Publications by authors named "Matthew M Burg"

136 Publications

Anhedonic Depression Is Not Associated With Risk of Recurrent Major Adverse Cardiac Events and All-Cause Mortality in Acute Coronary Syndrome Patients.

Ann Behav Med 2021 Oct 12. Epub 2021 Oct 12.

Center for Personalized Health, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.

Background: Depression after acute coronary syndrome (ACS) is common and increases risks of adverse outcomes, but it remains unclear which depression features are most associated with major adverse cardiac events (MACE) and all-cause mortality (ACM).

Purpose: To examine whether a subtype of depression characterized by anhedonia and major depressive disorder (MDD) predicts 1-year MACE/ACM occurrence in ACS patients compared to no MDD history. We also consider other depression features in the literature as predictors.

Methods: Patients (N = 1,087) presenting to a hospital with ACS completed a self-report measure of current depressive symptoms in-hospital and a diagnostic interview assessing MDD within 1 week post-hospitalization. MACE/ACM events were assessed at 1-, 6-, and 12-month follow-ups. Cox regression models were used to examine the association of the anhedonic depression subtype and MDD without anhedonia with time to MACE/ACM, adjusting for sociodemographic and clinical covariates.

Results: There were 142 MACE/ACM events over the 12-month follow-up. The 1-year MACE/ACM in patients with anhedonic depression, compared to those with no MDD, was somewhat higher in an age-adjusted model (hazard ratio [HR] = 1.63, p = .08), but was not significant after further covariate adjustment (HR = 1.24, p = .47). Of the additional depression features, moderate-to-severe self-reported depressive symptoms significantly predicted the risk of MACE/ACM, even in covariate-adjusted models (HR = 1.72, p = .04), but the continuous measure of self-reported depressive symptoms did not.

Conclusion: The anhedonic depression subtype did not uniquely predict MACE/ACM as hypothesized. Moderate-to-severe levels of total self-reported depressive symptoms, however, may be associated with increased MACE/ACM risk, even after accounting for potential sociodemographic and clinical confounders.
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http://dx.doi.org/10.1093/abm/kaab092DOI Listing
October 2021

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

Contemp Clin Trials 2021 Sep 29;110:106583. Epub 2021 Sep 29.

VA VISN 17 Center of Excellence for Research on Returning War Veterans, Waco, TX, USA; Central Texas Veterans Health Care System, Temple, TX, USA. Electronic address:

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.
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http://dx.doi.org/10.1016/j.cct.2021.106583DOI Listing
September 2021

Sex Differences in Use of a Clinical Complexity Measure to Predict Primary Care Utilization.

J Womens Health (Larchmt) 2021 Aug 12. Epub 2021 Aug 12.

VA Connecticut Healthcare System, West Haven, Connecticut, USA.

The Veterans Affairs (VA)-developed Care Assessment Need (CAN) score, a risk-stratification tool used to identify complex high-risk patients and guide VA care coordination, was designed to predict hospitalization or death. Little is known about its utility in predicting primary care utilization or if gender differences in this metric are detectable. Our objective was to determine association of CAN score quintiles with high primary care visit (PCV) utilization among Veterans, the impact of adding reproductive health and psychosocial variables to the model and the difference between men and women Veterans. The sample included men and women from the post-9/11 cohort receiving VA care for at least 1 year, 2010-2017 ( = 665,379). PCV data for each year were collected from national Corporate Data Warehouse. A cumulative count ≥6 visits in a year was used as an indication for high PCV utilization in the analyses. After accounting for potential confounding factors, women were associated with 42% higher odds of heavy PCV utilization (adjusted odds ratio: 1.42, 95% confidence interval: 1.37-1.46) than men. However, there was a significant interaction between sex and CAN quintiles ( < 0.001). After adjusting for all the covariates, CAN score quintiles appeared to have stronger associations and better predictive accuracy on the risk of 1-year heavy PCV utilization for men than for women. Further research is needed to understand sex differences in Veterans Health Administration clinical complexity measures and whether they can be successfully used to identify high-risk, high-utilizing women Veterans.
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http://dx.doi.org/10.1089/jwh.2021.0103DOI Listing
August 2021

Pain intensity and pain medication prescription patterns in Veterans with heart failure and back pain.

Heart Lung 2021 Nov-Dec;50(6):770-774. Epub 2021 Jul 2.

VA Connecticut Healthcare System, West Haven, CT, USA; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.

Background: Pain and heart failure are highly comorbid.

Objectives: The purpose of this study was to examine differences in pain intensity and pain medication prescriptions among Veterans with comorbid heart failure and pain and those with pain alone.

Methods: The Musculoskeletal Disorder (MSD) cohort includes 5,237,763 Veteran diagnosed with a musculoskeletal disorder between 2000 and 2013. Veterans with comorbid heart failure and back pain (heart failure+, n = 3,950, M = 70.5 ± 12) were compared to those with back pain alone (heart failure-, n = 165,290, M = 52.1 ± 17.5).

Results: In multivariate adjusted models, heart failure+ was associated with a higher likelihood of moderate/severe pain (OR = 1.12; 95% CI 1.04-1.21), a higher likelihood of opioids (OR = 1.63; CI = 1.52-1.75) and/or gabapentin prescriptions (OR = 1.18; CI = 1.02-1.36), but a lower likelihood of NSAID prescriptions (OR = 0.57; CI = 0.50-0.66).

Conclusions: Comorbid cardiovascular and pain conditions present a challenge in clinical management that warrants further study.
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http://dx.doi.org/10.1016/j.hrtlng.2021.04.016DOI Listing
July 2021

Variation in propofol induction doses administered to surgical patients over age 65.

J Am Geriatr Soc 2021 08 31;69(8):2195-2209. Epub 2021 Mar 31.

Department of Anesthesiology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.

Background/objectives: Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery.

Design: Retrospective observational study using the Multicenter Perioperative Outcomes Group data set.

Setting: Thirty-six institutions across the United States.

Participants: A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018.

Intervention: None.

Measurements: Total induction bolus dose of propofol administered.

Results: The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older.

Conclusion: The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.
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http://dx.doi.org/10.1111/jgs.17139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373684PMC
August 2021

A broken heart after child loss.

Eur Heart J 2021 04;42(15):1496-1498

Yale University, School of Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA.

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http://dx.doi.org/10.1093/eurheartj/ehab058DOI Listing
April 2021

Baseline Characteristics from the Women Veterans Cohort Study: Gender Differences and Similarities in Health and Healthcare Utilization.

J Womens Health (Larchmt) 2021 07 13;30(7):944-955. Epub 2021 Jan 13.

VA Connecticut Healthcare System, West Haven, Connecticut, USA.

With the unprecedented expansion of women's roles in the U.S. military during recent (post-9/11) conflicts in Iraq and Afghanistan, the number of women seeking healthcare through the Veterans Health Administration (VHA) has increased substantially. Women Veterans often present as medically complex due to multiple medical, mental health, and psychosocial comorbidities, and consequently may be underserved. Thus, we conducted the nationwide Women Veterans Cohort Study (WVCS) to examine post-9/11 Veterans' unique healthcare needs and to identify potential disparities in health outcomes and care. We present baseline data from a comprehensive questionnaire battery that was administered from 2016 to 2019 to a national sample of post-9/11 men and women Veterans who enrolled in Veterans Affairs care (WVCS2). Data were analyzed for descriptives and to compare characteristics by gender, including demographics; health risk factors and symptoms of cardiovascular disease, chronic pain, and mental health; healthcare utilization, access, and insurance. WVCS2 included 1,141 Veterans (51% women). Women were younger, more diverse, and with higher educational attainment than men. Women also endorsed lower traditional cardiovascular risk factors and comorbidities (, weight, hypertension) and greater nontraditional cardiovascular risk factors (, trauma, psychological symptoms). More women reported single-site pain (, neck, stomach, pelvic) and multisite pain, but did not differ from men in posttraumatic stress disorder (PTSD) symptoms or treatment for PTSD. Women seek care at VHA medical centers more frequently, often combined with outside health services, but do not significantly differ from men in their insurance coverage. Overall, this investigation indicates substantial variation in risk factors, health outcomes, and healthcare utilization among post-9/11 men and women Veterans. Further research is needed to determine best practices for managing women Veterans in the VHA healthcare system.
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http://dx.doi.org/10.1089/jwh.2020.8732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8290312PMC
July 2021

Reliability of Office, Home, and Ambulatory Blood Pressure Measurements and Correlation With Left Ventricular Mass.

J Am Coll Cardiol 2020 12;76(25):2911-2922

Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA.

Background: Determining the reliability and predictive validity of office blood pressure (OBP), ambulatory BP (ABP), and home BP (HBP) can inform which is best for diagnosing hypertension and estimating risk of cardiovascular disease.

Objectives: This study aimed to assess the reliability of OBP, HBP, and ABP and evaluate their associations with left ventricular mass index (LVMI) in untreated persons.

Methods: The Improving the Detection of Hypertension (IDH) study, a community-based observational study, enrolled 408 participants who had OBP assessed at 3 visits, and completed 3 weeks of HBP, 2 24-h ABP recordings, and a 2-dimensional echocardiogram. Mean age was 41.2 ± 13.1 years, 59.5% were women, 25.5% African American, and 64.0% Hispanic.

Results: The reliability of 1 week of HBP, 3 office visits with mercury sphygmomanometry, and 24-h ABP were 0.938, 0.894, and 0.846 for systolic and 0.918, 0.847, and 0.843 for diastolic BP, respectively. The correlations among OBP, HBP, and ABP, corrected for regression dilution bias, were 0.74 to 0.89. After multivariable adjustment including OBP and 24-h ABP, 10 mm Hg higher systolic and diastolic HBP were associated with 5.07 (standard error [SE]: 1.48) and 3.92 (SE: 2.14) g/m higher LVMI, respectively. After adjustment for HBP, neither systolic or diastolic OBP nor ABP was associated with LVMI.

Conclusions: OBP, HBP, and ABP assess somewhat distinct parameters. Compared with OBP (3 visits) or 24-h ABP, systolic and diastolic HBP (1 week) were more reliable and more strongly associated with LVMI. These data suggest that 1 week of HBP monitoring may be the best approach for diagnosing hypertension.
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http://dx.doi.org/10.1016/j.jacc.2020.10.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749264PMC
December 2020

Posttraumatic Stress Disorder, Antidepressant Use, and Hemorrhagic Stroke in Young Men and Women: A 13-Year Cohort Study.

Stroke 2021 01 10;52(1):121-129. Epub 2020 Dec 10.

VA Connecticut Healthcare System, West Haven (A.E.G., M.M.B., S.G.H., C.A.B., M.S., J.D., J.J.S.).

Background And Purpose: Antidepressants are commonly prescribed for posttraumatic stress disorder (PTSD) and may increase the risk of bleeding, including hemorrhagic stroke.

Methods: We prospectively examined independent effects of PTSD, selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRI) on the risk of incident hemorrhagic stroke in a nationwide sample of 1.1 million young and middle-aged veterans. Time-varying multivariate Cox models were used to examine hemorrhagic stroke risk by PTSD status and use of SSRI or SNRI while adjusting for demographics, lifestyle factors, stroke, and psychiatric comorbidities. Sensitivity analyses controlled for health care utilization.

Results: During 13 years of follow-up (2.14 years on average), 507 patients (12% women) suffered a hemorrhagic stroke. The overall incidence rate was 1.70 events per 10 000-person years. In unadjusted models, PTSD was associated with an 82% greater risk of new-onset hemorrhagic stroke (hazard ratio [HR], 1.82 [95% CI, 1.48-2.24]), SSRI use was associated with a >2-fold risk (HR, 2.02 [95% CI, 1.66-2.57]), and SNRI use was associated with a 52% greater risk (HR, 1.52 [95% CI, 1.08-2.16]). In fully adjusted models, effects of PTSD and SNRI were attenuated (adjusted HR, 1.03 [95% CI, 0.81-1.34]; adjusted HR, 1.19 [95% CI, 0.83-1.71]), but SSRI use remained associated with a 45% greater risk of hemorrhagic stroke (adjusted HR, 1.45 [95% CI, 1.13-1.85]). Hypertension, drug abuse, and alcohol abuse were also associated with increased stroke risk. Nonobesity and being non-Hispanic were protective factors. In sensitivity analyses, health care utilization was a small but significant predictor of stroke.

Conclusions: In the largest known investigation of PTSD and antidepressant-associated risk for hemorrhagic stroke in young adults, use of SSRIs, but neither PTSD nor SNRIs were independently associated with incident stroke. SNRIs may be preferable for treating PTSD and comorbid conditions, although pursuing other modifiable risk factors and non-pharmacological treatments for PTSD also remains essential.
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http://dx.doi.org/10.1161/STROKEAHA.120.030379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770089PMC
January 2021

Health psychology in the time of COVID-19.

Health Psychol 2020 Dec;39(12):1021-1025

College of Nursing.

has received numerous papers over the past several months on topics related to the COVID-19 pandemic. Many of them concern depression, anxiety, stress, or other forms of distress in the general population or in health care workers. We have received far fewer papers on COVID-related health behaviors and health communications-factors that have played central roles in the spread of the pandemic and that are major topics in health psychology. Our experience is consistent with the published scientific literature on the pandemic. A Medline search that we conducted in late September yielded over 23,000 English-language articles pertaining to COVID-19. Over 1,400 of them concerned topics that are within the scope of . As shown in Table 1, COVID-related mental disorders comprised the largest category. Many other studies concerned other forms of stress or emotional distress. At least 248 articles addressed the profound ethnic and racial disparities in COVID-19 infection and death rates and in access to health care that are accentuating longstanding health inequities; 22 (9%) of these articles addressed behavioral or psychosocial aspects of COVID-19 health disparities. Thus, the literature on the behavioral and psychosocial aspects of the pandemic has been dominated, so far at least, by research on stress or distress. Fewer reports have been published so far on critical COVID-related health behaviors, health communication, or health disparities. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/hea0001049DOI Listing
December 2020

Psychological stress in heart failure: a potentially actionable disease modifier.

Heart Fail Rev 2021 May 20;26(3):561-575. Epub 2020 Nov 20.

Yale School of Medicine, Department of Internal Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA.

Psychological stress is common in patients with heart failure, due in part to the complexities of effective disease self-management and progressively worsening functional limitations, including frequent symptom exacerbations and hospitalizations. Emerging evidence suggests that heart failure patients who experience higher levels of stress may have a more burdensome disease course, with diminished quality of life and increased risk for adverse events, and that multiple behavioral and pathophysiological pathways are involved. Furthermore, the reduced quality of life associated with heart failure can serve as a life stressor for many patients. The purpose of this review is to summarize the current state of the science concerning psychological stress in patients with heart failure and to discuss potential pathways responsible for the observed effects. Key knowledge gaps are also outlined, including the need to understand patterns of exposure to various heart failure-related and daily life stressors and their associated effects on heart failure symptoms and pathophysiology, to identify patient subgroups at increased risk for stress exposure and disease-related consequences, and the effect of stress specifically for patients who have heart failure with preserved ejection fraction. Stress is a potentially modifiable factor, and addressing these gaps and advancing the science of stress in heart failure is likely to yield important insights about actionable pathways for improving patient quality of life and outcomes.
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http://dx.doi.org/10.1007/s10741-020-10056-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026548PMC
May 2021

Effects of ambulatory blood pressure monitoring on sleep in healthy, normotensive men and women.

Blood Press Monit 2021 Apr;26(2):93-101

Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, Connecticut.

Objectives: To determine the effect of ambulatory blood pressure monitoring (ABPM) on sleep quality among healthy adults and to explore possible effect modification by demographics.

Methods: We examined data from 192 relatively healthy young (median age: 31; 33% men, 18% with clinic BP >130/80 mmHg) participants in an observational study of sleep and arterial stiffness. Demographic/health questionnaires were completed. A wrist-based accelerometer assessed sleep for seven nights, and sleep duration, wakefulness after sleep onset (WASO), fragmentation (physical restlessness), midpoint, and efficiency were estimated. ABPM was conducted for one 36-h period, including one actigraphy night.

Results: Within-subject comparisons indicated that WASO and fragmentation were higher, midpoint was later, and efficiency was lower on the ABPM night (Ps < 0.001-0.038). Neither age nor sex moderated these associations. Among older adults, a later midpoint and worse fragmentation were observed with ABPM (Ps = 0.002-0.010). There was also a main effect of sex: men demonstrated shorter sleep duration, greater WASO and fragmentation, and less efficiency than women (Ps = 0.002-0.046). With ABPM, women had worse fragmentation and a later midpoint (Ps = 0.002-0.049); for men, WASO and fragmentation were worse (Ps = 0.003-0.023). Importantly, this study does not address whether the effect of wearing ABPM on sleep in turn affects BP during sleep.

Conclusions: ABPM appears to modestly disturb actigraphy-assessed sleep among healthy adults. Researchers and clinicians should consider the downstream effects of performing ABPM and whether these effects are more pronounced in those who typically experience sleep disturbance.
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http://dx.doi.org/10.1097/MBP.0000000000000494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7933045PMC
April 2021

The Foundational Role of Cardiovascular Imaging in the Characterization of Mental Stress-Induced Myocardial Ischemia in Patients with Coronary Artery Disease.

Curr Cardiol Rep 2020 10 10;22(12):162. Epub 2020 Oct 10.

Section of Cardiovascular Medicine, Yale School of Medicine, 950 Campbell Ave. / 111B, West Haven, CT, 06516, USA.

Purpose Of Review: Mental stress-provoked myocardial ischemia (MSIMI) is an ischemic phenomenon provoked by the experience of psychologically stressful circumstances. While MSIMI was initially identified 50 years ago during activities of daily living through the use of wearable Holter monitor, subsequent research utilized the technologies of cardiac imaging-ventriculography and myocardial perfusion-under controlled conditions to pursue an understanding of pathophysiology and prognosis. This work revealed that MSIMI occurs in almost half of patients with stable coronary artery disease (CAD) and is associated with cardiac events and early mortality. We provide a focused review of the instrumental role that cardiac imaging has played in elucidating how stress affects cardiac physiology and how emerging diagnostic techniques will allow for further research on stress-mediated changes in the coronary macro- and microvasculature.

Recent Findings: Observations about the cardiac response to mental stress diverge from underlying cornerstones of the traditional CAD paradigm which is based upon myocardial oxygen demand and the degree of epicardial coronary stenosis. Evidence from studies utilizing non-invasive and invasive studies of coronary perfusion indicates perturbations in the microvascular compartment in response to mental stress. Cardiovascular imaging enjoined with mental stress provocation may be a commanding tool to advance our understanding of non-obstructive CAD and the coronary microvasculature. This further understanding will facilitate incorporation of mental stress testing in the clinical care of patients with discrepant diagnostic work-up of CAD and in patients who experience anginal symptoms due to non-exertional and/or emotional triggers. Such algorithms will be crucial to identify treatment targets to modify the risk associated with mental stress-associated ischemia and adverse prognosis.
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http://dx.doi.org/10.1007/s11886-020-01407-wDOI Listing
October 2020

Effects of Psychological Stress on Vascular Physiology: Beyond the Current Imaging Signal.

Curr Cardiol Rep 2020 10 9;22(12):156. Epub 2020 Oct 9.

Section of Cardiovascular Medicine, Yale School of Medicine, 950 Campbell Ave./111B, West Haven, CT, 06516, USA.

Purpose Of Review: This review describes the effects of psychological stress on the physiology of the entire vascular system, from individual cellular components to macrovascular and microvascular responses, and highlights the importance of the vascular system in the context of current limitations in cardiac imaging for evaluation of the cardiovascular response to mental stress.

Recent Findings: The physiological responses that mediate vascular changes are based on evolutionary needs, but there is increasing evidence that the long-term consequences of psychological stress can precipitate the development and progression of cardiovascular disease (CVD). While there is an extensive body of literature describing localized physiological responses or overt cardiovascular manifestations, often framed within the organ-specific scope of cardiovascular imaging, there has not been a comprehensive description of the global vascular effects of psychological stress. Given the global nature of these processes, targeted cardiovascular imaging modalities may be insufficient. Here we approach the vascular response to mental stress systematically, describing the effects on the endothelium, vascular smooth muscle, and adventitia. We then address the mental stress effects on large vessels and the microvascular compartment, with a discussion of the role of microvascular resistance in the pathophysiology of mental stress-induced myocardial ischemia. Vascular responses to psychological stress involve complex physiological processes that are not fully characterized by routine cardiovascular imaging assessments. Future research incorporating standardized psychological assessments targeted toward vascular mechanisms of stress responses is required to guide the development of behavioral and therapeutic interventions.
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http://dx.doi.org/10.1007/s11886-020-01406-xDOI Listing
October 2020

Dying to know: prognosis communication in heart failure.

ESC Heart Fail 2020 Sep 24. Epub 2020 Sep 24.

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.

Prognosis communication in heart failure is often narrowly defined as a discussion of life expectancy, but as clinical guidelines and research suggest, these discussions should provide a broader understanding of the disease, including information about disease trajectory, the experiences of living with heart failure, potential burden on patients and families, and mortality. Furthermore, despite clinical guidelines recommending early discussions, evidence suggests that these discussions occur infrequently or late in the disease trajectory. We review the literature concerning patient, caregiver, and clinician perspectives on discussions of this type, including the frequency, timing, desire for, effects of, and barriers to their occurrence. We propose an alternate view of prognosis communication, in which the patient and family/caregiver are educated about the nature of the disease at the time of diagnosis, and a process of engagement is undertaken so that the patient's full participation in their care is marshalled, and the care team engages the patient in the informed decision making that will guide care throughout the disease trajectory. We also identify and discuss evidence gaps concerning (i) patient preferences and readiness for prognosis information along the trajectory; (ii) best practices for communicating prognosis information; and (iii) effects of prognosis communication on patient's quality of life, mental health, engagement in critical self-care, and clinical outcomes. Research is needed to determine best practices for engaging patients in prognosis communication and for evaluating the effects of this communication on patient engagement and clinical outcomes.
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http://dx.doi.org/10.1002/ehf2.12941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754721PMC
September 2020

Cardiovascular Imaging of Biology and Emotion: Considerations Toward a New Paradigm.

Circ Cardiovasc Imaging 2020 08 7;13(8):e011054. Epub 2020 Aug 7.

Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (J.L.M., S.S., M.M.B., S.P., R.S.).

Central activation in response to emotion and cognitive stress induces perturbations in the heart and the peripheral vasculature that differ in physiology and clinical manifestations when compared with exercise-induced changes. While our conventional framework of epicardial coronary artery disease is foundational in cardiology, an expanded paradigm is required to address the cardiovascular response to mental stress (MS) and its associated risks, thus addressing the intersection of the patient's ecological and psychosocial experience with cardiovascular biology. To advance the field of MS in cardiovascular health, certain core challenges must be addressed. These include differences in the trigger activation between exercise and emotion, identification and interpretation of imaging cues as measures of pathophysiologic changes, characterization of the vascular response, and identification of central and peripheral treatment targets. Sex and psychosocial determinants of health are important in understanding the emerging overlap of MS-induced myocardial ischemia with microvascular dysfunction and symptoms in the absence of obstructive disease. In overcoming these critical knowledge gaps, integration of the field of MS will require implementation studies to guide use of MS testing, to support diagnosis of MS induced cardiac and vascular pathophysiology, to assess prognosis, and understand the role of endotying to direct therapy.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.011054DOI Listing
August 2020

Impact of Mental Stress and Anger on Indices of Diastolic Function in Patients With Heart Failure.

J Card Fail 2020 Nov 1;26(11):1006-1010. Epub 2020 Aug 1.

Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Background: Under controlled conditions, mental stress can provoke decrements in ventricular function, yet little is known about the effect of mental stress on diastolic function in patients with heart failure (HF).

Methods And Results: Twenty-four patients with HF with ischemic cardiomyopathy and reduced ejection fraction (n = 23 men; mean left ventricular [LV] ejection fraction 27 ± 9%; n = 13 with baseline elevated E/e') completed daily assessment of perceived stress, anger, and negative emotion for 7 days, followed by a laboratory mental stress protocol. Two-dimensional Doppler echocardiography was performed at rest and during sequential anger recall and mental arithmetic tasks to assess indices of diastolic function (E, e', and E/e'). Fourteen patients (63.6%) experienced stress-induced increases in E/e', with an average baseline to stress change of 6.5 ± 9.3, driven primarily by decreases in early LV relaxation (e'). Age-adjusted linear regression revealed an association between 7-day anger and baseline E/e'; patients reporting greater anger in the week before mental stress exhibited higher resting LV diastolic pressure.

Conclusions: In patients with HF with reduced ejection fraction, mental stress can provoke acute worsening of LV diastolic pressure, and recent anger is associated with worse resting LV diastolic pressure. In patients vulnerable to these effects, repeated stress exposures or experiences of anger may have implications for long-term outcomes.
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http://dx.doi.org/10.1016/j.cardfail.2020.07.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704726PMC
November 2020

Awareness for Anxiety in Women: A Great Start.

Ann Intern Med 2020 07 9;173(1):67-68. Epub 2020 Jun 9.

Yale University School of Medicine and VA Connecticut Healthcare System, New Haven, Connecticut (M.M.B.).

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http://dx.doi.org/10.7326/M20-3116DOI Listing
July 2020

Modifiable lifestyle factors in women with Takotsubo syndrome: A case-control study.

Heart Lung 2020 Sep - Oct;49(5):524-529. Epub 2020 Mar 18.

Centers for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, RI, United States; Schools of Medicine and Public Health, Brown University, Providence, RI, United States. Electronic address:

Background: There is limited information on the relationship between modifiable lifestyle factors and Takotsubo syndrome (TS).

Objectives: To determine the association of physical activity, smoking, alcohol use, and caffeinated coffee consumption with TS.

Methods: This case-control study enrolled women with newly diagnosed TS (n = 45), women post-myocardial infarction (MI; n = 32), and healthy women volunteers (HC; n = 30). Information on physical activity, smoking, alcohol use, and caffeinated coffee consumption was collected 1-month post-discharge for TS and MI, and 1-month post-enrollment for HC.

Results: TS women reported a higher prevalence of lifetime smoking and cigarette packs/day, greater coffee consumption, and less physical activity than HC. Associations with cigarette and coffee use remained significant in adjusted models. Physical activity, smoking, and coffee consumption were similar in TS and MI women.

Conclusions: Use of psychostimulants (caffeine and cigarettes) may play a role in TS pathophysiology. These findings need to be confirmed in larger, fully powered studies.
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http://dx.doi.org/10.1016/j.hrtlng.2020.03.001DOI Listing
March 2021

Association of prescription opioids and incident cardiovascular risk factors among post-9/11 Veterans.

Prev Med 2020 05 22;134:106036. Epub 2020 Feb 22.

Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, United States of America; Yale School of Medicine, New Haven, CT, United States of America. Electronic address:

Reports indicate that long-term opioid therapy is associated with cardiovascular disease (CVD). Using VA electronic health record data, we measured the impact of opioid use on the incidence of modifiable CVD risk factors. We included Veterans whose encounter was between October 2001 to November 2014. We identified Veterans without CVD risk factors during our baseline period, defined as the date of first primary care visit plus 365 days. The main exposure was opioid prescriptions (yes/no, long-term (i.e. ≥90 days) vs no opioid, and long-term vs short-term (i.e. <90 days)), which was time-updated yearly from the end of the baseline period to February 2015. The main outcome measures were incident CVD risk factors (hypertension, dyslipidemia, diabetes, obesity, and current smoking). After excluding prevalent CVD risk factors, we identified 308,015 Veterans. During the first year of observation, 12,725 (4.1%) Veterans were prescribed opioids, including 2028 (0.6%) with long-term exposure. Compared to patients without opioid use, Veterans with opioid use were more likely to have CVD risk factors. Those with long-term exposure were at higher risk of having hypertension (adjusted average hazards ratio [HR] 1.45, 99% confidence interval [CI] 1.33-1.59), dyslipidemia (HR 1.45, 99% CI 1.35-156), diabetes (HR 1.30, 99% CI 1.07-1.57), current smoking status (HR 1.34, 99% CI 1.24-1.46), and obesity (HR 1.22, 99% CI 1.12-1.32). Compared to short-term exposure, long-term had higher risk of current smoking status (HR 1.12, 99% CI 1.01-1.24). These findings suggest potential benefit to screening and surveillance of CVD risk factors for patients prescribed opioids, especially long-term opioid therapy.
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http://dx.doi.org/10.1016/j.ypmed.2020.106036DOI Listing
May 2020

Barriers to cardiovascular disease preventive behaviors among OEF/OIF/OND women and men veterans.

Health Psychol 2020 Apr 30;39(4):298-306. Epub 2020 Jan 30.

VA Connecticut Healthcare System.

Objective: OEF/OIF/OND Veterans have an elevated risk for developing cardiovascular disease (CVD), but research suggests that engagement in CVD preventive behaviors is low even among at-risk individuals. It is critical to understand barriers to prevention engagement among Veterans to inform the development of tailored interventions addressing barriers and reducing CVD incidence.

Method: The Women Veterans Cohort Study survey of OEF/OIF/OND Veterans (586 women and 555 men) assessed patient, interpersonal, and systems level barriers to CVD risk prevention. Prevalence of barriers was determined, and chi-squares were conducted to examine sex differences. Multivariate logistic regressions were conducted to determine if sex differences remained when adjusting for demographic factors (age, marital status, education, employment status).

Results: Despite a low response rate (11.5%), endorsement of barriers was high for both women and men, with most (56.8%) not perceiving themselves to be at CVD risk. More men preferred making no lifestyle change (40.9% vs. 29.1%). More women endorsed lack of confidence (42.4% vs. 36.1%), stress (36.9% vs. 27.8%) and depression (36.9% vs. 27.8%), and inadequate social support (26% vs. 20.9%), along with the belief that their clinician does not perceive them as at risk (57.8% vs. 32%) and has not explained CVD preventive behaviors (19% vs. 12.3%). Multivariate analyses reduced statistical significance of sex differences.

Conclusions: Given the low response rate, testing of efforts-for example, implementation science methods-to assess CVD risk reduction barriers in this population are needed, a task for which the Veterans Health Administration is well suited. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/hea0000844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7078021PMC
April 2020

The role of insomnia in the association between posttraumatic stress disorder and hypertension.

J Hypertens 2020 04;38(4):641-648

VA Connecticut Healthcare System, West Haven.

Objective: Posttraumatic stress disorder (PTSD) is associated with incident hypertension. Although this relationship is poorly understood, PTSD is also associated with insomnia symptoms, which increases the risk for hypertension. Whether insomnia contributes to PTSD-associated risk for hypertension is unknown.

Methods: We examined self-report survey and electronic health record data from 1109 participants in the Women Veterans Cohort Study (mean age: 43.8 ± 10.9 years; 52% women, 81% White) to assess the cross-sectional associations between PTSD symptom severity, recent symptoms of insomnia, and hypertension, defined as self-reported treatment for high blood pressure in the last year. Structural equation modeling was used to examine whether insomnia symptoms mediate the association between PTSD and hypertension.

Results: PTSD symptom severity was associated with hypertension (r = 0.09, P < 0.001). PTSD symptom severity and hypertension were each associated with the insomnia symptoms difficulty falling asleep, difficulty staying asleep, and worry/distress about sleep problems (PTSD: rs = 0.58--0.62, P <  0.001; hypertension: rs = 0.07--0.10, P <  0.001). A latent variable derived from those symptoms mediated 9% of the association between PTSD symptom severity and hypertension (P = 0.02).

Conclusion: In this study of young and middle-aged Veterans, insomnia symptoms mediated the association between PTSD and hypertension. Difficulties falling asleep and maintaining sleep and related distress may be particularly deleterious for cardiovascular health in Veterans. Longitudinal data is required to further investigate the associations between PTSD, insomnia, and hypertension.
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http://dx.doi.org/10.1097/HJH.0000000000002311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176546PMC
April 2020

Posttraumatic Stress Disorder and Risk for Stroke in Young and Middle-Aged Adults: A 13-Year Cohort Study.

Stroke 2019 11 17;50(11):2996-3003. Epub 2019 Oct 17.

Department of Internal Medicine, Division of Cardiovascular Medicine (L.R., R.L., A.E.G., P.W.C., C.E.C., M.M.B.), Yale School of Medicine, New Haven, CT.

Background and Purpose- In older populations, transient ischemic attack (TIA) and ischemic stroke have been linked to psychological factors, including posttraumatic stress disorder (PTSD). Whether PTSD also increases risk for early incident stroke in young adults is unknown. Methods- We prospectively assessed the incidence of TIA and ischemic stroke in a cohort of 987 855 young and middle-aged Veterans (mean age of 30.29±9.19 years; 87.8% men, 64.4% white) who first accessed care through the Veterans Health Administration from October 2001 to November 2014 and were free of TIA and ischemic stroke at baseline. For each outcome, time-varying multivariate Cox models were constructed to examine the effect of PTSD on incident stroke. We also assessed for effect modification by sex. Additional sensitivity analyses controlled for healthcare utilization. Results- Over a 13-year period, TIA and ischemic stroke were diagnosed in 766 and 1877 patients, respectively. PTSD was diagnosed in 28.6% of the sample during follow-up. In unadjusted analyses, PTSD was significantly associated with new-onset TIA (hazard ratio [HR], 2.02; 95% CI, 1.62-2.52) and ischemic stroke (HR, 1.62; 95% CI, 1.47-1.79). In fully adjusted models, the association between PTSD and incident TIA (HR, 1.61; 95% CI, 1.27-2.04) and ischemic stroke (HR, 1.36; 95% CI, 1.22-1.52) remained significant. The effect of PTSD on ischemic stroke risk was stronger in men than in women (HR, 0.63; 95% CI, 0.47-0.86; =0.003), but no effect of sex was found for TIA. Conclusions- PTSD is associated with a significant increase in risk of early incident TIA and ischemic stroke independent of established stroke risk factors, coexisting psychiatric disorders, and healthcare utilization. Sex moderated the relationship for adults with ischemic stroke but not TIA. These findings suggest that psychological factors, including PTSD, may be important targets for future age-specific prevention strategies for young adults.
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http://dx.doi.org/10.1161/STROKEAHA.119.026854DOI Listing
November 2019

Posttraumatic Stress Disorder and Risk for Early Incident Atrial Fibrillation: A Prospective Cohort Study of 1.1 Million Young Adults.

J Am Heart Assoc 2019 10 28;8(19):e013741. Epub 2019 Sep 28.

Department of Internal Medicine (Cardiovascular Medicine) Yale School of Medicine New Haven CT.

Background Acute psychological stress and negative emotions are known risk factors for atrial fibrillation (AF). Whether exposure to chronic stress syndromes, such as posttraumatic stress disorder (PTSD), also increases susceptibility to AF is unknown. Methods and Results We prospectively assessed the incidence of AF over a 13-year period among 988 090 young and middle-aged veterans (mean age, 30.29±9.19 years; 87.8% men, 64.5% white) who first accessed care through the Veterans Health Administration from October 2001 to November 2014 and were free of AF, atrial flutter, or atrial tachycardia at baseline. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of PTSD to new AF. We also tested for effect modification by sex and controlled for healthcare use. During a mean follow-up of 4.8 years, 2491 patients were diagnosed with AF. Patients with PTSD had a higher overall incidence of AF (<0.0001) and were more likely to develop AF at a younger age than those without PTSD (=0.004). PTSD was significantly associated with incident AF in unadjusted models (hazard ratio, 1.31; 95% CI, 1.19-1.43) and models that adjusted for demographics, lifestyle factors, cardiovascular risk factors, and depression (hazard ratio, 1.13; 95% CI, 1.02-1.24). The interaction with sex was nonsignificant (=0.93). Conclusions PTSD was associated increased risk for early incident AF after adjustment for established AF risk factors and depression in this cohort of young and middle-aged veterans. Findings from this study require validation in more diverse populations to determine their generalizability.
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http://dx.doi.org/10.1161/JAHA.119.013741DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6806049PMC
October 2019

Catheter Ablation and Cognitive Impairment in Atrial Fibrillation: Another Hit or a Silver Bullet?

Circ Arrhythm Electrophysiol 2019 07 1;12(7):e007521. Epub 2019 Jul 1.

Section of Cardiovascular Medicine, Department of Internal Medicine (L.R., M.M.B., R.L.), Yale School of Medicine, New Haven, CT.

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http://dx.doi.org/10.1161/CIRCEP.119.007521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384245PMC
July 2019

Behavioral economics implementation: Regret lottery improves mHealth patient study adherence.

Contemp Clin Trials Commun 2019 Sep 31;15:100387. Epub 2019 May 31.

Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA.

Background: Nonadherence to study protocols reduces the generalizability, validity, and statistical power of longitudinal studies.

Purpose: To determine whether an automated electronically-delivered regret lottery would improve adherence to an intensive mHealth self-monitoring protocol as part of a longitudinal observational study.

Methods: We enrolled 77 adults into a 52-week study requiring five daily ecologic momentary assessments (EMA) of stress and daily accelerometer use. We performed a pre/post single-arm study to evaluate the efficacy of a lottery intervention in improving adherence to this protocol. Midway through the study, participants were invited to enter a weekly regret lottery ($50 prize, expected value <$1) in which prize collection was contingent upon meeting adherence thresholds for the prior week. Study protocol adherence before and after lottery initiation were compared using mixed models repeated measures analysis of variance.

Results: 62 participants consented to lottery participation. In the 12 weeks prior to lottery initiation, weekly adherence was declining (slope -1.4%/week). The weekly per-participant probability of adherence was higher after lottery initiation when comparing the 4-week (32% pre-lottery vs 50% post-lottery, p < 0.001), 8-week (37% vs 49%, p < 0.001), and 12-week periods (39% vs 45%, p = 0.001) before and after lottery initiation. However, the rate of decline in adherence over time was unchanged.

Conclusion: The implementation of an automated, electronically-delivered weekly regret lottery improved adherence with an intensive self-monitoring study protocol. Regret lotteries may represent a cost-effective tool to improve adherence and reduce bias caused by dropout or nonadherence.
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http://dx.doi.org/10.1016/j.conctc.2019.100387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6555893PMC
September 2019

Effect of β-blockers on triggering of symptomatic atrial fibrillation by anger or stress.

Heart Rhythm 2019 08 3;16(8):1167-1173. Epub 2019 Jun 3.

Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven Connecticut.

Background: Anger and stress can trigger episodes of atrial fibrillation (AF) in patients with a history of AF.

Objective: The purpose of this study was to determine whether β-blockers can protect against emotionally triggered AF.

Methods: In this prospective, controlled, electronic diary-based study of emotions preceding AF, patients with a history of paroxysmal or persistent AF (N = 91) recorded their rhythm on event monitors at the time of AF symptoms and completed a diary entry querying mood states (eg, anger and stress) for the preceding 30 minutes (pre-AF "case period") for 1 year. Also, patients underwent monthly 24-hour Holter monitoring during which they were prompted to complete a diary entry twice per hour. Diaries recorded during sinus rhythm comprise controls. Patients' exposure to each emotion was compared between the pre-AF case period and control periods by using generalized estimating equation modeling, as well as interactions between β-blocker use and emotion tested.

Results: Sixty percent were prescribed β-blockers. A total of 163 symptomatic AF episodes (in 34 patients) and 11,563 Holter-confirmed sinus rhythm control periods had associated diary data. Overall, the likelihood of an AF episode was significantly higher during anger or stress. This effect, however, was significantly attenuated in patients on β-blockers (odds ratio 22.5; 95% confidence interval 6.7-75.4, P < .0001 for patients not prescribed β-blockers vs odds ratio 4.0, 95% confidence interval 1.7-9.5, P = .002 for those prescribed β-blockers; P = .02 for the interaction). Exclusion of patients on sotalol did not affect findings.

Conclusion: Anger or stress can trigger AF, but use of β-blockers greatly attenuates this deleterious physiological response.
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http://dx.doi.org/10.1016/j.hrthm.2019.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759206PMC
August 2019

Further Examination of the Pain Stages of Change Questionnaires Among Chronic Low Back Pain Patients: Long-term Predictive Validity of Pretreatment and Posttreatment Change Scores and Stability of Posttreatment Scores.

Clin J Pain 2019 09;35(9):744-752

Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, VA Connecticut Healthcare System.

Objectives: In order to maximize the therapeutic benefits of cognitive-behavioral therapy (CBT) for chronic pain, individuals need to be motivated to adopt a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was developed to measure patients' readiness to adopt a self-management approach to chronic pain. The present study examined whether pretreatment and posttreatment PSOCQ change scores among chronic low back pain patients could predict 6- and 12-month follow-up outcomes, and the stability of posttreatment PSOCQ scores during follow-up.

Methods: Participants were recruited from a VA primary care clinic. Data from 60 participants assigned to either regular CBT or a modified CBT (ie, PRIME CBT) condition were analyzed in the present study. Self-report measures including PSOCQ, pain severity, disability, and depressive symptom severity were administered at pretreatment, 10 weeks posttreatment, 6-month and follow-up assessments.

Results: Multiple regression analyses showed that pretreatment and posttreatment changes in the Action/Maintenance scores significantly predicted pain severity at 6 months, and changes in the Precontemplation scores significantly predicted disability at 6 months. None of the PSOCQ change scores significantly predicted depressive symptom severity. Posttreatment Precontemplation and Action/Maintenance scores were quite stable, even at 12-month follow-up.

Conclusions: Changes in patients' attitudes toward adopting a pain self-management approach may serve as one of the therapeutic mechanisms and predict long-term function. This study also revealed that changed attitudes toward chronic pain self-management remain quite stable over time. Adoption of beliefs consistent with chronic pain self-management during treatment may promote sustained benefits.
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http://dx.doi.org/10.1097/AJP.0000000000000733DOI Listing
September 2019
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