a 4.20 unit decrease in glucose standard deviation ( β = -0.19), and a 0.01 unit decrease in glucose coefficient of variation ( β = -0.08; all p values.05). There was less consistent support for the reverse pathway, with only two metrics significantly related to next-hour partner involvement: glucose level ( β = 0.15) and TBR ( β = 0.21), such that having higher levels and meeting target TBR were significantly predictive of next-hour partner involvement.This is the first study showing that partner involvement in daily diabetes management predicts short-term glucose control. More research is needed to understand how partners influence glycemic control and evaluate interventions that promote their involvement in diabetes care.

Background Spouses often attempt to influence patients' diabetes self-care. Spousal influence has been linked to beneficial health outcomes in some studies, but to negative outcomes in others. Purpose We aimed to clarify the conditions under which spousal influence impedes glycemic control in patients with type 2 diabetes. Spousal influence was hypothesized to associate with poorer glycemic control among patients with high diabetes distress and low relationship quality. Methods Patients with type 2 diabetes and their spouses (N = 63 couples) completed self-report measures before patients initiated a 7-day period of continuous glucose monitoring. Mean glucose level and coefficient of variation (CV) were regressed on spousal influence, diabetes distress, relationship quality, and their two- and three-way interactions. Results The three-way interaction significantly predicted glucose variability, but not mean level. Results revealed a cross-over interaction between spousal influence and diabetes distress at high (but not low) levels of relationship quality, such that spousal influence was associated with less variability among patients with low distress, but more among those with high distress. Among patients with high distress and low relationship quality, a 1 SD increase in spousal influence predicted a difference roughly equivalent to the difference between the sample mean CV and a CV in the unstable glycemia range. Conclusions This was the first study to examine moderators of the link between spousal influence and glycemic control in diabetes. A large effect was found for glucose variability, but not mean levels. These novel results highlight the importance of intimate relationships in diabetes management.

This study investigated whether loneliness would predict physical and mental health-related quality of life (HRQoL) over 9 months and examined whether medical adherence would mediate their associations in patients with coronary heart disease (CHD). The overall design is a three-wave longitudinal study. A sample of 255 outpatients with CHD was recruited from a community-based cardiac rehabilitation programme. Participants, with a mean age of 63 years, completed measures assessing loneliness, depression and physical and mental HRQoL at baseline. Medical adherence was assessed at 3 months, and physical and mental HRQoL were reassessed at 9 months. A total of 88% of participants reported moderate or high loneliness. Baseline loneliness predicted physical and mental HRQoL at 9 months after adjusting for baseline physical and mental HRQoL, respectively. The effects remained significant when depression was also adjusted. Medical adherence at 3 months partially mediated the associations of baseline loneliness with 9-month physical and mental HRQoL. Findings underline the necessity of assessing loneliness for CHD patients to promote long-term medical adherence and further improve physical and mental HRQoL.

Research on the underlying structure of sleep measures in patients with coronary heart disease (CHD) is lacking. Existing research on sleep and health outcomes primarily focused on only one dimension of sleep (e.g., sleep duration), leaving other aspects unexamined. To address this gap, this study examined the measurement structure of Pittsburgh Sleep Quality Index (PSQI) and its associations with health-related quality of life among CHD patients. Participants were 167 CHD patients from a cardiac wellness program. Confirmatory factor analysis revealed that the two-factor structure with sleep efficiency and perceived sleep quality best fitted the data. Concurrent validity analyses with structural equation modeling showed that, when considered simultaneously, perceived sleep quality, but not sleep efficiency, was significantly associated with emotional, physical, and social quality of life. Findings demonstrated that the PSQI consists of two moderately correlated factors that are differentially associated with separate health domains in cardiac patients.

Although sleep problems are common among patients with coronary heart disease (CHD), there is a lack of prospective research examining its influence on health consequences over time. This study investigated whether poor sleep quality predicted patients' decline in physical health functioning over 6 months and whether social support buffered its detrimental effect. Participants were 185 patients with CHD, who completed measures of sleep, psychosocial characteristics, and physical health functioning at baseline and 6 months. Hierarchical regression analyses were conducted to examine whether global sleep index and its subscales, including sleep efficiency, perceived sleep quality, and daily disturbances (sleep disturbances and daytime dysfunction), predicted the decline of physical health functioning at 6 months. Social support was examined for its moderating effect in buffering the negative influence of poor sleep quality on physical health functioning over 6 months. Findings showed that poorer global sleep index, especially subscales of daily disturbances and lower sleep efficiency, significantly predicted greater decline of physical health functioning at 6 months, even after adjusting for covariates, including baseline functioning and depression. Moreover, social support was found to buffer the detrimental impact of poor sleep quality, especially low sleep efficiency, on 6-month physical health functioning. Findings suggest that improving sleep quality for patients with CHD may be promising to facilitate their long-term health maintenance.

OBJECTIVES Although effective medical treatments have proved to successfully improve prognoses and outcomes of patients with coronary heart disease (CHD), low adherence to treatments is still common among patients. Deleterious impact of psychological distress on medical adherence has been recognized; however, few studies examined the influence of change in psychological distress on attenuation in adherence. This study investigated whether three common manifestations of distress (depression, anxiety, and perceived stress) and their changes predicted decline in medical adherence among CHD patient over 9 months. DESIGN A three-wave longitudinal study. METHODS Participants were 255 CHD patients with a mean age of 63 years. Psychological distress, medication adherence, and specific treatment adherence were assessed at baseline, 3 months, and 9 months. Hierarchical regression analyses were conducted to examine the influences of psychological distress on medical adherence over 9 months. All models were adjusted for baseline medication or specific adherence, demographic, and medical covariates. RESULTS Baseline depression and its changes over time significantly predicted greater decline in both medication adherence (βs = .15-.20, ps

Background Poor adherence to medical regimens is a serious problem that interferes with heart failure (HF) patients’ disease management and contributes to poor clinical outcomes. Few prospective studies have examined the psychosocial predictors of adherence over time in HF patients. Purpose This study examined the influences of depression, self-efficacy, social support, and their changes on self-reported medical adherence over 6 months in HF patients. Methods Participants were 252 HF outpatients, among whom 168 completed follow-up assessments. Hierarchical multiple regression analyses were conducted to examine whether psychosocial variables and their changes prospectively predicted adherence at 6 months, after adjusting for baseline adherence, age, gender, ethnicity, marital status, education, HF severity, medical comorbidity, and mental health treatment. Results Baseline self-efficacy (β = .22, p < .05), increase in self-efficacy (β = .34, p < .001), and decrease in depression (β = –.15, p = .05) predicted improved adherence over 6 months, but social support did not. In the combined model that included all significant psychosocial predictors from previous analyses, baseline self-efficacy (β = .37, p = .001) and its increase (β = .35, p < .001) emerged as independent predictors of improved adherence at 6 months. Conclusions Promoting self-efficacy and reducing depressive symptoms may be promising targets of behavioral interventions to facilitate long-term disease management in HF patients.

Few studies have examined the interplay between psychosocial and physiological variables in prediction of mortality in heart failure (HF) patients. This study investigated the prospective influence of marital status, social support, depression, and C-reactive protein (CRP) on the mortality of patients with chronic HF. In addition, it examined whether there was a mediating relationship between social support and marital status and whether depression and inflammation influenced one another to predict mortality of HF patients. The participants were 220 HF patients, among whom 48 were deceased over an average of 4.60 years. A number of psychosocial and biomedical variables were examined for their associations with mortality and their relationships between each other in hierarchical logistic regression analyses. After adjusting for New York Heart Association (NYHA) class, age, and gender, being unmarried predicted mortality (OR = 2.80, p = 0.004), whereas perceived social support did not. Higher CRP was not associated with depression, and it independently predicted mortality (OR = 1.92, p = 0.030). Depression predicted mortality only in the univariate analysis (OR = 1.02, p = 0.030), but the association was no longer significant either after removing somatic items or after adjusting for covariates. In the combined multivariate model, marital status (OR = 2.20, p = 0.047), CRP (OR = 1.91, p = 0.035), and NYHA class (OR = 2.41, p = 0.001) independently predicted mortality. Monitoring chronic HF patients who are unmarried, with elevated inflammation, or in higher NYHA class may help identify those at greater mortality risk to implement targeted intervention.

An urgent need exists to identify predictive biomarkers to guide management of diabetic foot ulcers (DFUs). The steroid hormone, cortisol, is elevated in chronic inflammatory states and its pathogenic role and/or prognostic role for poor outcomes across a range of diseases has been suggested. However, the role of cortisol in DFUs is not well understood and the significance of local, tissue-specific cortisol regulation in DFUs remains unclear. We performed a multi-center study of 63 well vascularized, superficial neuropathic, non-infected DFU subjects receiving standard care and used wound biopsy obtained at baseline study to quantify expression levels (via immunohistochemistry) of the major cortisol synthesis enzymes CYP11B1 and 11BHSD1, and other inflammatory cytokines. Subjects were predominantly men in their late-fifties (58±10 years) with poor glycemic control (HbA1C 8.9±2.3%); while hemoglobin (12.6±1.8g/dl), creatinine (1.27±0.5mg/dl) and albumin (4.1±0.42g/dl) were within the normal range. We found high cutaneous levels of CYP11B1 strongly linked to failure to heal DFUs at 6 weeks (p≤0.016), while 11BHSD1 did not correlate with healing (p=0.351). In the logistic regression analyses controlling for demographics and disease characteristics, higher levels of CYP11B1 (10-based log-transformed) were predictive of non-healing of DFU at 6 weeks (OR = 6.83, p =.010). High local tissue levels of the pro-inflammatory TNFalpha were also significantly associated with lack of ulcer healing (p≤0.019). This observation is consistent with reports that TNFalpha is essential for local induction of CYP11B1. In turn, local induction of CYP11B1 and subsequent induced tissue cortisol levels activate membranous glucocorticoid receptor triggering PLC/PKC/GSK-3beta/beta-catenin pathway that inhibits healing. Taken together, these data suggest CYP11B1 is a potential predictive biomarker for DFU outcomes, and may serve as a future target for therapeutic interventions. Disclosure L. Vileikyte: None. B. Shen: None. I. Pastar: None. A.J. Boulton: None. R. Kirsner: None. M. Tomic-Canic: None. M. Hardman: None.

Objective Association between endometriosis and ovarian cancer has been well established. Nonetheless, endometriosis may also be associated with endometrial cancer because of shared etiological mechanisms of both estrogen stimulation and chronic inflammation; however, the association between these 2 disorders has rarely been investigated. Methods The National Health Insurance Research Databases in Taiwan were retrieved and analyzed. The case cohort consisted of patients with a diagnosis of endometriosis between January 1997 and December 2000 (N = 15,488). For the construction of control cohort, 8 age- and sex-matched control patients for every patient in the case cohort were selected using a random sampling method (n = 123,904). All subjects were tracked for 10 years from the date of entry to identify whether they had developed endometrial cancer. The Cox proportional hazards regression model was used to evaluate 10-year event occurrence of endometrial cancer. Results During the 10-year follow-up period, 392 participants developed endometrial cancer, with 104 (0.7%) distributed in the case cohort and 288 (0.2%) in the control cohort. Multivariable Cox regression modeling demonstrates a higher risk for developing endometrial cancer in the case cohort than in the control cohort (adjusted hazard ratio [aHR], 2.83; 95% confidence interval [CI], 1.495.35; P Conclusions Patients diagnosed with endometriosis may harbor an increased risk for developing endometrial cancer in their later life. Closer monitoring is advised for this patient population.

Abdominal obesity and chronic stress have independent effects on cardiac autonomic regulation, and may also interact to influence cardiovascular reactivity. In addition to main effects, we hypothesized that abdominal obesity and chronic stress would interact and predict blunted cardiovascular reactivity. One hundred and twenty-two undergraduate students engaged in two stressful laboratory tasks while cardiovascular activity was assessed. Results indicated that higher abdominal obesity significantly predicted blunted systolic blood pressure (SBP) and mean arterial pressure (MAP) change, while chronic stress was not directly associated with any measure of cardiovascular reactivity. Furthermore, there was a significant interaction between abdominal obesity and chronic stress on SBP and MAP change such that among participants with higher chronic stress, higher abdominal obesity was significantly associated with reduced SBP and MAP reactivity. In addition, body-mass index (BMI), a measure of overall obesity, also had both main and interaction effects with chronic stress to predict blunted cardiovascular reactivity. These results suggest that abdominally obese individuals may incur difficulty in mounting appropriately-sized cardiovascular responses during acute stress, particularly when under high levels of chronic stress.

Although hostility and depression have been linked to higher cardiac risk and poor prognosis of patients with coronary heart disease (CHD), there is a lack of research that studies how they may influence the short-term outcomes among patients participating in cardiac rehabilitation (CR). This study aimed to investigate the influence of hostility and depression on patients’ exercise tolerance and improvement trajectory in a CR program over 6 weeks. Participants were 142 patients with CHD, with a mean age of 62 years. Latent growth curve modeling was conducted to determine whether hostility and depression predicted patients’ baseline exercise tolerance and rates of improvement on treadmill, while controlling for age and severity of illness. In addition, analysis was conducted to examine whether depression mediated the influence of hostility on exercise outcomes. Patients with CHD with higher hostility scores had a lower baseline exercise tolerance and slower rates of improvement over 6 weeks. Depressive symptom severity mediated the influence of hostility on exercise baseline and improvement. Patients with higher hostility were more likely to have more severe depressive symptoms, which in turn were associated with lower baseline exercise tolerance and slower improvement. While both hostility and depression predicted the exercise outcomes in CR, depression explained the influence of hostility. The findings underscore the importance of addressing psychosocial issues in treatment of CHD patients and provide support for psychosocial interventions in CR to facilitate patients’ recovery.

Nonadherence to treatment recommendations is a leading preventable cause of rehospitalization and premature mortality in chronic heart failure (HF) patients. This study examined whether self-efficacy mediates the contributions of social support and depression to treatment adherence. A sample of 252 HF outpatients with a mean age of 54 years completed self-report questionnaires assessing depression, perceived social support, self-efficacy, and treatment adherence. Self-efficacy mediated the associations of social support and depression with treatment adherence after adjusting for demographic (age, gender, marital status, education, and ethnicity) and medical (New York Heart Association Classification and comorbidity) covariates. Self-efficacy explains the influence of social support and depression on treatment adherence and may be a key target for interventions to improve disease management and self-care behaviors in HF patients.

Medication non-adherence is common and a primary reason for poor medical outcomes among individuals with heart failure (HF). This study's aims were to determine whether depression, hostility, and the personality-based Millon Behavioral Medicine Diagnostic (MBMD) Medication Abuse scale were associated with medication adherence (e.g., beta-blockers, ACE inhibitors, diuretics, statins) beyond contributions of demographic, medical, and psychosocial variables in an ethnically-diverse sample of 105 men and women diagnosed with HF. In hierarchical regression, greater MBMD Medication Abuse scale scores were associated with poorer adherence above and beyond both depression (β = .236, t[102] = 2.113, p = .037) and hostility (β = .244, t[102] = 2.506, p = .014). The Medication Abuse scale also completely mediated the relationship between adherence and depression. These findings suggest that personality measures such as the MBMD and hostility scales might be utilized in future studies investigating predictors of adherence and also used clinically to predict medication adherence among HF patients.

Rationale Tobacco use for many people is compulsive in nature. Compelling theories of how smoking becomes compulsive exist but are largely based on extrapolation from neuroscience findings. Research on smokers is impeded, in part, by a lack of instruments that specifically measure compulsive smoking. Objective This study evaluated the measurement structure and validity of the Obsessive Compulsive Smoking Scale (OCSS), a ten-item questionnaire designed to measure compulsive smoking. Methods Participants were 239 daily smokers (≥1 cigarette/day), including 142 students at a public university in Chicago and 97 veterans treated at the VA Boston Healthcare System. The OCSS and questionnaires measuring current and past smoking, cigarette craving, automatic smoking, and nicotine dependence were administered. Results Factor analysis with maximum likelihood extraction and oblique rotation revealed two correlated underlying factors, interpreted as “Preoccupation with Smoking” and “Compulsive Drive.” The measurement structure was consistent across students and veterans, and confirmed in an independent sample of adults (n = 95). Veterans exhibited higher OCSS scores (full scale and subscales) than students. Across groups, higher OCSS scores were positively correlated with smoking intensity, craving, and nicotine dependence. OCSS full-scale and compulsive drive scores, but not smoking preoccupation scores, were inversely correlated with past month smoking reduction and minutes since last cigarette. Conclusions The OCSS is a valid and reliable inventory for measuring the degree to which daily smokers are preoccupied with smoking and engage in compulsive tobacco use, and may be useful for advancing understanding of core smoking phenotypes or for tailoring cessation therapies.

OBJECTIVE—To assess whether psychological constructs of hostility, anger, type A behavior pattern, and depressive symptom severity 1) were associated with concurrent and prospective fasting glucose levels and 2) whether this association was moderated by marital status. RESEARCH DESIGN AND METHODS—Participants were 485 healthy men ([mean ± SD] age 59 ± 7 years) without a history of heart disease, diabetes, or taking related medications in the Veterans Affairs Normative Aging Study. Their fasting glucose levels between 1986 and 1995 were examined. Hierarchical linear regressions were conducted to investigate whether hostility, anger, type A behavior, and depressive symptoms were associated with concurrent fasting glucose levels as well as fasting glucose 9 years later, controlling for standard sociodemographic and biomedical covariates, including baseline fasting glucose, age, education, marital status, BMI, total cholesterol, and systolic blood pressure. RESULTS—Although none of the psychological variables were associated with concurrent fasting glucose, Cook-Medley hostility (β = 0.105), anger (β = 0.091), and type A behavior (β = 0.152) each were associated with prospective fasting glucose 9 years later, controlling for standard covariates. Depressive symptom severity was not associated with either concurrent or follow-up glucose levels. Further analysis showed that marital status moderated the effects of these characteristics on follow-up fasting glucose such that hostility, anger, and type A behavior were significant only among those who were not married (β = 0.348, 0.444, 0.439, respectively; all P CONCLUSIONS—Hostility, anger, and type A behavior appear to be independent risk factors for impaired glucose metabolism among unmarried older men.

It appears interesting that 2 of the world’s most intellectual and scientifically productive minds commented often about the relevance of sexual function and its potential problems. Johann Wolfgang Von Goethe (1749-1832) was not only a writer and scientist who independently discovered the human intermaxillary bone in 1784 and the first who formulated a theory of plant metamorphosis, but many of Goethe’s artistic works such as Faust or the Venetian Epigrams do contain a relatively heavy sexual content, since he saw sexuality in general as a topic that merited poetic and artistic depiction. A few hundred years earlier than that, Leonardo da Vinci (1452-1519), the epitome of the Italian Renaissance stated: “The penis does not obey the order of its master, who tries to erect or shrink it at will, whereas instead the penis erects freely while its master is asleep. The penis must be said to have its own mind, by any stretch of the imagination.” Since then, researchers have determined the penis isn’t quite as independently minded as da Vinci observed hundreds of years ago, but is largely under the control of the central nervous system and its function as a sexual organ is highly dependent on vascular properties. In spite of the appreciation of sexuality as essential in human life and the attempts to understand the pathophysiology of dysfunction by these and several other extraordinary minds, the acceptance of sexual problems, in men as well as in women up to this day and therefore, the intuitive search for scientific answers continues to be blurred by an overwhelming lack of comprehension. Sexual Dysfunction in Cardiac Rehabilitation Patients Is Much More Than Simply an Epiphenomenon and Needs More Study Ernst R. Schwarza and Biing-Jiun Shenb

Objectives This study investigated whether anxiety characteristics independently predicted the onset of myocardial infarction (MI) over an average of 12.4 years and whether this relationship was independent of other psychologic variables and risk factors. Background Although several psychosocial factors have been associated with risk for MI, anxiety has not been examined extensively. Earlier studies also rarely addressed whether the association between a psychologic variable and MI was specific and independent of other psychosocial correlates. Methods Participants were 735 older men (mean age 60 years) without a history of coronary disease or diabetes at baseline from the Normative Aging Study. Anxiety characteristics were assessed with 4 scales (psychasthenia, social introversion, phobia, and manifest anxiety) and an overall anxiety factor derived from these scales. Results Anxiety characteristics independently and prospectively predicted MI incidence after controlling for age, education, marital status, fasting glucose, body mass index, high-density lipoprotein cholesterol, and systolic blood pressure in proportional hazards models. The adjusted relative risk (95% confidence interval [CI]) of MI associated with each standard deviation increase in anxiety variable was 1.37 (95% CI 1.12 to 1.68) for psychasthenia, 1.31 (95% CI 1.05 to 1.63) for social introversion, 1.36 (95% CI 1.10 to 1.68) for phobia, 1.42 (95% CI 1.14 to 1.76) for manifest anxiety, and 1.43 (95% CI 1.17 to 1.75) for overall anxiety. These relationships remained significant after further adjusting for health behaviors (drinking, smoking, and caloric intake), medications for hypertension, high cholesterol, and diabetes during follow-up and additional psychologic variables (depression, type A behavior, hostility, anger, and negative emotion). Conclusions Anxiety-prone dispositions appear to be a robust and independent risk factor of MI among older men.

PURPOSE: Anxiety has been associated with the development and recurrence of coronary heart disease (CHD). The objective of this study was to estimate the prevalence of anxiety disorders in men and women with established CHD. METHODS: One hundred fifty CHD patients were evaluated via a semistructured, psychiatric interview to assess both current and lifetime prevalence rates of anxiety disorders. RESULTS: Approximately 36.0% (n = 54) of cardiac patients met the diagnostic criteria for at least 1 current anxiety disorder, and 45.3% (n = 68) presented with an anxiety disorder at some point in their lifetime. Social phobia and generalized anxiety disorder were the most prevalent anxiety disorders observed, with current prevalence rates of 21.3% and 18.7%, respectively, and a lifetime prevalence of 26%. In addition, the current prevalence rate of specific phobia was approximately 14.7%, whereas 15.3% met the lifetime criteria. Lower prevalence rates for panic disorder (current = 4.7%, lifetime = 5.3%), agoraphobia (current = 3.3%, lifetime = 4.7%), posttraumatic stress disorder (current = 0%, lifetime = 1.5%), and obsessive compulsive disorder (current = 0%, lifetime = 0.7%) were observed. Female cardiac patients evidenced significantly higher current (women = 58.3% vs. 25.5%, P < .001) and lifetime (women = 70.8% vs. men = 33.3%, P < .001) rates of anxiety disorders compared with their male counterparts. CONCLUSIONS: A considerable number of CHD patients evidence a significant history of anxiety. Greater efforts to identify and treat anxiety in outpatient cardiology and cardiac rehabilitation settings are needed.

Components of the metabolic syndrome are typically intercorrelated in epidemiologic studies and, when combined, predict type 2 diabetes and cardiovascular diseases. However, it remains unclear whether a single construct underlies the various components and which of the components are most closely associated with the underlying syndrome. Here, we use our confirmatory factor analytic model of the metabolic syndrome to examine the extent to which measures of ambulatory blood pressure, reflecting blood pressure variability throughout the day and night, may strengthen the association between blood pressure and the other components of the syndrome.Participants were a community sample of 358 men (248 with hypertension), ages 40-70, not receiving antihypertensive medications. Confirmatory factor analysis was employed to examine model fit and the strength of association between clinic and ambulatory blood pressure and the metabolic syndrome.The blood pressure factor loaded significantly on the underlying metabolic syndrome but the strength of association was not as great (loading = 0.34, p0.01) as those observed for the obesity, insulin resistance and lipid factors. The factor loadings for the ambulatory measures (awake loading = 0.19; sleep loading = 0.16, p values0.01) were significant but smaller in magnitude than the loadings for clinic blood pressure.Both clinic and ambulatory measures of blood pressure are significantly associated with the underlying metabolic syndrome using confirmatory factor analytic methods. However, the strength of association appears greater for the clinic measures relative to the ambulatory measures in this study.

This study assessed whether perceived stress as measured by the Perceived Stress Scale (PSS) was associated with a decline in CD4+ cell counts over a six-month period in 59 men and 41 women living with HIV-1. Participants underwent psychological and medical assessment at the study entry (baseline) and again at six months post-baseline. In a hierarchical regression model controlling for sociodemographic (e.g. age, gender, education, income) and disease-related variables (e.g. duration of antiretroviral treatment, antiretroviral treatment and adherence, CD4+ cell count and viral load), perceived stress was associated with the decline in CD4+ cell count over the six-month period. These findings suggest perceived psychosocial stress is associated with CD4+ cell count decline independent of sociodemographic factors and disease status among men and women on antiretroviral medication for HIV/AIDS.

OBJECTIVE Studies indicate that off-loading adherence is low in patients with diabetic foot ulcers (DFUs), which may subsequently delay healing. However, there is little empirical evidence for this relationship or the factors that influence adherence. RESEARCH DESIGN AND METHODS This prospective, multicenter, international study of 79 (46 from the U.K. and 33 the U.S.) persons with type 2 diabetes and plantar DFUs assessed the association between off-loading adherence and DFU healing over a 6-week period. Additionally, potential demographic, disease, and psychological determinants of adherence were examined. DFUs were off-loaded with a removable device (77% a removable cast walker). Off-loading adherence was assessed objectively by activity monitors. Patient-reported measures included Hospital Anxiety and Depression Scale (HADS), Neuropathy and Foot Ulcer Quality of Life (NeuroQoL) instrument, and Revised Illness Perception Questionnaire (IPQ-R). RESULTS Off-loading adherence was monitored for 35 ± 10 days, and devices were used during 59 ± 22% of subjects' activity. In multivariate analyses, smaller baseline DFU size, U.K. study site, and better off-loading adherence predicted smaller DFU size at 6 weeks (P < 0.05). Better off-loading adherence was, in turn, predicted by larger and more severe baseline DFUs, more severe neuropathy, and NeuroQoL foot pain (P < 0.05). In contrast, greater NeuroQoL postural instability predicted worse off-loading adherence (P < 0.001). HADS and IPQ-R measures were not significantly associated with off-loading adherence. CONCLUSIONS Off-loading adherence is associated with the amount of DFU healing that occurs, while postural instability is a powerful predictor of nonadherence. Clinicians should take this neuropathic symptom into consideration when selecting an off-loading device, as off-loading–induced postural instability may further contribute to nonadherence.

Yao An Shen,1,* Ing Luen Shyu,2,* Maggie Lu,3 Chun Lin He,4 Yen Mei Hsu,2 Hsiang Fa Liang,3 Chih Peng Liu,3 Ren Shyan Liu,5,6 Biing Jiun Shen,7 Yau Huei Wei,1 Chi Mu Chuang2,4 1Institute of Biochemistry and Molecular Biology, School of Life Sciences, 2Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, 3Biomedical Technology and Device Research Laboratories, Industrial Technology Research Institute, Hsinchu, 4Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, 5Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, 6National PET/Cyclotron Center, Taipei Veterans General Hospital, Taipei, Taiwan; 7Division ofPsychology, Nanyang Technological University, Singapore *These authors contributed equally tothe work Abstract: The current enhanced permeability and retention (EPR)-based approved nanomedicines have had little impact in terms of prolongation of overall survival in patients with cancer. For example, the two Phase III trials comparing Doxil®, the first nanomedicine approved by the US Food and Drug Administration, with free doxorubicin did not find an actual translation of the EPR effect into a statistically significant increase in overall survival but did show less cardiotoxicity. In the current work, we used a two-factor factorial experimental design with intraperitoneal versus intravenous delivery and nanomedicine versus free drug as factors to test our hypothesis that regional (intraperitoneal) delivery of nanomedicine may better increase survival when compared with systemic delivery. In this study, we demonstrate that bypassing, rather than exploiting, the EPR effect via intraperitoneal delivery of nanomedicine harboring a sustained-release function demonstrates dual pharmacokinetic advantages, producing more efficient tumor control and suppressing the expression of stemness markers, epithelial-mesenchymal transition, angiogenesis signals, and multidrug resistance in the tumor microenvironment. Metastases to vital organs (eg, lung, liver, and lymphatic system) are also better controlled by intraperitoneal delivery of nanomedicine than by standard systemic delivery of the corresponding free drug. Moreover, the intraperitoneal delivery of nanomedicine has the potential to replace hyperthermic intraperitoneal chemotherapy because it shows equal efficacy and lower toxicity. In terms of efficacy, exploiting the EPR effect may not be the best approach for developing a nanomedicine. Because intraperitoneal chemotherapy is a type of regional chemotherapy, the pharmaceutical industry might consider the regional delivery of nanomedicine as a valid alternative pathway to develop their nanomedicine(s) with the goal of better tumor control in the future. Keywords: enhanced permeability and retention effect, liposome, paclitaxel, ovarian cancer&nbsp

Purpose The metabolic syndrome (MS) is conceived as a cluster of disorders that increase risk for coronary heart disease and type 2 diabetes. Studies examining its structure primarily have used an exploratory factor analytic technique, but yielded discrepant results. There also is a lack of research that investigates whether the clustering pattern is similar across sex and ethnic groups. This study uses confirmatory factor analysis to evaluate the factor structure of the MS and examines its similarity between men and women and across three ethnic groups (Caucasian, African, and Cuban Americans). Method A hierarchical four-factor model with an overarching MS factor uniting insulin resistance, obesity, lipid, and blood pressure factors was tested with 517 individuals from the Miami Community Health Study. Results Findings show that the proposed structure was well supported (comparative fit index = 0.97) and similar between men and women and across ethnic groups. The MS was represented strongly by insulin resistance, followed by obesity, lipid factors, and, to a lesser extent, a blood pressure factor. Conclusions This study provides empirical support for identifying and diagnosing the MS by its component factors in a diverse population.

This study tested whether suppressed hostility predicted incident hypertension (HTN) in initially nonhypertensive men, using prospective data from the Normative Aging Study. Six hundred twenty-seven men who completed the MMPI and participated in a subsequent laboratory assessment were included in the study. The Cook-Medley Hostility scale (Ho), a suppression factor, and other risk factors were used to predict incident HTN over a 3-year period. Logistic regression showed a significant three-way interaction among Ho, suppression, and age in predicting incident HTN. Among middle-aged men (

PURPOSE: Epidemiological studies have demonstrated that depression is an independent risk factor for the development and recurrence of coronary heart disease (CHD). The prevalence of depressive disorders, however, is not well documented in CHD patients enrolled in cardiac rehabilitation (CR). The purpose of this study was to estimate the prevalence of current and lifetime depressive disorders in the CR setting. METHODS: One hundred ten men and women diagnosed with CHD and enrolled in a phase II CR program were screened via a psychiatric, structured interview to assess current and lifetime history of major depressive disorder, minor depression, and dysthymic disorder. RESULTS: A total of 17 (15.5%) individuals screened positive for a current depressive disorder at entry into the CR program, with 10 (9.1%) individuals screening positive for major depressive disorder, 7 (6.4%) for minor depression, and 6 (5.5%) for dysthymic disorder. With respect to lifetime prevalence of mood disorders, 29 (26.4%) individuals met the diagnostic criteria for at least one depressive disorder during their lifetime. The lifetime prevalence of major depressive disorder, minor depression, and dysthymic disorder was 11.8%, 14.5%, and 10.9%, respectively. Female CR participants evidence significantly higher current and lifetime prevalence rates for depressive disorders compared to their male counterparts. CONCLUSIONS: The results of this study suggest that a substantial number of CHD patients enrolled in CR report a clinically significant history of depression. Efforts to assess and treat depression are needed in the CR setting and may be associated with better adherence to lifestyle modification programs.

Compared to other ethnic groups, Asian Americans show significantly lower rates of cardiovascular disease (CVD). We tested the hypothesis that Asian Americans would show reduced cardiovascular responses to laboratory stressors than Caucasians. Forty-three Asians (18 men, 25 women) and 77 Caucasians (36 men, 41 women) with a mean age of 24 years (SD = 3.93) participated in a stress reactivity protocol consisting of four tasks (speech, serial subtraction, mirror tracing, handgrip) while heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were measured. Asian Americans demonstrated overall lower reactivity across tasks for SBP F(1,117 = 7.48, p < .01) and a trend toward lower HR response F(1,117 = 3.18, p < .10). A significant ethnicity by task interaction was observed for HR reactivity F(3,351 = 2.94, p < .05) such that Caucasians showed greater responses for the subtraction task.

We were pleased that van Netten et al. (1) appreciate the importance of our article (2) substantiating the relationship between adherence to off-loading modalities and healing of diabetic foot ulcers (DFUs). Their letter contained several comments regarding our article that we address here. The first comment by van Netten et al. is regarding the rationale for using a surrogate clinical outcome (ulcer area reduction) rather than ulcer healing by a fixed time, preferably 12 weeks, which would allow for direct comparisons with other articles on off-loading. It is important to note, as was outlined in our article, that the study associated with our publication was not limited …

Negative emotions, such as depression and anxiety, have been associated with the development of coronary heart disease (CHD). In multivariate models, negative emotions have predicted CHD outcomes, such as nonfatal myocardial infarction and CHD mortality. Few studies, however, have investigated this relation while controlling for variables associated with the metabolic syndrome or those indicative of sympathetic nervous system activity. We prospectively examined the relation between negative emotions and incident CHD in older men (mean 60.3 +/- 7.9 years) participating in the Normative Aging Study (NAS). Four hundred ninety-eight men who completed the Minnesota Multiphasic Personality Inventory (MMPI) and who participated in a subsequent laboratory assessment were included in the study. All men were not on medication and free of diagnosed CHD and diabetes. Negative emotions were measured by the MMPI Welsh A scale, which is comprised of 39 items measuring symptoms of depression and anxiety. Negative emotion score, sociodemographic characteristics, health behaviors, components of the metabolic syndrome, and stress hormones were used to predict incident CHD over a 3-year follow-up period. During follow-up, 45 CHD events were observed. In unadjusted logistic regression analyses, negative emotions significantly predicted the incidence of CHD (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01 to 1.10, p = 0.02). After adjusting for potential covariates, negative emotions continued to predict the incidence of CHD (OR 1.06, 95% CI 1.01 to 1.12, p = 0.02) A linear, dose-response relation was observed (chi-square 10.8, degree of freedom 2, p = 0.005): participants who had the highest level of negative emotions experienced the greatest incidence of CHD.

The metabolic syndrome, manifested by insulin resistance, obesity, dyslipidemia, and hypertension, is conceived to increase the risk for coronary heart disease and type II diabetes. Several studies have used factor analysis to explore its underlying structure among related risk variables but reported different results. Taking a hypothesis-testing approach, this study used confirmatory factor analysis to specify and test the factor structure of the metabolic syndrome. A hierarchical four-factor model, with an overarching metabolic syndrome factor uniting the insulin resistance, obesity, lipid, and blood pressure factors, was proposed and tested with 847 men who participated in the Normative Aging Study between 1987 and 1991. Simultaneous multi-group analyses were also conducted to test the stability of the proposed model across younger and older participants and across individuals with and without cardiovascular disease. The findings demonstrated that the proposed structure was well supported (comparative fit index = 0.97, root mean square error approximation = 0.06) and stable across subgroups. The metabolic syndrome was represented primarily by the insulin resistance and obesity factors, followed by the lipid factor, and, to a lesser extent, the blood pressure factor. This study provides an empirical foundation for conceptualizing and measuring the metabolic syndrome that unites four related components (insulin resistance, obesity, lipids, and blood pressure).

Few studies have examined the prospective influences of depression and anxiety on physical health functioning in heart failure (HF) patients. Prior studies were also limited by employing psychological measures containing somatic items confounded with HF symptoms. This study examined whether depression, anxiety, social support, and their changes predicted the decline of physical functioning in HF patients over 6 months. Participants were 238 HF patients among whom 164 provided follow-up data. The depression and anxiety measures did not contain somatic items. After controlling for baseline physical functioning and demographic and medical covariates, baseline depression and its increase, as well as baseline anxiety and its increase, independently predicted greater decline in physical functioning at 6 months. Social support and its change were not associated with either concurrent or follow-up physical functioning. Depression, anxiety, and their changes independently predicted the decline of physical health functioning over 6 months.

Previous research has indicated that anxiety may be associated with adverse health outcomes in heart failure patients. Little research, however, has explored whether anxiety interacts with patients’ coping strategies in their associations with physical functioning. The present study examined whether coping strategies moderated the association between anxiety and self-rated physical functioning in 273 heart failure patients. Hierarchical multiple regression analysis, adjusting for demographic and medical covariates, indicated that both anxiety (b = 1.15, β = 0.46, P < 0.001) and avoidant coping (b = 0.43, β = 0.16, P < 0.01) were significantly associated with poorer physical functioning in separate models. Results also demonstrated a significant interaction between avoidant coping and anxiety (b = 0.56, β = 0.14, P < 0.01), such that the association between anxiety and poorer physical functioning was stronger for patients who frequently used avoidant coping strategies than for those who avoided less frequently. Approach coping, however, was not directly associated with physical functioning, nor did it moderate the association between anxiety and physical functioning. The findings suggest that anxious heart failure patients who engage in avoidant coping may be at particular risk for physical dysfunction.

The relationships among stress, obesity, and inflammation in women remain unclear. This study examined the relationships among marital stress, waist circumference, and C-reactive protein (CRP) in 201 healthy women from the Stockholm Female Coronary Risk Study. We tested whether marital stress was associated with CRP and whether this association was moderated by waist circumference. Hierarchical multiple regression revealed that after adjusting for age, occupation status, fasting glucose, apolipoprotein A1, apolipoprotein B, blood pressure, smoking, and menopausal status, marital stress was not directly associated with CRP. However, waist circumference significantly moderated the association between marital stress and CRP (p = 0.012) such that marital stress was significantly associated with higher CRP among women with larger waist circumferences but not in those with smaller waists. More obese women may be particularly vulnerable to the effects of marital stress by manifesting higher inflammation.

This study provides the first national estimates of the prevalence and correlates of intimate partner violence (IPV) among Asian Americans. Population estimates are based on data from 1470 Asian Americans interviewed for the National Latino and Asian American Study. Interviews were conducted in English, Chinese, Tagalog, or Vietnamese. Results suggest that rates of IPV among Asian Americans are low compared to the general U.S. population. Minor violence victimization by a current intimate partner was reported by 10.2% of women and 12.0% of Asian American men. Notably, a greater proportion of participants admitted having perpetrated IPV than having been a victim. Predictors of IPV included younger age, higher SES, alcohol- and substance-use disorders, depression, ethnicity, and being U.S.-born. Results suggest the need for additional research to examine the interactions between gender, ethnicity, and acculturation to develop group-specific models of IPV risk and resilience within diverse Asian American groups.

Treatment for localized prostate carcinoma (PCa) is frequently associated with decrements in sexual functioning and satisfaction. Given the highly interpersonal nature of these decrements, interpersonal problems (such as interpersonal sensitivity) may affect recovery of sexual functioning after PCa treatment through interference with physician and partner communication and through distorted cognitions surrounding sexual dysfunction. The objective of the present study was to determine the effect of interpersonal sensitivity on several treatment indicators, including response to a group-based psychosocial intervention.Participants were 101 older men recovering from radical prostatectomy who were enrolled in a randomized controlled trial of a 10-week group-based cognitive-behavioral stress management (CBSM) intervention. Measures included the Inventory of Interpersonal Problems and the sexual functioning subscale of the University of California-Los Angeles quality-of-life measure.At baseline, interpersonal sensitivity was related to a belief linking sexual dysfunction to core male identity (r=.29, P.05). Using hierarchical regression, we found that (a) the CBSM intervention was effective in promoting sexual recovery in all participants, and (b) this effect was moderated by interpersonal sensitivity, such that individuals with higher levels of interpersonal sensitivity made larger improvements in sexual functioning in response to CBSM.CBSM was effective in improving sexual function after radical prostatectomy. Individuals with higher levels of interpersonal sensitivity were more likely to perceive sexual dysfunction as a threat to masculine identity and made larger gains in the CBSM intervention. Results and relevance to the older male cancer patients are discussed from the perspective of interpersonal theory.

This study investigated whether anxiety characteristics independently predicted the onset of myocardial infarction (MI) over an average of 12.4 years and whether this relationship was independent of other psychologic variables and risk factors.Although several psychosocial factors have been associated with risk for MI, anxiety has not been examined extensively. Earlier studies also rarely addressed whether the association between a psychologic variable and MI was specific and independent of other psychosocial correlates.Participants were 735 older men (mean age 60 years) without a history of coronary disease or diabetes at baseline from the Normative Aging Study. Anxiety characteristics were assessed with 4 scales (psychasthenia, social introversion, phobia, and manifest anxiety) and an overall anxiety factor derived from these scales.Anxiety characteristics independently and prospectively predicted MI incidence after controlling for age, education, marital status, fasting glucose, body mass index, high-density lipoprotein cholesterol, and systolic blood pressure in proportional hazards models. The adjusted relative risk (95% confidence interval [CI]) of MI associated with each standard deviation increase in anxiety variable was 1.37 (95% CI 1.12 to 1.68) for psychasthenia, 1.31 (95% CI 1.05 to 1.63) for social introversion, 1.36 (95% CI 1.10 to 1.68) for phobia, 1.42 (95% CI 1.14 to 1.76) for manifest anxiety, and 1.43 (95% CI 1.17 to 1.75) for overall anxiety. These relationships remained significant after further adjusting for health behaviors (drinking, smoking, and caloric intake), medications for hypertension, high cholesterol, and diabetes during follow-up and additional psychologic variables (depression, type A behavior, hostility, anger, and negative emotion).Anxiety-prone dispositions appear to be a robust and independent risk factor of MI among older men.

OBJECTIVE Previous research has produced mixed results pertaining to the association between hostility and insulin resistance. These inconsistent findings may be the result of a lack of studies examining potential moderators of this relationship and inconsistent measures of insulin resistance and/or hostility. We hypothesized that hostility may interact with circulating norepinephrine (NEPI) levels, indexed by 24-hour urine concentrations, to affect insulin resistance. METHODS Six hundred forty-three men (mean age = 63.1 years) free of diabetic medications completed the Minnesota Multiphasic Personality Inventory and participated in a laboratory assessment. The Cook-Medley Hostility (Ho) and 24-hour urine NEPI were used to predict insulin resistance defined by the homeostatic model assessment (HOMA) index, 2-hour postchallenge glucose (PCGL), and insulin levels (PCIL) after controlling for nine common covariates. RESULTS Multiple regression showed that the two-way interaction between Ho and NEPI significantly predicted HOMA and PCIL, but not PCGL, after controlling for covariates. Simple regression slopes of Ho on HOMA and PCIL were explored and indicated that, at higher levels of NEPI, higher Ho was associated with higher HOMA (beta = 0.14, p < .05). Ho was not a significant predictor of HOMA at mean and lower levels of NEPI. Similar results were obtained for PCIL, but not PCGL. Cynicism, but not other subscales of Ho, was similarly related to insulin resistance and NEPI. CONCLUSION Individuals with high stress and high hostility were more likely to have insulin resistance. It is important to study moderators in the relationship between hostility and insulin resistance.

Background: Recent literature has indicated that a significant percentage of oncology patients describe finding some benefit (e.g., improved personal growth, sense of meaning, and enhanced interpersonal relationships) in the cancer experience. However, few studies have investigated the role of group-based psychosocial interventions in improving benefit finding (BF), and virtually none have investigated these constructs in men.Purpose: This study examined whether a cognitive-behavioral stress management (CBSM) intervention improves BF and quality of life (QoL) in men recovering from treatment for localized prostate cancer.Methods: Participants in this study were 191 men (M age = 65.1) treated with radiation or radical prostatectomy for clinically localized (i.e., Stage I or II) prostate cancer. Participants were primarily non-Hispanic White (40%) or Hispanic (41 %), followed by Black (18%) and other ethnicity (1 %), were an average of 65.1 years old (SD = 7.7), and earned an average of $47,800 annually (SD = $41,000). Participants were randomized to either a 10-week group-based cognitive-behavioral stress management intervention or a half-day educational seminar as a control condition. All participants provided demographic information and completed the Positive Contributions Scale-Cancer to assess BF, the Functional Assessment of Cancer Therapy to measure quality of life, and a measure of perceived stress management skills. Structural equation modeling was utilized for all analyses.Results: Results indicated that the CBSM condition led to increases in BF and QoL and that these changes were mediated by the development of stress management skills.Conclusions: Results support the use of group-based cognitive-behavioral interventions in promoting QoL and BF in this population.

Objectives To examine the quality of life (QOL) in a sample of men recently treated for localized prostate cancer to determine whether minority men are at greater risk of decrements in QOL and to identify factors that might explain disparities in QOL outcomes. Methods The relationship between ethnicity and QOL was evaluated in a diverse sample of 204 men (85 non-Hispanic white, 37 African-American, and 82 Hispanic men). We also assessed associations with other factors known to be related to QOL (ie, sociodemographic, medical, and health behavior factors). Hierarchical regression analysis was used to assess the relationship between ethnicity and QOL. Factors that were anticipated to explain the ethnic differences in QOL were then added in stepwise analyses. Results Ethnic group membership was related to QOL such that minority men had lower QOL than non-Hispanic white men. In subsequent steps, the association between ethnic group membership and QOL was partially mediated by sociodemographic, medical, and health behavior factors, with each factor adding significant incremental variance (5%, 5%, and 17%, respectively). Three variables remained significant in the final model, which explained 37% of the variance in QOL scores: medical comorbidity, physical activity, and sleep functioning. Conclusions Health behaviors appear to be strongly related to men’s QOL after prostate cancer treatment. Intervention studies aimed at improving QOL should include a brief assessment of health behaviors and may want to incorporate intervention components designed to address physical activity and sleep functioning.

Objective This study investigated hostility, social support, coping, depression, and their contributions to concurrent and posttreatment quality of life (QoL) among a group of patients participating in a 6-week cardiac rehabilitation program. Method Both direct and mediational relationships among psychosocial factors, QoL baseline, and QoL outcome were examined using structural equation modeling analysis, while age, education, and severity of illness (risk for future event) were controlled. Results The final model was well supported ( χ 2 =64.88, df =56, P >.05; CFI=.99, RMSEA=.04). Results indicated that baseline QoL, hostility, and depressive symptom severity directly and independently predicted QoL outcome, while depression and hostility were also associated with baseline QoL. Hostility, social support, and maladaptive coping also contributed to baseline and follow-up QoL by their associations with depression. Conclusion Psychosocial characteristics were interrelated, and they predicted postrehabilitation QoL outcome directly or indirectly through depression symptom severity.

This study examined the role of acculturation and its direct and indirect impact on depressive symptom severity through various correlates, including socioeconomic status (SES), stress, social support, personality negativity, and physical health perception. Using structural equation modeling, the proposed model was tested with 983 employed Chinese Americans from a representative community sample, the majority of whom were immigrants. The results demonstrated that acculturation, correlated with SES, contributed to depressive symptom severity only through indirect pathways. Higher acculturation was found associated with higher stress that in turn contributed to more elevated depressive symptoms. On the other hand, higher acculturation was also found strongly correlated with higher SES, which was associated with lower depressive symptoms directly or indirectly through several mediators. Better support, lower personality negativity, better health perception, and lower stress were found mediating the relationship between higher SES and lower depressive symptom severity. The simultaneous multigroup analysis showed that the final model was comparable for both men and women with very few differences.

We were pleased to see the article by Pladevall et al. (1) in a recent issue of Diabetes Care , as it extends our prior results to Spanish and Mauritian samples. While the authors suggest that their findings differ from our results in the Normative Aging …

Introduction: Hospitalizations for acute decompensated heart failure represent a progression of worsening symptoms and quality of life, yet is little known about the relationship of perceived pain and hospital readmission rates. Hypothesis: The manifestation of pain in patients with heart failure is associated with an increased rate of hospital readmissions. Methods: We examined the records of 591 patients admitted to a tertiary care center with a diagnosis of heart failure who had standardized pain scale assessment (0, no pain, to 10, worst pain ever) completed upon admission and evaluated the number of readmissions over one year. Results: The frequency of readmissions was 0.3760.85 for heart failure and 1.1661.59 for any cause, respectively. There was no association between pain and readmission in the total population, however there was significant association in the 211 patients who endorsed pain $1 and hospital length of stay #30 days. Logistic regression analysis demonstrated that pain predicted an increase in the likelihood of readmissions for heart failure within one year, with an Odds Ratio (OR) of 1.23 (p 50.006, 95% CI51.060 1.416) independent of coronary artery disease, diabetes, pulmonary disease, renal insufficiency, depression, anemia and depressed left ventricular function. This association also appeared stronger in men, OR 1.26 (p50.026, 95%CI51.0281.553) compared to women, OR 1.20 (p50.09, 95%CI50.973-1.471). Conclusion: The manifestation of pain in heart failure patients is associated with increased rates of readmissions independent of coronary artery disease diabetes, pulmonary disease, renal insufficiency, depression, anemia and depressed left ventricular function.