Society for Ambulatory Assessment

First quarter 2007 (January to March)

Altunkan S., Genc Y. & Altunkan E. (Mar 2007). A comparative study of an ambulatory blood pressure measuring device and a wrist blood pressure monitor with a position sensor versus a mercury sphygmomanometer. Eur J Intern Med, 18(2):118-23.

BACKGROUND: Self-measurements of blood pressure (BP) and 24-hour BP measurements are better predictors of cardiovascular mortality and morbidity than office BP measurements. The objective of this study was to compare the accuracy and precision of a wrist BP monitor with a position sensor (Omron 637IT) and of an ambulatory BP measuring monitor (ABPM; Nissei DS-250) with a mercury sphygmomanometer. METHODS: A total of 139 patients (69 women and 70 men) were included in the study. The BP of each subject was first measured with a mercury device using the same (left) arm. After this, the wrist monitor was used for BP measurement. Upon completion of the BP readings, 24-hour BP monitoring was performed using Nissei DS-250 monitors. Mean and standard deviations were calculated for all devices. In order to assess the agreement between the measurement methods, the Bland-Altman method and graphics were utilized. RESULTS: The mean systolic BP measured by the mercury device was 133.2+/-18.4 mmHg and the diastolic BP was 85.4+/-12.5 mmHg, whereas the digital device measured systolic BP as 135.7+/-17.2 mmHg and diastolic BP as 87.0+/-12.5 mmHg. The 24-hour BP measurement was 134.6+/-16.6 mmHg for systolic BP and 85.6+/-11.1 mmHg for diastolic BP. The difference with regard to systolic BP between the mercury and the Omron devices was -2.5+/-5.3 mmHg, which is within the AAMI standard. However, while the mean values of the differences between the mercury and ABPM devices remained under 5 mmHg, their standard deviation was above +/- 8 mmHg. For diastolic BP, the difference between all of the devices was below 5+/-8 mmHg. CONCLUSIONS: The wrist BP monitor produced results consistent with those of the mercury sphygmomanometer when both were compared with the results of the ABPM. As BP measurement with these devices is a practical and repeatable method, they can be used instead of ABPM in the diagnosis and monitoring of hypertension. However, there is a need for further comparative studies.

Buysse D.J., Thompson W., Scott J., Franzen P.L., Germain A., Hall M., Moul D.E., Nofzinger E.A. & Kupfer D.J. (Apr 2007). Daytime symptoms in primary insomnia: A prospective analysis using ecological momentary assessment. Sleep Med, 8(3):198-208. [Epub 2007 Mar 23]
OBJECTIVES: To prospectively characterize and compare daytime symptoms in primary insomnia (PI) and good sleeper control (GSC) subjects using ecological momentary assessment; to examine relationships between daytime symptom factors, retrospective psychological and sleep reports, and concurrent sleep diary reports. METHODS: Subjects included 47 PI and 18 GSC. Retrospective self-reports of daytime and sleep symptoms were collected. Daytime symptoms and sleep diary information were then collected for 1 week on hand-held computers. The Daytime Insomnia Symptom Scale (DISS) consisted of 19 visual analog scales completed four times per day. Factors for the DISS were derived using functional principal components analysis. Nonparametric tests were used to contrast DISS, retrospective symptom ratings, and sleep diary results in PI and GSC subjects, and to examine relationships among them. RESULTS: Four principal components were identified for the DISS: Alert Cognition, Negative Mood, Positive Mood, and Sleepiness/Fatigue. PI scored significantly worse than GSC on all four factors (p<0.0003 for each). Among PI subjects DISS scales and retrospective psychological symptoms were related to each other in plausible ways. DISS factors were also related to self-report measures of sleep, whereas retrospective psychological symptom measures were not. CONCLUSIONS: Daytime symptom factors of alertness, positive and negative mood, and sleepiness/fatigue, collected with ecological momentary assessment, showed impairment in PI versus GSC. DISS factors showed stronger relationships to retrospective sleep symptoms and concurrent sleep diary reports than retrospective psychological symptoms. The diurnal pattern of symptoms may inform studies of the pathophysiology and treatment outcome of insomnia.

Chandra S., Shiffman, S. & Scharf, D.M. (Feb 2007). Daily Smoking Patterns, Their Determinants, and Implications for Quitting. Experimental and Clinical Psychopharmacology, 15(1):67-80.

In this article, the authors examine daily temporal patterns of smoking in relation to environmental restrictions on smoking and cessation outcomes. Time-series methods were used for analyzing cycles in 351 smokers who monitored their smoking in real time for 2 weeks. The waking day was divided into 8 “bins” of approximately 2 hr, cigarette counts were tallied for each bin, and temporal patterns of smoking and restriction were analyzed. Cluster analyses of smoking patterns by time of day resulted in 4 clusters: daily decline (n = 30; 9%), morning high (n = 43; 12%), flatline (n = 247; 70%), and daily dip-evening incline (n = 31; 9%). Clusters differed in baseline demographic, smoking, and psychosocial variables. Results suggest that smoking behavior can be characterized by regular patterns of smoking frequency during the waking day: Smoking in the flatline cluster was within ±0.5 standard deviation at all times. For the other clusters, smoking was high in the morning (daily dip-evening incline: +1.7 standard deviations; morning high: +2.8 standard deviations; daily decline: +1.7 standard deviations); moderate (morning high: -0.8 standard deviations; daily decline: +0.3 standard deviations) or low (daily dip-evening incline: -1.0 standard deviations) midday; and high (daily dip-evening incline: +2.0 standard deviations), moderate (morning high: +0.5 standard deviations), or low (daily decline: -1.5 standard deviations) in the evening. Daily smoking patterns were related to environmental smoking restrictions, but the strength of this relationship differed among clusters and by time of day. Clusters differed in lapse risk.

Cuspidi C., Meani S., Sala C., Valerio C., Fusi V., Zanchetti A. & Mancia G. (Feb 2007). How reliable is isolated clinical hypertension defined by a single 24-h ambulatory blood pressure monitoring? J Hypertens, 25(2):315-20.

BACKGROUND: Isolated clinical hypertension (ICH) is characterized by a persistently elevated clinic blood pressure in the presence of a normal day-time or 24-h ambulatory blood pressure (ABP). This definition is based on a single ABP monitoring (ABPM) and little attention has been focused on the reproducibility of this condition. OBJECTIVE: To investigate the reliability of the criteria currently recommended by major hypertension guidelines to detect ICH based on a single 24-h ABPM session. METHODS: A total of 611 never-treated grade 1 and 2 hypertensive patients (mean age 46 +/- 12 years) referred for the first time to our out-patient clinic, underwent repeated clinic blood pressure measurements, routine investigations, two 24-h periods of ABPM 1-4 weeks apart, cardiac and carotid ultrasound examinations. ABPM was always performed over a working day and the same daily activities were recommended during the two periods. ICH was diagnosed by the following criteria: (i) mean daytime values < 135/85 mmHg or (ii) mean 24-h blood pressure values < 125/80 mmHg during the first ABPM. RESULTS: The overall prevalence of ICH was 7.1% according to criterion (i) and 5.4% according to criterion (ii). Twenty (46.6%) of the 43 patients with mean daytime blood pressure values < 135/85 mmHg during the first ABPM, exceeded this cut-off value during the second ABPM period. Twenty-two (66.6%) of the 33 patients with mean 24-h blood pressure values < 120/80 mmHg during the first ABPM did not confirm a normal blood pressure profile during the second ABPM recording. Cardiovascular involvement was significantly lower in subjects with persistent normal ABP compared to those with non-reproducible ICH pattern or sustained hypertensives. CONCLUSIONS: These findings clearly indicate that: (i) the classification of ICH on the basis of a single ABPM, using the cut-offs suggested by major hypertension guidelines, has a limited short-term reproducibility and (ii) repeated ABPM recordings should be recommended to correctly diagnose patients with ICH and improve cardiovascular risk stratification.

DeHart T. & Pelham B.W. (2007). Fluctuations in state implicit self-esteem in response to daily negative events. Journal of Experimental Social Psychology, 43(2007):157–165.

A repeated assessment study examined changes in state implicit self-esteem after negative events. Multilevel analyses revealed that trait explicit self-esteem and self-concept clarity moderated the within-person association between daily negative events and state implicit self-esteem. People with low trait explicit self-esteem or low self-concept clarity experienced decreases in state implicit self-esteem when they experienced negative life events. In contrast, for people with high trait explicit self-esteem or high self-concept clarity, state implicit self-esteem remained stable after negative events. In addition, changes in state implicit self-esteem remained significant after controlling for state explicit self-esteem and daily negative affect. This study is the first to study changes in implicit self-esteem in the context of daily life events.

Ebner-Priemer U.W., Kuo J., Kleindienst N., Welch S.S., Reisch T., Reinhard I., Lieb K., Linehan M.M. & Bohus M. (2007 Jan 4). State affective instability in borderline personality disorder assessed by ambulatory monitoring. Psychol Med, 1-10 [Epub ahead of print]

Background. Although affective instability is an essential criterion for borderline personality disorder (BPD), it has rarely been reported as an outcome criterion. To date, most of the studies assessing state affective instability in BPD using paper-pencil diaries did not find indications of this characteristic, whereas in others studies, the findings were conflicting. Furthermore, the pattern of instability that characterizes BPD has not yet been identified.Method. We assessed the affective states of 50 female patients with BPD and 50 female healthy controls (HC) during 24 hours of their everyday life using electronic diaries.Results. In contrast to previous paper-and-pencil diary studies, heightened affective instability for both emotional valence and distress was clearly exhibited in the BPD group but not in the HC group. Inconsistencies in previous papers can be explained by the methods used to calculate instability (see Appendix). In additional, we were able to identify a group-specific pattern of instability in the BPD group characterized by sudden large decreases from positive mood states. Furthermore, 48% of the declines from a very positive mood state in BPD were so large that they reached a negative mood state. This was the case in only 9% of the HC group, suggesting that BPD patients, on average, take less time to fluctuate from a very positive mood state to a negative mood state.Conclusion. Future ambulatory monitoring studies will be useful in clarifying which events lead to the reported, sudden decrease in positive mood in BPD patients.

Ebner-Priemer U.W., Welch S.S., Grossman P., Reisch T., Linehan M.M. & Bohus M. (Apr 2007). Psychophysiological ambulatory assessment of affective dysregulation in borderline personality disorder. Psychiatry Res, 150(3):265-75. [Epub 2007 Feb 23]

Many experts now believe that pervasive problems in affect regulation constitute the central area of dysfunction in borderline personality disorder (BPD). However, data is sparse and inconclusive. We hypothesized that patients with BPD, in contrast to healthy gender and nationality-matched controls, show a higher frequency and intensity of self-reported emotions, altered physiological indices of emotions, more complex emotions and greater problems in identifying specific emotions. We took a 24-hour psychophysiological ambulatory monitoring approach to investigate affect regulation during everyday life in 50 patients with BPD and in 50 healthy controls. To provide a typical and unmanipulated sample, we included only patients who were currently in treatment and did not alter their medication schedule. BPD patients reported more negative emotions, fewer positive emotions, and a greater intensity of negative emotions. A subgroup of non-medicated BPD patients manifested higher values of additional heart rate. Additional heart rate is that part of a heart rate increase that does not directly result from metabolic activity, and is used as an indicator of emotional reactivity. Borderline participants were more likely to report the concurrent presence of more than one emotion, and those patients who just started treatment in particular had greater problems in identifying specific emotions. Our findings during naturalistic ambulatory assessment support emotional dysregulation in BPD as defined by the biosocial theory of [Linehan, M.M., 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder. The Guildford Press, New York.] and suggest the potential utility for evaluating treatment outcome.

Eissa M.A., Meininger J.C., Nguyen T.Q. & Chan W. (Feb 2007). The relationship of ambulatory blood pressure to physical activity in a tri-ethnic population of obese and nonobese adolescents. Am J Hypertens, 20(2):140-7.

BACKGROUND: The association between physical activity (PA) and ambulatory blood pressure (ABP) is documented in adults. This association and factors that may modify it, such as obesity, have not been reported in adolescents. The aims of this study were to determine the association of PA with ABP in 11- to 16-year-old adolescents, and to examine the modifying effects of obesity and other factors. METHODS: Data on 24-h ABP and PA were obtained from 374 adolescents using the wrist actigraph. Correlations between average PA for every 5-min interval preceding each BP measurement and ABP were calculated during the awake period. Mixed-effects models were used with ABP variables as separate, dependent variables. In addition to PA scores for 5 min preceding each BP, body mass index (BMI) z-score and other variables were added to the models as covariates and as interaction terms with activity. RESULTS: Correlations of PA for 5 min preceding BP measurements were 0.22 and 0.25 for systolic blood pressure (SBP) and diastolic blood pressure (DBP) respectively. In mixed-effects analysis, each 1-unit increase in PA was associated with an increase in SBP of 0.02 mm Hg, in DBP of 0.01 mm Hg, and in HR of 0.02 beat/min (P < .0001). The association of BP with PA was significantly less for those with higher BMI z-scores (SBP, P < .001, DBP, P = .027). The associations of PA with SBP and HR were modified by sexual maturation status of the adolescents. CONCLUSIONS: This study found that PA is associated with ABP measurements. These associations are modified by obesity status and other variables. Recognizing these associations may improve the interpretation of ABP measurements.

Ekelund U., Griffin S.J. & Wareham N.J. (Feb 2007). Physical activity and metabolic risk in individuals with a family history of type 2 diabetes. Diabetes Care, 30(2):337-42.

OBJECTIVE: We sought to examine the independent associations between different dimensions of physical activity with intermediary and clustered metabolic risk factors in overweight individuals with an increased risk of type 2 diabetes to inform future preventive action. RESEARCH DESIGN AND METHODS: We measured total body movement and five other subcomponents of physical activity by accelerometry in 258 adults (aged 30-50 years) with a family history of type 2 diabetes. We estimated aerobic fitness from an incremental treadmill exercise test. We measured body composition by bioimpedance and waist circumference, blood pressure, fasting triglycerides, HDL cholesterol, glucose, and insulin with standard methods. We constructed a standardized continuously distributed variable for clustered risk. RESULTS: Total body movement (counts . day(-1)) was significantly and independently associated with three of six risk factors (fasting triglycerides, insulin, and HDL) and with clustered metabolic risk (P = 0.004) after adjustment for age, sex, and obesity. Time spent at moderate- and vigorous-intensity physical activity (MPVA) was independently associated with clustered metabolic risk (P = 0.03). Five- and 10-min bouts of MVPA, time spent sedentary, time spent at light-intensity activity, and aerobic fitness were not significantly related with clustered risk after adjustment for confounding factors. CONCLUSIONS: Total body movement is associated with intermediary phenotypic risk factors for cardiovascular disease and metabolic disease and with clustered metabolic risk independent of aerobic fitness and obesity. Increasing the total amount of physical activity in sedentary and overweight individuals may have beneficial effects on metabolic risk factors.

Fahrenberg J., Myrtek M., Pawlik K. & Perrez M. (2007). Ambulatory assessment – Capturing behavior in daily life. A behavioral science approach to psychology. Psychologische Rundschau, 58(1), 12-23.

Ambulatory Assessment refers to the use of computer-assisted methodology for self-reports, behavior records or physiological measurements, while the participant undergoes normal daily activities. For this, since the nineteeneighties portable microcomputer systems and physiological recorders/analyzers have been developed. In contrast to their use in medicine, up until today the new methods have hardly entered the domain of psychology. Questionnaire methods are still preferred, in spite of the known deficiencies of retrospective self-reports. Assessment strategies include: continuous monitoring, monitoring with time and event sampling methods, in-field psychological testing, field experimentation, interactive assessment, symptom monitoring, and self-management. These approaches are innovative and address ecological validity, context specificity, and are suitable for practical applications. The advantages of this methodology, as well as issues of acceptance, compliance, and reactivity are discussed. Many technical developments and research contributions came from the German-speaking countries and the Netherlands. Nonetheless, but also the current Decade of Behavior (APA) calls for a more wide-spread use of such techniques and developments in assessment. This position paper seeks to make the case for this approach by demonstrating the advantages – and in some domains – necessities of ambulatory monitoring methodology for a behavioral science orientation in psychology.

Ferraris J.R., Ghezzi L., Waisman G.& Krmar R.T.(Feb 2007). ABPM vs office blood pressure to define blood pressure control in treated hypertensive paediatric renal transplant recipients. Pediatr Transplant, 11(1):24-30.

While 24-h ambulatory blood pressure monitoring (ABPM) is an established tool for monitoring antihypertensive therapy in adults, data in children are scarce. We retrospectively analysed whether office blood pressure (BP) is reliable for the diagnosis of BP control in 26 treated hypertensive paediatric renal transplants. Controlled office BP was defined as the mean of three replicate systolic and diastolic BP recordings less than or equal to the 95th age-, sex- and height-matched percentile on the three-outpatient visits closest to ABPM. Controlled ABPM was defined as systolic and diastolic daytime BP < or =95th distribution adjusted height- and sex-related percentile of the adapted ABPM reference. Eight recipients (30%) with controlled office BP were in fact categorized as having non-controlled BP by ABPM criteria. Overall, when office BP and ABPM were compared using the Bland and Altman method, the 95% limits of agreement between office and daytime values ranged from -12.6 to 34.1 mmHg for systolic and -23.9 to 31.7 mmHg for diastolic BP, and the mean difference was 10.7 and 3.9 mmHg respectively. Office readings miss a substantial number of recipients who are hypertensive by ABPM criteria. Undertreatment of hypertension could be avoided if ABPM is applied as an adjunct to office readings.

Fox K.R., Stathi A., McKenna J. & Davis M.G. (2007 Feb 7). Physical activity and mental well-being in older people participating in the Better Ageing Project. Eur J Appl Physiol. [Epub ahead of print]

Increasing evidence suggests that physical activity can prevent some aspects of mental illness in older people such as depression, dementia and Alzheimer’s disease. Additionally, limited research has shown that engagement in structured exercise can improve aspects of psychological well-being such as mood and self-perceptions in older adults. However, the relationship between incidental daily activity such as walking or time spent sedentary, with psychological well-being has not been investigated. The Better Ageing Project provided an opportunity to assess well-being and quality of life using standardised questionnaires with 176 adults aged 70 and over. Accelerometry was used to objectively assess daily energy expended in physical activity at different levels of intensity. In addition, an assessment of the impact of the 12-month Better Ageing structured group exercise programme was assessed through questionnaires and interviews. Total daily physical activity energy expenditure (joules/day) and amount of time spent in activity of at least moderate intensity were weakly related (r = 0.20-0.28) to quality of life, subjective well-being and physical self-perceptions. Time spent sedentary (min/day) was weakly and negatively related to several mental health indicators. The quantitative data showed only minor psychological benefits of the exercise intervention. In contrast, interviews with 27 research participants and 4 exercise leaders suggested that important improvements in perceived function and social benefits had been experienced.

Friedberg, F. & Quick, J.M.S. (Jan 2007). Alexithymia in Chronic Fatigue Syndrome: Associations With Momentary, Recall, and Retrospective Measures of Somatic Complaints and Emotions. Psychosomatic Medicine, 69(1):54-60.

Objective: The relationship between alexithymia and real-time momentary symptom assessments has not been reported. This cross-sectional study hypothesized that alexithymia would be a predictor of somatic symptoms using three different types of symptom measurement (momentary, recall, and retrospective) in the medically unexplained illness of chronic fatigue syndrome (CFS). In addition, it was hypothesized that negative affect would be a significant mediator of the relationship between alexithymia and somatic symptoms. Finally, the relation of alexithymia to physical illness attribution (a CFS illness predictor) was explored. Methods: Participants were 111 adults with CFS. Alexithymia was assessed with the Toronto Alexithymia Scale. Momentary ratings of current symptoms and affect were recorded in electronic diaries carried for 3 weeks. Weekly recall of these momentary reports was also recorded. Retrospective measures included 6-month ratings of fatigue and pain, the Fatigue Severity Scale, the Brief Pain Inventory-Short Form, a CFS symptom measure, the Beck Depression Inventory-II, the Beck Anxiety Inventory, and an illness attribution rating. Results: Partial correlations, controlling for age and sex, yielded no significant associations between general or specific forms of alexithymia and momentary ratings of fatigue or pain. On the other hand, a significant association, partially mediated by anxiety scores, was found between a specific form of alexithymia and a retrospective pain measure. Finally, physical illness attribution was not significantly associated with alexithymia. Conclusion: Based on assessments of real-time and retrospectively measured symptoms, these data provided only modest support for the alexithymia construct as a predictor of somatic symptoms in people with CFS.

Goldberg J., Wolf A., Silberstein S., Gebeline-Myers C., Hopkins M., Einhorn K. & Tolosa J.E. (Mar 2007). Evaluation of an electronic diary as a diagnostic tool to study headache and premenstrual symptoms in migraineurs. Headache, 47(3):384-96.

Objective.-To evaluate an electronic diary as a tool to evaluate the occurrence and relationship of headaches and premenstrual syndrome (PMS) symptoms throughout the menstrual cycle in women with migraine. Background.-Menstrually related headache and PMS significantly impact the quality of life of many women. The time relationship of these 2 menstrually related problems is not well understood and not well described. Methods.-Twenty women with migraine experiencing regular menstrual cycles were enrolled in a prospective study designed to date- and time-stamp data, both self- and computer-prompted, headache and PMS symptoms, for 3 consecutive months. A previously validated PMS score was calculated by grading 23 PMS criteria on a scale of 0 to 3 (0 = no symptoms, 3 = severe symptoms). Results.-The total number of data entries recorded was 2009, composed of 56 menstrual cycles in 20 migraineurs. Five hundred forty-four entries reported a current, prodromal, or previous headache. The mean daily occurrence of headache increased beginning on cycle day -5, peaked on days +1 to +5, and returned to baseline by day +7. Mean daily PMS scores ranged from 2.4 to 12. Mean daily PMS scores peaked on days -6 to +2 and returned to baseline by day +8. Conclusions.-An electronic diary may have potential as a diagnostic tool in studying headaches and PMS symptoms throughout the menstrual cycle. The occurrence of headache and PMS symptoms in migraineurs follows similar time courses.

Goodwin J., Bilous M., Winship S., Finn P. & Jones S.C. (Apr 2007). Validation of the Oscar 2 oscillometric 24-h ambulatory blood pressure monitor according to the British Hypertension Society protocol. Blood Press Monit, 12(2):113-7.

OBJECTIVES: Accuracy of blood pressure measuring devices is of prime importance and should be validated before devices are used clinically. We carried out an independent evaluation of the Oscar 2 oscillometric ambulatory blood pressure monitor (SunTech Medical, Model 222) according to the British Hypertension Society (BHS) Protocol. METHODS: Validation of the Oscar 2 was carried out in accordance with Part 1 of the British Hypertension Society protocol. Having successfully completed the first three phases, in the static validation phase blood pressure measurements were made on 114 participants simultaneously by two observers blinded from each other’s readings and those of the device, giving 255 data pairs for systolic and diastolic blood pressure. Readings were made using simultaneous same-arm measurement, each observer using a dual-head binaural stethoscope and a calibrated mercury sphygmomanometer. Data were recorded independently, to the nearest 2 mmHg and were checked by the supervisor who operated the device. RESULTS: The device mean and observer means (and standard deviations) were exceptionally close across a high range of pressures, with a mean difference for the better observer of 0+/-7 mmHg and -1+/-6 mmHg for systolic and diastolic blood pressure, respectively. With 62% of all systolic blood pressure standard vs. device differences equal or less than 5 mmHg, and 70% of all similar differences for diastolic blood pressure equal to or less than 5 mmHg, the device was categorized as Grade A for systolic and diastolic blood pressure. CONCLUSION: The Oscar 2 was graded A for both systolic and diastolic blood pressure by the British Hypertension Society protocol and can be recommended for clinical use in an adult population.

Hacker E.D. & Ferrans C.E. (Mar 2007). Ecological momentary assessment of fatigue in patients receiving intensive cancer therapy. J Pain Symptom Manage, 33(3):267-75.

The ability to accurately assess the incidence, intensity, and timing of cancer-related fatigue is important for clinicians attempting to manage this symptom and for researchers evaluating interventions to reduce or alleviate fatigue. This methodological report describes our experiences with ecological momentary assessment (EMA) and discusses its applicability for capturing real-time, real-world assessments of fatigue in patients receiving intensive cancer therapy. This methodological report is part of a larger study examining fatigue and physical activity before and after hematopoietic stem cell transplantation (HSCT). A prospective, repeated measures design was used to assess changes in fatigue three days before and three days after intensive cancer therapy and HSCT. A convenience sample (n=20 before HSCT, and n=17 after HSCT) was drawn from two Midwestern academic medical centers. Real-time fatigue was measured with a single-item, global, fatigue intensity scale. Multiple fatigue assessments were conducted throughout each study day. Data were collected electronically, facilitating examination of compliance. Subjects responded to fatigue intensity queries 87% of the time before HSCT and 86% after HSCT. Response rates were not unduly influenced by level of fatigue, time of day, or gender. The study findings demonstrate that it is feasible to use computerized EMA to collect self-report fatigue data in acutely ill oncology patients. Most HSCT patients were able to provide real-time fatigue data even when experiencing multiple side effects from the preparatory regimen. EMA is a novel approach that holds substantial promise for investigating fatigue and other cancer symptoms.

Haynes, S.N. & Yoshioka, D.T. (Mar 2007). Clinical Assessment Applications of Ambulatory Biosensors. Psychological Assessment, 19(1):44-57.

Ambulatory biosensor assessment includes a diverse set of rapidly developing and increasingly technologically sophisticated strategies to acquire minimally disruptive measures of physiological and motor variables of persons in their natural environments. Numerous studies have measured cardiovascular variables, physical activity, and biochemicals such as cortisol in psychopathology and treatment research. The physiological concomitants of many behavior and medical disorders and the benefits of a multimethod assessment strategy provide strong rationales for clinical applications of ambulatory biosensor measurement. A number of psychometric dimensions of evaluation are important in clinical applications of biosensor measurement, including accuracy and validity, reliability and consistency, clinical utility, incremental validity and utility, sensitivity to change, generalizability, cost benefits, and the conditional nature of dimensions of biomeasure evaluation. The authors review ambulatory biosensor methods and make recommendations for use of the technology.

Hermida R.C., Ayala D.E., Fernandez J.R., Mojon A. & Calvo C. (Feb 2007). Influence of measurement duration and frequency on ambulatory blood pressure monitoring. Rev Esp Cardiol, 60(2):131-8.

INTRODUCTION AND OBJECTIVES: Most studies of ambulatory blood pressure monitoring have involved taking measurements every 15-30 minutes over a 24-hour period. We investigated the effect of measurement duration and frequency on the diagnostic blood pressure values obtained by ambulatory monitoring. METHODS: The study involved 1450 hypertensive patients and a control group of 378 normotensive volunteers. Blood pressure was measured at 20-minute intervals from 07:00 to 23:00 and at 30-minute intervals at night for 48 consecutive hours. Data were subdivided in such a way as to generate different series of data that were collected at 1-, 2-, 3-, or 4-hour intervals over the 48-hour period. In addition, two data series at the original measurement frequency were derived for the first and second 24-hour periods. The correspondence between the mean blood pressure values derived from the original data series and those from the different subdivided data series was assessed. RESULTS: Variability in the estimated mean blood pressure increased progressively as the measurement frequency decreased: the error range grew from 11 mmHg for hourly data to 28 mmHg for 4-hourly data. The error range was even greater (i.e., 36 mmHg) for data divided into 24-hour series at the original sampling rate. CONCLUSIONS: This study demonstrates that the reproducibility of mean blood pressure values depends more on measurement duration than measurement frequency. The findings indicate that monitoring blood pressure for only 24 hours may be insufficient for diagnosing hypertension, identifying a dipper circadian pattern, or assessing treatment efficacy.

Herscovici S., Pe’er A., Papyan S. & Lavie P. (Feb 2007). Detecting REM sleep from the finger: an automatic REM sleep algorithm based on peripheral arterial tone (PAT) and actigraphy. Physiol Meas, 28(2):129-40. [Epub 2006 Dec 12]

Scoring of REM sleep based on polysomnographic recordings is a laborious and time-consuming process. The growing number of ambulatory devices designed for cost-effective home-based diagnostic sleep recordings necessitates the development of a reliable automatic REM sleep detection algorithm that is not based on the traditional electroencephalographic, electrooccolographic and electromyographic recordings trio. This paper presents an automatic REM detection algorithm based on the peripheral arterial tone (PAT) signal and actigraphy which are recorded with an ambulatory wrist-worn device (Watch-PAT100). The PAT signal is a measure of the pulsatile volume changes at the finger tip reflecting sympathetic tone variations. The algorithm was developed using a training set of 30 patients recorded simultaneously with polysomnography and Watch-PAT100. Sleep records were divided into 5 min intervals and two time series were constructed from the PAT amplitudes and PAT-derived inter-pulse periods in each interval. A prediction function based on 16 features extracted from the above time series that determines the likelihood of detecting a REM epoch was developed. The coefficients of the prediction function were determined using a genetic algorithm (GA) optimizing process tuned to maximize a price function depending on the sensitivity, specificity and agreement of the algorithm in comparison with the gold standard of polysomnographic manual scoring. Based on a separate validation set of 30 patients overall sensitivity, specificity and agreement of the automatic algorithm to identify standard 30 s epochs of REM sleep were 78%, 92%, 89%, respectively. Deploying this REM detection algorithm in a wrist worn device could be very useful for unattended ambulatory sleep monitoring. The innovative method of optimization using a genetic algorithm has been proven to yield robust results in the validation set.

Houtveen, J.H. & Oei, N.Y.L. (Mar 2007). Recall bias in reporting medically unexplained symptoms comes from semantic memory. Journal of Psychosomatic Research, 62(3):277-282.

Objective: When people report somatic complaints retrospectively, they depend on their memory. Therefore, retrospective reports can be influenced by general beliefs on sickness and health from semantic memory. We hypothesized that individuals with medically unexplained symptoms (MUS) would have recall biases stronger than those of people without complaints when reporting symptoms retrospectively, and that this effect would be a function of time between symptom experience and report. Methods: To compare two time frames, 37 participants who were high and low on MUS reported momentary symptoms combined by daily recall and weekly recall using an electronic diary. Results: Both groups reported more symptoms when recalling the entire week than what could be expected from average momentary reports. However, participants high on MUS also reported more symptoms when recalling a week than when recalling a day. For this group, recall bias was not associated with peak heuristic or symptoms variability. Conclusion: Symptom reports in people high on MUS increases as time passes by, probably as a result of a shift in memory retrieval strategy from using episodic knowledge to using semantic beliefs.

Kleiboer, A.M., Kuijer, R.G. & Hox, J.J. (Jan 2007). Daily negative interactions and mood among patients and partners dealing with multiple sclerosis (MS): The moderating effects of emotional support. Social Science & Medicine, 64(2):389-400.

Negative interactions with intimate partners may have adverse consequences for well-being, especially for individuals dealing with chronic illness. However, it is not clear whether negative interactions affect both dimensions of positive and negative well-being and factors that may moderate this effect have not been well-described. The aim of the present study was to examine the association between daily received negative responses from the partner and end-of-day positive and negative mood in patients with multiple sclerosis (MS) and their intimate partners. Further, the moderating role of receiving emotional support from the partner on the same day was examined. Sixty-one MS patients and their intimate partners were approached via one MS centre and the neurology department of one hospital in the Netherlands and completed computerized diaries for 14 days. Both partners filled out diaries at the end of each day, recording received negative responses, emotional support and end-of-day positive and negative mood. In line with a domain specific model, patients or partners who reported receiving negative responses on a day had higher end-of-day negative mood, whereas received negative responses were unrelated to end-of-day positive mood. Further, for both patients and partners, the adverse effect of received negative responses on end-of day mood was moderated by receiving emotional support on the same day.

Kudielka B.M., Buchtal J., Uhde A. & Wust S. (Jan 2007). Circadian cortisol profiles and psychological self-reports in shift workers with and without recent change in the shift rotation system. Biol Psychol, 74(1):92-103. [Epub 2006 Nov 13]

Cortisol profiles including the cortisol rise in the first hour after awakening (CAR) were assessed during shift work and days off (eight saliva samples per shift). Participants were 102 healthy permanent day and night shift workers (comparison groups) and former permanent day and night shift workers after implementation of a new fast-forward rota including morning, evening, and night shifts. Results show that the CAR is detectable in day as well as night shifts. In permanent night workers cortisol profiles appear to be blunted during night work and days off. However, circadian cortisol profiles are not disturbed in former night workers who recently switched to the fast rotating shift schedule. In contrast, implementation of night work in former day workers seems to lead to initially blunted cortisol profiles that normalize after a short adjustment period. Results of a psychological assessment including exhaustion, chronic stress, effort-reward imbalance, and ratings of sleep quality and sleep length are also presented.

Larkin K.T., Schauss S.L., Elnicki D.M. & Goodie J.L. (2007 Mar 15). Detecting white coat and reverse white coat effects in clinic settings using measures of blood pressure habituation in the clinic and patient self-monitoring of blood pressure. J Hum Hypertens. [Epub ahead of print]

To examine the utility of blood pressure (BP) habituation within and across multiple clinic visits and patient-determined home BP monitoring for detecting white coat (WCE) and reverse white coat effects (RWCE) commonly observed in medical settings, 54 patients undergoing evaluation for hypertension in an internal medicine group practice were categorized according to the magnitude of differences between systolic BP (SBP) and diastolic BP (DBP) obtained in the clinic and through ambulatory BP monitoring. BPs were measured four times during three separate clinic visits, during a 1-week home BP monitoring period, and during a single 24-h ambulatory monitoring period. Patients whose mean clinic and average daytime BPs were within +/-5 mm Hg were categorized as having stable BP; patients whose clinic BPs were >5 mm Hg of their daytime BPs were categorized as showing a WCE and patients whose average daytime BPs were >5 mm Hg of their clinic BPs were categorized as showing a RWCE. Results revealed that degree of habituation occurring between the first and third clinic visits significantly predicted magnitude of both the WCE and RWCE for SBP, with greater habituation being associated with the WCE and lesser habituation associated with the RWCE. Greater SBP habituation within clinic visits was associated with the WCE for SBP and greater DBP habituation within clinic visits was associated with the WCE for DBP. Lesser DBP habituation within clinic visits was associated with the RWCE for both SBP and DBP. Home BP monitoring did not contribute to predicting either WCE or RWCE.

Maffiuletti N.A., Gorelick M., Kramers-de Quervain I., Bizzini M., Munzinger J.P., Tomasetti S. & Stacoff A. (2007 Feb 28). Concurrent validity and intrasession reliability of the IDEEA accelerometry system for the quantification of spatiotemporal gait parameters. Gait Posture. [Epub ahead of print]

The aim of this pilot study was to evaluate concurrent validity and intrasession reliability of the IDEEA (Minisun, Fresno, CA) accelerometry system (and associated software) with force plate measurements for spatiotemporal gait variables recorded during normal walking. Ten healthy individuals were asked to walk at a self-selected comfortable speed, over five multicomponent force plates embedded into the walkway floor. For each trial, spatiotemporal gait parameters (single support time, cadence, speed, step and stride length) obtained by the force plates were compared to those recorded by IDEEA. Concurrent (criterion-related) validity between the two systems was analysed with intraclass correlation (ICC) (2,1). Intrasession reliability was quantified by using coefficient of variations (CV) and ICC. For the ensemble of the parameters, ICC (2,1) ranged between 0.998 (cadence) and 0.784 (step length right) (p<0.001-0.01). However, speed, step length and stride length were significantly lower for IDEEA ( approximately 7%; p<0.001) compared to force plate data. Intrasession reliability of IDEEA was excellent, with CV lower than 5.7 and ICC higher than 0.961. The present accelerometry system demonstrated strong concurrent validity for the assessment of spatiotemporal gait parameters. However, spatial variables (stride and step length) and walking speed were significantly underestimated compared with analyses using force plates.

Nagels, G., Engelborghs, S. & Vloeberghs, E. (Jan 2007). Correlation between actigraphy and nurses’ observation of activity in dementia. International Journal of Geriatric Psychiatry, 22(1):84-86.

Recently, actigraphy has been validated as a tool for the evaluation of agitated behaviour in dementia. As quantification of agitated behaviour nowadays mostly relies on (subjective) caregiver-based information, we set up a study to correlate actigraphic recordings with nurses’ observations of activity in dementia. Actigraphic recordings were made using an octagonal basic motionlogger (Ambulatory monitoring, New York, USA), as described in detail elsewhere. Subjects wore the actigraph continuously on the non-dominant wrist. The device provides three possible modes of measurement: Zero Crossing Mode (ZCM), Time-Above-Threshold (TAT), and Proportional Integrating Measure (PIM). Moderate positive but highly significant correlations were found between actigraphic recordings and observed activity scores, as rated by experienced nursing staff. These data further support the role of actigraphy for the standardised and objective evaluation of activity disturbances in dementia, which is one of the most frequently observed behavioural disturbances in dementia. An important potential advantage of actigraphy is that it does not require an observer during the recording period. Indeed, behavioural observation and behavioural assessment scales heavily depend on observers, which might provide information of varying quality.

O’Connell, K.A., Hosein, V.L. & Schwartz, J.E. (Jan 2007). How Does Coping Help People Resist Lapses During Smoking Cessation? Health Psychology, 26(1):77-84.

Objectives: To determine whether types of coping strategies have differential effects on preventing lapses and lowering urge levels and to investigate mechanisms by which coping strategies prevent lapses during smoking cessation. Design: Sixty-one respondents performed ecological momentary assessment using palm-top computers and tape recorders to report their coping strategies and urge levels before and after temptations to smoke. Multilevel linear regression models were used to compare the effects of individual strategy types with the average strategy. Main Outcome Measures: Lapses versus resisted temptations and changes in urge levels. Results: Number of strategies significantly predicted resisting smoking and change in urge levels. Compared with the effect of the average strategy, movement/exercise was marginally worse at preventing lapses, and food/drink was marginally related to higher postcoping urge levels. Conclusion: Although using multiple coping strategies helps people resist the urge to smoke, no particular coping strategy works better than any other. Coping strategies prevent lapses by reducing high urge levels during temptations.

Piasecki, T.M., Hufford, M.R. & Solhan, M. (Mar 2007). Assessing Clients in Their Natural Environments With Electronic Diaries: Rationale, Benefits, Limitations, and Barriers. Psychological Assessment, 19(1):25-43.

Increasingly, mobile technologies are used to gather diary data in basic research and clinical studies. This article considers issues relevant to the integration of electronic diary (ED) methods in clinical assessment. EDs can be used to gather rich information regarding clients’ day-to-day experiences, aiding diagnosis, treatment planning, treatment implementation, and treatment evaluation. The authors review the benefits of using diary methods in addition to retrospective assessments, and they review studies assessing whether EDs yield higher quality data than conventional, less expensive paper-pencil diaries. Practical considerations–including what platforms can be used to implement EDs, what features they should have, and considerations in designing diary protocols for sampling different types of clinical phenomena–are described. The authors briefly illustrate with examples some ways in which ED data could be summarized for clinical use. Finally, the authors consider barriers to clinical adoption of EDs. EDs are likely to become increasingly popular tools in routine clinical assessment as clinicians become more familiar with the logic of diary designs; as software packages evolve to meet the needs of clinicians; and as mobile technologies become ubiquitous, robust, and inexpensive.

Plamondon A., Delisle A., Larue C., Brouillette D., McFadden D., Desjardins P. & Lariviere C. (2007 Mar 21). Evaluation of a hybrid system for three-dimensional measurement of trunk posture in motion. Appl Ergon. [Epub ahead of print]

Ambulatory assessment of trunk posture is important in improving our understanding of the risk of low back injury. Recently, small inertial sensors combining accelerometers, gyroscopes and magnetometers were developed and appear to be promising for measuring human movement. However, the validity of such sensors for assessing three-dimensional (3D) trunk posture in motion has not been documented. The purpose of this study was to evaluate a hybrid system (HS) composed of two inertial sensors for the 3D measurement of trunk posture. A secondary purpose was to explore the utility of adding another source of information, a potentiometer, to measure the relative rotation between both sensors in order to improve the validity of the system. The first sensor was placed over the sacrum and the second on the upper part of the thorax. Both sensors were linked by a flexible rod with a potentiometer. A complementary quaternion filter algorithm was used to estimate trunk orientation by taking advantage of the nine components of each sensor and the potentiometer. The HS’s orientations were compared to those obtained from a 3D optoelectronic system. Validation of the HS was performed in three steps in which six subjects had to perform manual handling tasks in: (1) static postures; (2) dynamic motions of short duration (30s); and (3) dynamic motions of long duration (30min). The results showed that the root mean square (RMS) error of the HS was generally below 3 degrees for the flexion and lateral bending axes, and less than 6 degrees for the torsion axis, and that this error was lower for the short-duration tests compared to the long-duration one. The potentiometer proved to be an essential addition, particularly when the magnetometer signals were corrupted and only the gyroscope and accelerometer could be combined. It is concluded that the HS can be a useful tool for quantifying 3D trunk posture in motion.

Raselli, C. & Broderick, J.E. (Mar 2007). The association of depression and neuroticism with pain reports: A comparison of momentary and recalled pain assessment. Journal of Psychosomatic Research, 62(3):313-320.

Objective: Pain assessment has been shown to be affected by depression, neuroticism, and recall bias. The purpose of this study was to determine whether momentary pain assessment, compared with recalled pain reports, would diminish the influence of neuroticism and depression on the measurement of pain. Methods: Patients with chronic pain (n=66) completed depression (Beck Depression Inventory II) and neuroticism (NEO Personality Inventory) questionnaires, made weekly recall pain ratings, judged their change in pain from 1 week to the next over a 4-week period, and collected momentary reports of pain intensity and pain unpleasantness over a 2-week period. Results: Analyses showed that neuroticism and depression correlated with pain intensity and pain unpleasantness at low levels for both momentary and recalled pain reports. Neuroticism and depression did not influence the accuracy of recalled pain (difference between momentary and recalled data). Both neuroticism and depression were systematically associated with ratings of judged change in pain even when actual changes in pain were controlled. Specifically, for increased levels of baseline depression and neuroticism, patients displayed a pattern of judging recent pain as more severe than pain in the previous week following several weeks of symptom monitoring. Conclusion: There was little evidence for neuroticism and depression affecting either recall or momentary pain ratings or influencing the accuracy of recall ratings. However, neuroticism and depression did influence pain assessment when the task involved rating change in pain-a measure widely used in clinical research.

Ridgers N.D., Stratton G., Fairclough S.J. & Twisk J.W. (2007 Feb 1). Long-term effects of a playground markings and physical structures on children’s recess physical activity levels. Prev Med. [Epub ahead of print]

OBJECTIVE.: The aim of the study was to investigate the impact of a playground redesign intervention across time on children’s recess physical activity levels using combined physical activity measures and to evaluate the potential influence of covariates on the intervention effect. METHOD.: Fifteen schools located in areas of high deprivation in one large city in England each received pound20,000 through a national pound10 million Sporting Playgrounds Initiative to redesign the playground environment based on a multicolored zonal design. Eleven schools served as matched socioeconomic controls. Physical activity levels during recess were quantified using heart rate telemetry and accelerometry at baseline, 6 weeks and 6 months following the playground redesign intervention. Data were collected between July 2003 and January 2005 and analyzed using multilevel modeling. RESULTS.: Statistically significant intervention effects were found across time for moderate-to-vigorous and vigorous physical activity assessed using both heart rate and accelerometry. CONCLUSIONS.: The results suggest that a playground redesign, which utilizes multicolor playground markings and physical structures, is a suitable stimulus for increasing children’s school recess physical activity levels.

Rowlands A.V., Stone M.R. & Eston R.G. (Apr 2007). Influence of Speed and Step Frequency during Walking and Running on Motion Sensor Output. Med Sci Sports Exerc, 39(4):716-27.

PURPOSE: Studies have reported strong linear relationships between accelerometer output and walking/running speeds up to 10 km.h. However, ActiGraph uniaxial accelerometer counts plateau at higher speeds. The aim of this study was to determine the relationships of triaxial accelerometry, uniaxial accelerometry, and pedometry with speed and step frequency (SF) across a range of walking and running speeds. METHODS: Nine male runners wore two ActiGraph uniaxial accelerometers, two RT3 triaxial accelerometers (all set at a 1-s epoch), and two Yamax pedometers. Each participant walked for 60 s at 4 and 6 km.h, ran for 60 s at 10, 12, 14, 16, and 18 km.h, and ran for 30 s at 20, 22, 24, and 26 km.h. Step frequency was recorded by a visual count. RESULTS:: ActiGraph counts peaked at 10 km.h (2.5-3.0 Hz SF) and declined thereafter (r = 0.02, P > 0.05). After correction for frequency-dependent filtering, output plateaued at 10 km.h but did not decline (r = 0.77, P < 0.05). Similarly, RT3 vertical counts plateaued at speeds > 10 km.h (r = 0.86, P < 0.01). RT3 vector magnitude and anteroposterior and mediolateral counts maintained a linear relationship with speed (r > 0.96, P < 0.001). Step frequency assessed by pedometry compared well with actual step frequency up to 20 km.h (approximately 3.5 Hz) but then underestimated actual steps (Yamax r = 0.97; ActiGraph pedometer r = 0.88, both P < 0.001). CONCLUSION: Increasing underestimation of activity by the ActiGraph as speed increases is related to frequency-dependent filtering and assessment of acceleration in the vertical plane only. RT3 vector magnitude was strongly related to speed, reflecting the predominance of horizontal acceleration at higher speeds. These results indicate that high-intensity activity is underestimated by the ActiGraph, even after correction for frequency-dependent filtering, but not by the RT3. Pedometer output is highly correlated with step frequency.

Salarian A., Russmann H., Wider C., Burkhard P.R., Vingerhoets F.J. & Aminian K. (Feb 2007). Quantification of tremor and bradykinesia in Parkinson’s disease using a novel ambulatory monitoring system. IEEE Trans Biomed Eng, 54(2):313-22.

An ambulatory system for quantification of tremor and bradykinesia in patients with Parkinson’s disease (PD) is presented. To record movements of the upper extremities, a sensing units which included miniature gyroscopes, has been fixed to each of the forearms. An algorithm to detect and quantify tremor and another algorithm to quantify bradykinesia have been proposed and validated. Two clinical studies have been performed. In the first study, 10 PD patients and 10 control subjects participated in a 45-min protocol of 17 typical daily activities. The algorithm for tremor detection showed an overall sensitivity of 99.5% and a specificity of 94.2% in comparison to a video reference. The estimated tremor amplitude showed a high correlation to the Unified Parkinson’s Disease Rating Scale (UPDRS) tremor subscore (e.g., r = 0.87, p < 0.001 for the roll axis). There was a high and significant correlation between the estimated bradykinesia related parameters estimated for the whole period of measurement and respective UPDRS subscore (e.g., r = -0.83, p < 0.001 for the roll axis). In the second study, movements of upper extremities of 11 PD patients were recorded for periods of 3-5 hr. The patients were moving freely during the measurements. The effects of selection of window size used to calculate tremor and bradykinesia related parameters on the correlation between UPDRS and these parameters were studied. By selecting a window similar to the period of the first study, similar correlations were obtained. Moreover, one of the bradykinesia related parameters showed significant correlation (r = -0.74, p < 0.01) to UPDRS with window sizes as short as 5 min. Our study provides evidence that objective, accurate and simultaneous assessment of tremor and bradykinesia can be achieved in free moving PD patients during their daily activities.

Shelby-James T.M., Abernethy A.P., McAlindon A. & Currow D.C. (Feb 2007). Handheld computers for data entry: high tech has its problems too. Trials, 20;8:5.

BACKGROUND: The use of handheld computers in medicine has increased in the last decade, they are now used in a variety of clinical settings. There is an underlying assumption that electronic data capture is more accurate that paper-based data methods have been rarely tested. This report documents a study to compare the accuracy of hand held computer data capture versus more traditional paper-based methods. METHODS: Clinical nurses involved in a randomised controlled trial collected patient information on a hand held computer in parallel with a paper-based data form. Both sets of data were entered into an access database and the hand held computer data compared to the paper-based data for discrepancies. RESULTS: Error rates from the handheld computers were 67.5 error per 1000 fields, compared to the accepted error rate of 10 per 10,000 field for paper-based double data entry. Error rates were highest in field containing a default value. CONCLUSION: While popular with staff, unacceptable high error rates occurred with hand held computers. Training and ongoing monitoring are needed if hand held computers are to be used for clinical data collection.

Sonnenschein M., Mommersteeg P.M., Houtveen J.H., Sorbi M.J., Schaufeli W.B. & van Doornen L.J. (2007 Feb 20). Exhaustion and endocrine functioning in clinical burnout: An in-depth study using the experience sampling method. Biol Psychol. [Epub ahead of print]

The current study investigates the relationship between HPA-axis functioning and burnout symptoms by employing an electronic symptom diary. This diary method circumvents the retrospection bias induced by symptom questionnaires and allows to study relationships within-in addition to between-subjects. Forty two clinically burned-out participants completed the exhaustion subscale of the Maslach burnout inventory and kept an electronic diary for 2 weeks to assess momentary exhaustion and daily recovery through sleep. On 3 consecutive weekdays within the diary period, saliva was sampled to determine the cortisol awakening response (CAR), levels of dehydroepiandrosterone-sulphate (DHEAS) on the first 2 weekdays, and to conduct the dexamethasone suppression test (DST) on the third weekday. We found significant relationships between endocrine values and general momentary symptom severity as assessed with the diary, but not with the retrospective questionnaire-assessed burnout symptoms. Simultaneous assessments of endocrine values and burnout symptoms assessed with the diary after awakening rendered significant associations between persons, and a trend within persons. More severe burnout symptoms were consistently associated with a lower level and smaller increase of CAR, higher DHEAS levels, smaller cortisol/DHEAS ratios and a stronger suppression after DST. Burnout symptoms were significantly related to endocrine functioning in clinical burnout under the best possible conditions of symptom measurement. This adds support to the view that severity of burnout symptoms is associated with HPA-axis functioning.

Sonnenschein M., Sorbi M.J., van Doornen L.J., Schaufeli W.B.& Maas C.J. (Apr 2007). Evidence that impaired sleep recovery may complicate burnout improvement independently of depressive mood. J Psychosom Res, 62(4):487-94.

OBJECTIVE: This article examines recovery through sleep in relation to sleep quality, exhaustion, and depression in clinical burnout. We focus on actual recovery per night, given its relevance to burnout improvement. METHODS: Sixty clinically burned-out participants and 40 healthy controls recorded symptoms with an electronic diary for 2 weeks at random times per day. Recovery through sleep was defined as the difference in fatigue between late evening and the next morning. RESULTS: In clinical burnout, sleep quality and recovery are impaired, and depression is elevated. Poor recovery through sleep is associated with poor same-night sleep quality, clarifying the mechanisms underlying poor recovery. Individual differences in recovery though sleep were related to differences in refreshed awakening, but not to other sleep problems. Impaired recovery was also related to severity of exhaustion, but not to severity of depressive mood, indicating that, in burnout, nonprofit from sleep is a symptom of energy depletion, not a sign of depression. CONCLUSION: Impaired recovery through sleep may hamper recovery from burnout independently of the influence of depression.

Tobe S.W., Kiss A., Sainsbury S., Jesin M., Geerts R. & Baker B. (Feb 2007). The impact of job strain and marital cohesion on ambulatory blood pressure during 1 year: the double exposure study. Am J Hypertens, 20(2):148-53.

BACKGROUND: Psychosocial and lifestyle stressors, such as job strain and marital factors, have previously been associated with a sustained increase in blood pressure (BP). METHODS: In a 1-year longitudinal study, we evaluated whether job strain and marital cohesion continued to be associated with ambulatory blood pressure (ABP). The final study cohort included 229 male and female volunteers who were still employed and living with a significant other as at baseline and could complete all aspects of the follow-up testing. RESULTS: The interaction between job strain and marital cohesion was significantly associated with a change in ABP during 1 year for 24-h systolic BP but not diastolic BP (P = .018 and .13, respectively). This association also occurred for job strain (P = .011). Subjects with high job strain and a low cohesive marriage had an increase in systolic BP by 3 mm Hg during 1 year, and those with job strain who also had a highly cohesive marriage had a reduction of systolic BP by 3 mm Hg during 1 year. An exploratory analysis for gender effects found that the interaction between job strain and marital cohesion was found only in women (P = .025). CONCLUSIONS: Marital cohesion consistently interacted with the sustained elevation of BP associated with job strain over time in men and women. Low marital cohesion exacerbated the effect of job strain to elevate BP and high marital cohesion ameliorated it. This interaction may be gender specific in that it was demonstrated separately in women but not in men.

Vansteelandt K., Rijmen F., Pieters G., Probst M. & Vanderlinden J. (2007 Jan 17). Drive for thinness, affect regulation and physical activity in eating disorders: A daily life study. Behav Res Ther. [Epub ahead of print]

Using Ecological Momentary Assessment, the within patient associations between drive for thinness, emotional states, momentary urge to be physically active and physical activity were studied in 32 inpatients with an eating disorder. Participants received an electronic device and had to indicate at nine random times a day during 1 week their momentary drive for thinness, positive and negative emotional states and their urge to be physically active and physical activity. Multilevel analyses indicated that patients with higher mean levels for urge to be physically active were characterized by lower body mass index (BMI) and chronically negative affect whereas patients with higher mean levels for physical activity were characterized by lower BMI and higher dispositions for drive for thinness. In addition, within patient relations between drive for thinness and urge to be physically active were moderated by BMI and chronically negative affect whereas within patient relations between drive for thinness and physical activity were moderated by BMI. Finally, also positive emotional states were significantly associated with physical activity within patients. By using a daily process design, characteristics of physical activity were revealed that have not been identified with assessment methods that have a lower time resolution.

Webster, G. D., Kirkpatrick, L. A., Nezlek, J. B., Smith, C. V., & Paddock, E. L. (2007). Different slopes for different folks: Self-esteem instability and gender as moderators of the relationship between self-esteem and attitudinal aggression. Self and Identity, 6, 74-94.

The present research examined the relationships among self-esteem level, temporal self-esteem instability, gender, and self-reported aggression. Self-esteem level was negatively related to attitudinal aggression, although this relationship varied as a joint function of self-esteem instability and gender. It was strongest among men with unstable self-esteem and among women with stable self-esteem. Although self-esteem instability and narcissism (Study 3) were each positively related to behavioral aggression, the relationship between narcissism and attitudinal aggression varied as a function of self-esteem instability. The relationship between narcissism and attitudinal aggression was positive among people with stable self-esteem, but negative among people with unstable self-esteem, regardless of gender. The importance of considering gender, self-esteem instability, and narcissism in the self-esteem/aggression debate is discussed.

Wonderlich S.A., Rosenfeldt S., Crosby R.D., Mitchell J.E., Engel S.G., Smyth J. & Miltenberger R. (Feb 2007). The effects of childhood trauma on daily mood lability and comorbid psychopathology in bulimia nervosa. J Trauma Stress, 20(1):77-87.

A study of bulimic women examined the relationship between histories of childhood trauma and psychiatric disorders, as well as daily measures of mood and behavior. One hundred twenty-three women with bulimia nervosa were assessed with interviews and completed an Ecological Momentary Assessment (EMA) protocol in which they carried a palmtop computer for 2 weeks. Sexual abuse was associated with a history of mood and anxiety disorders, and emotional abuse with eating disorder psychopathology. In the EMA assessment, sexual abuse was associated with daily purging frequency and self-destructive behavior. Emotional abuse was associated with average daily mood and mood lability. These findings support the idea that child maltreatment may be associated with various aspects of bulimia-related psychopathology.

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