A New Big Five McAdams, Dan P; Pals, Jennifer L
The American psychologist,
04/2006, Letnik:
61, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Despite impressive advances in recent years with respect to theory and research, personality psychology has yet to articulate clearly a comprehensive framework for understanding the whole person. In ...an effort to achieve that aim, the current article draws on the most promising empirical and theoretical trends in personality psychology today to articulate 5 big principles for an integrative science of the whole person. Personality is conceived as (a) an individual's unique variation on the general evolutionary design for human nature, expressed as a developing pattern of (b) dispositional traits, (c) characteristic adaptations, and (d) self-defining life narratives, complexly and differentially situated (e) in culture and social context. The 5 principles suggest a framework for integrating the Big Five model of personality traits with those self-defining features of psychological individuality constructed in response to situated social tasks and the human need to make meaning in culture.
Background and Aims
Frailty, as measured by the Liver Frailty Index (LFI), is associated with liver transplant (LT) waitlist mortality. We sought to identify an optimal LFI cutoff that predicts ...waitlist mortality.
Approach and Results
Adults with cirrhosis awaiting LT without hepatocellular carcinoma at nine LT centers in the United States with LFI assessments were included. Multivariable competing risk analysis assessed the relationship between LFI and waitlist mortality. We identified a single LFI cutoff by evaluating the fit of the competing risk models, searching for the cutoff that gave the best model fit (as judged by the pseudo‐log‐likelihood). We ascertained the area under the curve (AUC) in an analysis of waitlist mortality to find optimal cutoffs at 3, 6, or 12 months. We used the AUC to compare the discriminative ability of LFI+Model for End Stage Liver Disease‐sodium (MELDNa) versus MELDNa alone in 3‐month waitlist mortality prediction. Of 1,405 patients, 37 (3%), 82 (6%), and 135 (10%) experienced waitlist mortality at 3, 6, and 12 months, respectively. LFI was predictive of waitlist mortality across a broad LFI range: 3.7‐5.2. We identified an optimal LFI cutoff of 4.4 (95% confidence interval CI, 4.0‐4.8) for 3‐month mortality, 4.2 (95% CI, 4.1‐4.4) for 6‐month mortality, and 4.2 (95% CI, 4.1‐4.4) for 12‐month mortality. The AUC for prediction of 3‐month mortality for MELDNa was 0.73; the addition of LFI to MELDNa improved the AUC to 0.79.
Conclusions
LFI is predictive of waitlist mortality across a wide spectrum of LFI values. The optimal LFI cutoff for waitlist mortality was 4.4 at 3 months and 4.2 at 6 and 12 months. The discriminative performance of LFI+MELDNa was greater than MELDNa alone. Our data suggest that incorporating LFI with MELDNa can more accurately represent waitlist mortality in LT candidates.
Frailty is associated with mortality in patients with cirrhosis. We measured frailty using 3 simple tests and calculated Liver Frailty Index (LFI) scores for patients at multiple ambulatory centers. ...We investigated associations between LFI scores, ascites, and hepatic encephalopathy (HE) and mortality.
Adults without hepatocellular carcinoma who were on the liver transplantation waitlist at 9 centers in the United States (N = 1044) were evaluated using the LFI; LFI scores of at least 4.5 indicated that patients were frail. We performed logistic regression analyses to assess associations between frailty and ascites or HE and competing risk regression analyses (with liver transplantation as the competing risk) to estimate sub-hazard ratios (sHRs) of waitlist mortality (death or removal from the waitlist).
Of study subjects, 36% had ascites, 41% had HE, and 25% were frail. The odds of frailty were higher for patients with ascites (adjusted odd ratio 1.56, 95% confidence interval CI 1.15–2.14) or HE (odd ratio 2.45, 95% CI 1.80–3.33) than for those without these features. Larger proportions of frail patients with ascites (29%) or HE (30%) died while on the waitlist compared with patients who were not frail (17% of patients with ascites and 20% with HE). In univariable analysis, ascites (sHR 1.52, 95% CI 1.14–2.05), HE (sHR 1.84, 95% CI 1.38–2.45), and frailty (sHR 2.38, 95% CI 1.77–3.20) were associated with waitlist mortality. In adjusted models, only frailty remained significantly associated with waitlist mortality (sHR 1.82, 95% CI 1.31–2.52); ascites and HE were not.
Frailty is a prevalent complication of cirrhosis that is observed more frequently in patients with ascites or HE and independently associated with waitlist mortality. LFI scores can be used to objectively quantify risk of death related to frailty—in excess of liver disease severity—in patients with cirrhosis.
To date, studies evaluating the association between frailty and mortality in patients with cirrhosis have been limited to assessments of frailty at a single time point. We aimed to evaluate changes ...in frailty over time and their association with death/delisting in patients too sick for liver transplantation.
Adults with cirrhosis, listed for liver transplantation at 8 US centers, underwent ambulatory longitudinal frailty testing using the liver frailty index (LFI). We used multilevel linear mixed-effects regression to model and predict changes in LFI (ΔLFI) per 3 months, based on age, gender, model for end-stage liver disease (MELD)-Na, ascites, and hepatic encephalopathy, categorizing patients by frailty trajectories. Competing risk regression evaluated the subhazard ratio (sHR) of baseline LFI and predicted ΔLFI on death/delisting, with transplantation as the competing risk.
We analyzed 2,851 visits from 1,093 outpatients with cirrhosis. Patients with severe worsening of frailty had worse baseline LFI and were more likely to have non-alcoholic fatty liver disease, diabetes, or dialysis-dependence. After a median follow-up of 11 months, 223 (20%) of the overall cohort died/were delisted because of sickness. The cumulative incidence of death/delisting increased by worsening ΔLFI group. In competing risk regression adjusted for baseline LFI, age, height, MELD-Na, and albumin, a 0.1 unit change in ΔLFI per 3 months was associated with a 2.04-fold increased risk of death/delisting (95% CI 1.35–3.09).
Worsening frailty was significantly associated with death/delisting independent of baseline frailty and MELD-Na. Notably, patients who experienced improvements in frailty had a lower risk of death/delisting. Our data support the longitudinal measurement of frailty, using the LFI, in patients with cirrhosis and lay the foundation for interventional work aimed at reversing frailty.
Frailty, as measured at a single time point, is predictive of death in patients with cirrhosis, but whether changes in frailty over time are associated with death is unknown. In a study of over 1,000 patients with cirrhosis who underwent frailty testing, we demonstrate that worsening frailty is strongly linked with mortality, regardless of baseline frailty and liver disease severity. Notably, patients who experienced improvements in frailty over time had a lower risk of death/delisting. Our data support the longitudinal measurement of frailty in patients with cirrhosis and lay the foundation for interventional work aimed at reversing frailty.
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•In patients with cirrhosis, changes in frailty were significantly associated with death/delisting.•Patients with cirrhosis who experienced improvements in frailty over time had a lower risk of death/delisting.•Our data support the longitudinal measurement of frailty in patients with cirrhosis.•This study lays the foundation for interventional work aimed at reversing frailty.
We developed the strength training intervention (STRIVE), a home-based exercise program targeting physical function in patients with cirrhosis. In this pilot study, we aimed to evaluate the safety ...and efficacy of STRIVE.
Eligible were adult patients with cirrhosis at 3 sites. Patients were randomized 2:1-12 weeks of STRIVE, a 30-minute strength training video plus a health coach or standard of care (SOC). Physical function and quality of life were assessed using the Liver Frailty Index (LFI) and Chronic Liver Disease Questionnaire (CLDQ), respectively.
Fifty-eight and 25 were randomized to STRIVE and SOC arms, respectively: 43% women, median age was 61 years, MELDNa, Model for End-Stage Liver Disease Sodium was 14, and 54% were Child-Pugh B/C. Baseline characteristics were similar in the STRIVE vs SOC arms except for rates of hepatic encephalopathy (19 vs 36%). LFI @ 12 weeks was available in 43 STRIVE and 20 SOC participants. After 12 weeks, the median LFI improved from 3.8 to 3.6 (ΔLFI -0.1) in the STRIVE arm and 3.7 to 3.6 (ΔLFI -0.1) in the SOC arm (P = 0.65 for ΔLFI difference). CLDQ scores improved from 4.6 to 5.2 in STRIVE participants (ΔCLDQ 0.38) and did not change in SOC participants (4.2-4.2; ΔCLDQ -0.03) (P = 0.09 for ΔCLDQ difference). One patient died (SOC arm) of bleeding. Only 14% of STRIVE participants adhered to the strength training video for 10-12 weeks. No adverse events were reported by STRIVE participants.
STRIVE, a home-based structured exercise program for patients with cirrhosis, was safely administered at 3 sites, but adherence was low. Although all participants showed minimal improvement in the LFI, STRIVE was associated with a substantial improvement in quality of life.
A recent study concluded that SARS‐CoV‐2 mRNA vaccine responses were improved among transplant patients taking mTOR inhibitors (mTORi). This could have profound implications for vaccine strategies in ...transplant patients; however, limitations in the study design raise concerns about the conclusions. To address this issue more robustly, in a large cohort with appropriate adjustment for confounders, we conducted various regression‐ and machine learning‐based analyses to compare antibody responses by immunosuppressive agents in a national cohort (n = 1037). MMF was associated with significantly lower odds of positive antibody response (aOR = 0.090.130.18). Consistent with the recent mTORi study, the odds tended to be higher with mTORi (aOR = 1.001.452.13); however, importantly, this seemingly protective tendency disappeared (aOR = 0.470.731.12) after adjusting for MMF. We repeated this comparison by combinations of immunosuppression agents. Compared to MMF + tacrolimus, MMF‐free regimens were associated with higher odds of positive antibody response (aOR = 2.394.267.92 for mTORi+tacrolimus; 2.345.5415.32 for mTORi‐only; and 6.7810.2515.93 for tacrolimus‐only), whereas MMF‐including regimens were not, regardless of mTORi use (aOR = 0.811.542.98 for MMF + mTORi; and 0.811.512.87 for MMF‐only). We repeated these analyses in an independent cohort (n = 512) and found similar results. Our study demonstrates that the recently reported findings were confounded by MMF, and that mTORi is not independently associated with improved vaccine responses.
Examination of the association of mammalian target of rapamycin inhibitors, mycophenolic acid, and other immunosuppressive agents with responses to SARS‐CoV‐2 mRNA vaccines shows that mycophenolic acid avoidance is independently associated with improved vaccine response.
IMPORTANCE: Female liver transplant candidates experience higher rates of wait list mortality than male candidates. Frailty is a critical determinant of mortality in patients with cirrhosis, but how ...frailty differs between women and men is unknown. OBJECTIVE: To determine whether frailty is associated with the gap between women and men in mortality among patients with cirrhosis awaiting liver transplantation. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study enrolled 1405 adults with cirrhosis awaiting liver transplant without hepatocellular carcinoma seen during 3436 ambulatory clinic visits at 9 US liver transplant centers. Data were collected from January 1, 2012, to October 1, 2019, and analyzed from August 30, 2019, to October 30, 2020. EXPOSURES: At outpatient evaluation, the Liver Frailty Index (LFI) score was calculated (grip strength, chair stands, and balance). MAIN OUTCOMES AND MEASURES: The risk of wait list mortality was quantified using Cox proportional hazards regression by frailty. Mediation analysis was used to quantify the contribution of frailty to the gap in wait list mortality between women and men. RESULTS: Of 1405 participants, 578 (41%) were women and 827 (59%) were men (median age, 58 interquartile range (IQR), 50-63 years). Women and men had similar median scores on the laboratory-based Model for End-stage Liver Disease incorporating sodium levels (MELDNa) (women, 18 IQR, 14-23; men, 18 IQR, 15-22), but baseline LFI was higher in women (mean SD, 4.12 0.85 vs 4.00 0.82; P = .005). Women displayed worse balance of less than 30 seconds (145 25% vs 149 18%; P = .003), worse sex-adjusted grip (mean SD, −0.31 1.08 vs −0.16 1.08 kg; P = .01), and fewer chair stands per second (median, 0.35 IQR, 0.23-0.46 vs 0.37 IQR, 0.25-0.49; P = .04). In unadjusted mixed-effects models, LFI was 0.15 (95% CI, 0.06-0.23) units higher in women than men (P = .001). After adjustment for other variables associated with frailty, LFI was 0.16 (95% CI, 0.08-0.23) units higher in women than men (P < .001). In unadjusted regression, women experienced a 34% (95% CI, 3%-74%) increased risk of wait list mortality than men (P = .03). Sequential covariable adjustment did not alter the association between sex and wait list mortality; however, adjustment for LFI attenuated the mortality gap between women and men. In mediation analysis, an estimated 13.0% (IQR, 0.5%-132.0%) of the gender gap in wait list mortality was mediated by frailty. CONCLUSIONS AND RELEVANCE: These findings demonstrate that women with cirrhosis display worse frailty scores than men despite similar MELDNa scores. The higher risk of wait list mortality that women experienced appeared to be explained in part by frailty.
Narrative identity refers to the internal, dynamic life story that an individual constructs to make sense of his or her life. We argue that narrative identity is closely tied to the subjective ...interpretation of oneself as happy. We present a view of eudaimonic well-being that extends beyond the sense of having pleasure and meaning in one’s life (measured as self-report well-being) to include higher degrees of psychosocial integration in that meaning (measured as ego development). This combination of qualities is characteristic of the good life, or
eudaimonia
, in a tradition dating to Aristotle. We then describe research showing how several patterns of narrative identity correspond to this extended notion of eudaimonic well-being. First, people at high levels of eudaimonic well-being tend to emphasize personal growth in their life stories, with different kinds of personal growth corresponding to different facets of eudaimonic well-being. Second, these people also tend to frame difficult life experiences as transformative experiences wherein they suffered deep pain but gained new insights about the self. Third, charting the move from suffering to an enhanced status or state, their stories often follow a culturally-shaped script of redemption, which in American society is often conceived as upward social mobility, liberation, recovery, atonement, or the full actualization of the inner self.
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