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Roxane Raffin Chan,1 Nicholas Giardino,2 Janet L Larson3 1College of Nursing, Michigan State University, East Lansing, 2Department of Psychiatry, 3School of Nursing, University of Michigan, Ann Arbor, MI, USA Abstract: Living well with chronic obstructive pulmonary disease (COPD) requires people to manage disease-related symptoms in order to participate in activities of daily living. Mindfulness practice is an intervention that has been shown to reduce symptoms of chronic disease and improve accurate symptom assessment, both of which could result in improved disease management and increased wellness for people with COPD. A randomized controlled trial was conducted to investigate an 8-week mindful meditation intervention program tailored for the COPD population and explore the use of breathing timing parameters as a possible physiological measure of meditation uptake. Results demonstrated that those randomized to the mindful meditation intervention group (N=19) had a significant increase in respiratory rate over time as compared to those randomized to the wait-list group (N=22) (P=0.045). It was also found that the mindful meditation intervention group demonstrated a significant decrease in level of mindfulness over time as compared to the wait-list group (P=0.023). When examining participants from the mindful meditation intervention who had completed six or more classes, it was found that respiratory rate did not significantly increase in comparison to the wait-list group. Furthermore, those who completed six or more classes (N=12) demonstrated significant improvement in emotional function in comparison to the wait-list group (P=0.032) even though their level of mindfulness did not improve. This study identifies that there may be a complex relationship between breathing parameters, emotion, and mindfulness in the COPD population. The results describe good feasibility and acceptability for meditation interventions in the COPD population. Keywords: integrative therapies, contemplative therapies, breathing timing parameters, chronic obstructive pulmonary disease, pulmonary rehabilitation

Sepehr Rejai,1 Nicholas D Giardino,2 Sangeetha Krishnan,1,3 Ira S Ockene,4 Melvyn Rubenfire,3 Elizabeth A Jackson1,31Michigan Cardiovascular Research and Reporting Program, 2Department of Psychiatry, 3Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA; 4Division of Cardiovascular Medicine, Department of Internal Medicine, University of Massachusetts Medical Center, Worcester, MA, USAAbstract: We sought to examine factors associated with depressive symptoms among patients with heart disease. Data from 197 patients admitted for coronary artery disease were examined using multivariate predictive models. Women and unmarried patients were more likely to report depressive symptoms. In multivariate models, we observed that depressive symptoms were associated with the level of tangible social (but not emotional) support, bodily pain, and vitality, but not the number of comorbidities, gender, or marital status.Keywords: heart disease, quality of life, depression

Abstract Background Anxiety in patients with chronic obstructive pulmonary disease (COPD) is associated with self-reported disability. The purpose of this study is to determine whether there is an association between anxiety and functional measures, quality of life and dyspnea. Methods Data from 1828 patients with moderate to severe emphysema enrolled in the National Emphysema Treatment Trial (NETT), collected prior to rehabilitation and randomization, were used in linear regression models to test the association between anxiety symptoms, measured by the Spielberger State Trait Anxiety Inventory (STAI) and: (a) six-minute walk distance test (6 MWD), (b) cycle ergometry peak workload, (c) St. Georges Respiratory Questionnaire (SRGQ), and (d) UCSD Shortness of Breath Questionnaire (SOBQ), after controlling for potential confounders including age, gender, FEV1 (% predicted), DLCO (% predicted), and the Beck Depression Inventory (BDI). Results Anxiety was significantly associated with worse functional capacity [6 MWD (B = -0.944, p < .001), ergometry peak workload (B = -.087, p = .04)], quality of life (B = .172, p < .001) and shortness of breath (B = .180, p < .001). Regression coefficients show that a 10 point increase in anxiety score is associated with a mean decrease in 6 MWD of 9 meters, a 1 Watt decrease in peak exercise workload, and an increase of almost 2 points on both the SGRQ and SOBQ. Conclusion In clinically stable patients with moderate to severe emphysema, anxiety is associated with worse exercise performance, quality of life and shortness of breath, after accounting for the influence of demographic and physiologic factors known to affect these outcomes. Trail Registration ClinicalTrials.gov NCT00000606

Combat-related posttraumatic stress disorder (PTSD) is common among returning veterans, and is a serious and debilitating disorder. While highly effective treatments involving trauma exposure exist, difficulties with engagement and early drop may lead to sub-optimal outcomes. Mindfulness training may provide a method for increasing emotional regulation skills that may improve engagement in trauma-focused therapy. Here, we examine potential neural correlates of mindfulness training and in vivo exposure (non-trauma focused) using a novel group therapy [mindfulness-based exposure therapy (MBET)] in Afghanistan (OEF) or Iraq (OIF) combat veterans with PTSD. OEF/OIF combat veterans with PTSD ( N  = 23) were treated with MBET ( N  = 14) or a comparison group therapy [Present-centered group therapy (PCGT), N  = 9]. PTSD symptoms were assessed at pre- and post-therapy with Clinician Administered PTSD scale. Functional neuroimaging (3-T fMRI) before and after therapy examined responses to emotional faces (angry, fearful, and neutral faces). Patients treated with MBET had reduced PTSD symptoms (effect size d  = 0.92) but effect was not significantly different from PCGT ( d  = 0.43). Improvement in PTSD symptoms from pre- to post-treatment in both treatment groups was correlated with increased activity in rostral anterior cingulate cortex, dorsal medial prefrontal cortex (mPFC), and left amygdala. The MBET group showed greater increases in amygdala and fusiform gyrus responses to Angry faces, as well as increased response in left mPFC to Fearful faces. These preliminary findings provide intriguing evidence that MBET group therapy for PTSD may lead to changes in neural processing of social-emotional threat related to symptom reduction.

Background: Recent studies suggest that mindfulness may be an effective component for posttraumatic stress disorder (PTSD) treatment. Mindfulness involves practice in volitional shifting of attention from "mind wandering" to present-moment attention to sensations, and cultivating acceptance. We examined potential neural correlates of mindfulness training using a novel group therapy (mindfulness-based exposure therapy (MBET)) in combat veterans with PTSD deployed to Afghanistan (OEF) and/or Iraq (OIF)., Methods: Twenty-three male OEF/OIF combat veterans with PTSD were treated with a mindfulness-based intervention (N = 14) or an active control group therapy (present-centered group therapy (PCGT), N = 9). Pre-post therapy functional magnetic resonance imaging (fMRI, 3 T) examined resting-state functional connectivity (rsFC) in default mode network (DMN) using posterior cingulate cortex (PCC) and ventral medial prefrontal cortex (vmPFC) seeds, and salience network (SN) with anatomical amygdala seeds. PTSD symptoms were assessed at pre- and posttherapy with Clinician Administered PTSD Scale (CAPS)., Results: Patients treated with MBET had reduced PTSD symptoms (effect size d = 0.92) but effect was not significantly different from PCGT (d = 0.46). Increased DMN rsFC (PCC seed) with dorsolateral dorsolateral prefrontal cortex (DLPFC) regions and dorsal anterior cingulate cortex (ACC) regions associated with executive control was seen following MBET. A group × time interaction found MBET showed increased connectivity with DLPFC and dorsal ACC following therapy; PCC-DLPFC connectivity was correlated with improvement in PTSD avoidant and hyperarousal symptoms., Conclusions: Increased connectivity between DMN and executive control regions following mindfulness training could underlie increased capacity for volitional shifting of attention. The increased PCC-DLPFC rsFC following MBET was related to PTSD symptom improvement, pointing to a potential therapeutic mechanism of mindfulness-based therapies., (© 2016 Wiley Periodicals, Inc.)

Emotional Processing Theory proposes that habituation to trauma-related stimuli is an essential component of PTSD treatment. However, the mechanisms underlying treatment-related habituation are not well understood. We examined one psychophysiological measure that holds potential for elucidating the biological processes involved in treatment response: trauma-potentiated startle response. Seventeen OEF/OIF combat Veterans participated in the study and completed three assessments using a trauma-potentiated startle paradigm over PTSD treatment. Results revealed different patterns of trauma-potentiated startle across treatment for responders and nonresponders, but no differences in within task habituation. Responders showed an increase followed by a decrease in trauma-potentiated startle, whereas nonresponders showed a relatively flat response profile. Results suggested that PTSD patients who engage with emotional content as demonstrated by greater startle reactivity may be more likely to respond to PTSD treatment. Furthermore, trauma-potentiated startle shows promise as an objective measure of psychophysiological responses involved in PTSD recovery., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Physical activity status is increasingly recognized as a reliable predictor of mortality and hospitalization in patients with chronic obstructive pulmonary disease (COPD). The reduction in physical activity occurs earlier in the clinical course of COPD than previously appreciated, possibly arising from breathlessness, reduced exercise tolerance, and adoption of a more sedentary lifestyle. To date, no clinical trial has evaluated the impact of pharmacotherapy on both lung function and physical activity. We recently designed a study that evaluates the impact of tiotropium (a once-daily inhaled anticholinergic) on lung function and physical activity in a maintenance/treatment-naïve Global Initiative for Chronic Obstructive Lung Disease (GOLD) Stage II COPD cohort. Previous studies have demonstrated that tiotropium improves lung function and exercise tolerance; whether these benefits translate into improvements in physical activity is the focus of the current work. Here we describe the rationale and challenges in developing and implementing this study and review its unique features and novel design, including: utility of direct activity monitoring in multicenter clinical trials; importance of behavioral-modification techniques (including motivational interviewing to improve patient self-efficacy and adherence for a healthy, more active lifestyle); utility of individualized activity plans that provide an integrated approach with pharmacotherapy and behavioral modification to help patients achieve a more active lifestyle.

Rationale: Home oxygen is the most expensive equipment item that Medicare purchases ($1.7 billion/year)., Objectives: To assess geographic differences in supplemental oxygen use., Methods: Retrospective cohort analysis of oxygen claims for a 20% random sample of Medicare patients hospitalized for obstructive lung disease in 1999 and alive at the end of 2000., Measurements and Main Results: While 33.7% of the 34,916 hospitalized patients used supplemental oxygen, there was more than a 4-fold difference between states and a greater than 6-fold difference between hospital referral regions with high/low utilization. Rocky Mountain States and Alaska had the highest utilization, while the District of Columbia and Louisiana had the lowest utilization. After adjusting for patient characteristics and elevation, high-utilization communities included low-lying areas in California, Florida, Michigan, Missouri, and Washington. Patients who were younger, male, white, and who had more comorbidities, more hospital admissions, and lived at higher altitudes and in areas of greater income also had higher odds of using supplemental oxygen. Residing in rural areas was associated with higher unadjusted oxygen use rates. After adjustment, patients living in large rural areas had higher odds of using oxygen than patients living in urban areas or in small rural areas., Conclusions: There is significant geographic variation in supplemental oxygen use, even after controlling for patient and contextual factors. The Centers for Medicare & Medicaid Services should examine these issues further and enact changes that ensure patient health and fiscal responsibility.

Background: HRQL in IPF patients is impaired. Data from other respiratory diseases led us to hypothesize that significant gender differences in HRQL in IPF also exist., Methods: Data were drawn from the NIH-sponsored Lung Tissue Research Consortium (LTRC). Demographic and pulmonary physiology data along with MMRC, SF-12, and SGRQ scores from women vs. men were compared with two-sample t-tests. Multivariate linear regression was used to examine the association between SF-12 component scores and gender while adjusting for other relevant variables., Results: The study sample consisted of 147 men and 74 women. Among several baseline variables, only DL(CO)% predicted differed between women and men, (43.7 vs. 38.0, p=0.03). In general, men exhibited lower (better) MMRC scores (1.7 vs. 2.4, p=0.02), particularly those with milder disease as measured by DL(CO)% predicted. In an adjusted analysis, SF-12 PCS scores in men were lower (worse) than women (p=0.01), an effect that was more pronounced in men with greater dyspnea scores. In a similar analysis, SF-12 MCS scores in women were lower than men (worse) (48.3 vs. 54.4, p=0.0004), an effect that was more pronounced in women with greater dyspnea scores., Conclusions: Significant gender differences in HRQL exist in IPF. As compared to women, men reported less severe dyspnea, had worse SF-12 PCS scores, but better SF-12 MCS scores. Dyspnea appears to have a greater impact on the physical HRQL of men and the emotional HRQL of women. An improved understanding of the mechanism behind these differences is needed to better target interventions.

Given clear connections between respiratory distress and subjective anxiety, it is not surprising that respiratory psychophysiologists have been interested in the psychobiology of anxiety. Given parallel links between anxiety and stress, it is not surprising that the hypothalamic-pituitary adrenal (HPA) stress system has also been a focus in anxiety research. However, despite extensive work in respiratory psychophysiology and stress neuroendocrinology--and evidence that these systems are jointly dysregulated in anxiety disorders--direct studies of their interactions are rare. This paper reviews evidence for scientific intersections, providing an overview of the HPA axis, its psychobiology, and shared neural substrates for HPA and respiratory control. We examine HPA hormone effects on respiration, immune/inflammatory mediators, and lung maturation. We also examine respiratory/dyspnea effects on HPA axis. There are clear points of intersection in the neuroscience of respiration and stress. Given the importance of both systems to an organism's ability to survive and adapt in challenging and changing environments, further study of their interactions is needed., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Objectives: Depression and anxiety are associated with significantly increased healthcare costs that include costs of non-psychiatric medical care. PTSD has been found to be related to many negative health perceptions and outcomes (e.g., [Resnick, H.S., Acierno, R., Kilpatrick, D.G., 1997. Health impact of interpersonal violence: II. Medical and mental health outcomes. Behavioral Medicine 23, 65-78]). The presence of comorbid depression and anxiety disorders in patients with posttraumatic stress disorder (PTSD) is well documented. This study aims to examine the effects of depression and anxiety on health satisfaction in veterans with PTSD., Methods: The current study utilizes archival data from a clinical sample of combat veterans (N=249) with and without PTSD in order to examine the unique contributions of anxiety and depression to reported health satisfaction., Results: After controlling for PTSD severity, combat exposure, and age, when both anxiety and depression are examined simultaneously in a regression to predict health satisfaction only depression significantly contributed and accounted for 10% of model variance., Conclusions: While both depression and anxiety are related to more negative reported health satisfaction among veterans in a PTSD clinic, depression appears to be a main contributor., Limitations: Evaluation and treatment seeking veterans may differ from a full range of veterans with PTSD. Closer examination with measures of depression and anxiety that more precisely separate these constructs is warranted. Finally, it is not known whether reported health satisfaction is related to an objective difference in health status or is more indicative of subjective expression of distress., (Published by Elsevier B.V.)

The natural course of chronic obstructive pulmonary disease (COPD) is complicated by the development of systemic consequences and co-morbidities. These may be major features in the clinical presentation of COPD, prompting increasing interest. Systemic consequences may be defined as non-pulmonary manifestations of COPD with an immediate cause-and-effect relationship, whereas co-morbidities are diseases associated with COPD. The major systemic consequences/co-morbidities now recognized are: deconditioning, exercise intolerance, skeletal muscle dysfunction, osteoporosis, metabolic impact, anxiety and depression, cardiovascular disease, and mortality. The mechanisms by which these develop are unclear. Probably many factors are involved. Two appear of paramount importance: systemic inflammation, which presents in some patients with stable disease and virtually all patients during exacerbations, and inactivity, which may be a key link to most COPD-related co-morbidities. Further studies are required to determine the role of inflammatory cells/mediators involved in systemic inflammatory processes in causing co-morbidities; the link between activity and co-morbidities; and how COPD therapy may affect activity. Both key mechanisms appear to be influenced significantly by COPD exacerbations. Importantly, although the prevalence of systemic consequences increases with increasing severity of airflow obstruction, both systemic consequences and co-morbidities are already present in the Global Initiative for Chronic Obstructive Lung Disease Stage II. This supports the concept of early intervention in chronic obstructive pulmonary disease. Although at present early intervention studies in COPD are lacking, circumstantial evidence suggests that current treatments may influence events leading to the systemic consequences and co-morbidities, and thus may affect the clinical manifestations of the disease.

Dysregulation within both respiratory control systems and the hypothalamic-pituitary adrenal (HPA) axis has been implicated in the pathophysiological of panic disorder. However, potential linkages between respiration and the HPA axis have rarely been examined in panic patients. We have previously published neuroendocrine and psychophysiological response data from a laboratory panic model using the respiratory stimulant doxapram. We now present a new, theoretically driven re-examination of linkages between HPA axis and respiratory measures in this model. Previous analyses showed elevated corticotropin (ACTH) and persistent tidal volume irregularity in panic patients, due to a high frequency of sighs. Regression analyses now show that tidal volume irregularity and sigh frequency were strongly predicted by pre-challenge ACTH levels, but not by subjective distress or panic symptoms. We predicted this relationship on the basis of our hypothesis that both the HPA axis and respiratory control systems may be reactive to contextual cues such as novelty or anticipation of future challenge. Follow-up work is needed to directly test this hypothesis., (Depression and Anxiety, 2008. Published 2007 Wiley-Liss, Inc.)

Objective: To describe how clinical practice in those who underwent carpal tunnel release (CTR) matched the American Association of Electrodiagnostic Medicine (AAEM) 1993 practice parameters for electrodiagnostic evaluation of carpal tunnel syndrome (CTS)., Design: Cohort study using 1998-1999 Medicare billing data., Setting: Washington State., Participants: State Medicare beneficiaries who underwent CTR in 1999 (N=1567) Interventions Not applicable., Main Outcome Measures: Compliance with the AAEM practice parameters., Results: Of the 1567 [corrected] receiving surgery, 324 [corrected] (20.7%) did not have any electrodiagnostic testing before surgery. One hundred seventy-one (10.9%) had testing performed that did not lead to the diagnosis of CTS. One thousand seventy-two (68.4%) patients were diagnosed with CTS through electrodiagnostic testing; 155 (9.9%) had less than 2 sensory nerves studied, 114 (7.3%) had less than 2 motor nerves studied, and 65 (4.2%) of the studies met neither the standard (sensory nerve testing) nor guideline (motor nerve testing). In a multivariate analysis, neurologists were more likely than physiatrists not to meet the AAEM standards (adjusted relative risk [adj RR]=1.61; 95% confidence interval [CI], 1.13-2.31) and patients living in rural areas were more likely to have no or inadequate testing (adj RR=1.6; 95% CI, 1.3-1.9)., Conclusions: Over one third of Medicare patients undergoing CTR in Washington State in 1999 may have had an inappropriate electrodiagnostic workup before the surgery. Policymakers should consider mandating an appropriate electrodiagnostic test before approving CTR.

Asthma can be affected by stress, anxiety, sadness, and suggestion, as well as by environmental irritants or allergens, exercise, and infection. It also is associated with an elevated prevalence of anxiety and depressive disorders. Asthma and these psychological states and traits may mutually potentiate each other through direct psychophysiological mediation, nonadherence to medical regimen, exposure to asthma triggers, and inaccuracy of asthma symptom perception. Defensiveness is associated with inaccurate perception of airway resistance and stress-related bronchoconstriction. Asthma education programs that teach about the nature of the disease, medications, and trigger avoidance tend to reduce asthma morbidity. Other promising psychological interventions as adjuncts to medical treatment include training in symptom perception, stress management, hypnosis, yoga, and several biofeedback procedures.

Chemical intolerance (CI) in humans is a poorly understood phenomenon of uncertain etiology, seemingly influenced by multiple factors both within and between affected individuals. Several authors have suggested that the development of CI in some individuals may be due, at least in part, to Pavlovian conditioning processes in which the expression of overt symptoms to certain substances reflects classically conditioned responses to previously neutral olfactory and contextual stimuli. In this paper, we describe the potential relationship between olfactory and contextual conditioning in experimental animals and the development and expression of CI in humans. Furthermore, as significant advances have been made in delineating the brain areas that underlie these learned responses, we also review recent research on the contributions of the amygdala and perirhinal cortical region to olfactory and contextual fear conditioning.

Idiopathic environmental intolerance (IEI) is a poorly understood condition that may involve disturbances in immunologic, neurologic, endocrine, behavioral, emotional, and cognitive processes. This chapter reviews theories and evidence that behavioral conditioning processes, including pharmacologic sensitization, conditioned immunomodulation, and conditioned odor and taste aversions, may play a role in the development and maintenance of IEI. It also reviews the psychophysiologic concepts of individual response specificity and situational response stereotypy as potential explanations for the individual differences observed in specific responses to environmental stimuli in patients with IEI. Finally, the treatment implications of a conditioning account of IEI are discussed as part of a more comprehensive treatment approach that incorporates other behavioral and nonbehavioral strategies.

In military courts of law, the good soldier defense is often used by the defendant to explain the presence of 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid in urine (hereafter referred to as THCA) above the Department of Defense (DOD) established limit of 15 ng/mL. The defense will contend the defendant unwittingly breathed side-stream marijuana smoke, thus resulting in the presence of THCA in the defendant's urine. The purpose of this work was to link an indoor air quality model (IAQ) with a pharmacokinetic (PK) model to predict a passive marijuana smoker's resultant concentration of the major urinary metabolite THCA.

Two genes (L5-67 and LUQ-1) that encode neuropeptide precursors have recently been shown to be expressed in a distinct and non-overlapping manner in the five left upper quadrant (LUQ) cells of the abdominal ganglion of Aplysia (Landry et al. [1992]. J. Neurobiol 23:89-101). By using wholemount immunohistochemistry and radioimmunoassay (RIA), the pattern of expression of these two genes was assessed at the protein level throughout the central nervous system (CNS) and in peripheral tissues of Aplysia californica. The distribution of LUQ-1 precursor-like immunoreactivity was fairly limited, occurring in the ventral LUQ cell (L5) and in a total of approximately 20 additional neurons in the abdominal and cerebral ganglia. L5-67 precursor-like immunoreactive material was more prevalent, appearing in a total of approximately 100 neurons distributed among each of the central ganglia. Identified L5-67-immunoreactive neurons included the four dorsal LUQ cells (L2-4 and L6) and two giant neurons (R2 and LPI1). In one group of cells, the H cluster of the cerebral ganglion, L5-67 immunofluorescence was substantially more intense in larger versus smaller animals, suggesting that this peptide precursor is subject to developmental regulation in certain neurons. Immunoelectron microscopic examination of the subcellular localization of L5-67 immunoreactivity in LUQ cell somata and axons revealed its association with dense-core vesicles (approximately 114 nm in diameter). In the periphery, L5-67-immunoreactive fibers were detected in specific regions of the circulatory system (auricle, ventricle, cristae aorta, anterior aorta) and the reproductive system (genital ganglion, large hermaphroditie duct, small hermaphroditie duct, ovotestis). The kidney and the intestine, two tissues in which considerable secretion and absorption occur, contained material immunoreactive to both L5-67 and LUQ-1 antisera. The localization of the two peptide precursors in these tissues differed substantially, with L5-67 occurring in widely ramifying varicose fibers, whereas LUQ-1 was found in restricted foci of fibers and in small spherical cells that appeared to lack processes. These results support previous findings concerning the heterogeneity of neurotransmitter phenotypes in the LUQ cells. Furthermore, they are indicative of a fairly broad role for the L5-67-derived neuropeptides, and a more limited role for the LUQ-1-derived neuropeptides, in the regulation of the visceral organ systems of Aplysia.

We have characterized emissions of trichoroethylene and chloroform (two highly volatile organic chemicals), as well as 1,2-dibromo-3-chloropropane (DBCP) (a moderately volatile organic chemical) from a full-size (1.5 m3), experimental shower. For typically hot showers (approximately 40 degrees C), the present volatilization was found to be approximately 80% for trichoroethylene (TCE), 60% for chloroform, and 20% for DBCP. Among the factors studied, the temperature of the water typically had a dominant effect on the total release of each of the three chemicals from the shower water to the air, such that the extent of volatilization increased as influent water temperature increased. For TCE, water flow rate was found to be negatively correlated with fractional volatilization, while airflow through the chamber had a small effect, although it did affect the ensuing air concentrations in the shower chamber.