<%BANNER%>

Patient Assisted Computerized Education for Recipients of Implantable Cardioverter Defibrillators (PACER)

Permanent Link: http://ufdc.ufl.edu/UFE0020624/00001

Material Information

Title: Patient Assisted Computerized Education for Recipients of Implantable Cardioverter Defibrillators (PACER) A Randomized Controlled Trial of the PACER Program
Physical Description: 1 online resource (82 p.)
Language: english
Creator: Kuhl, Emily Ann
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: computerized, icd, implantable, psychoeducation, psychosocial, web
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The implantable cardioverter defibrillator (ICD) is the treatment of choice for preventing and correcting potentially-lethal cardiac arrhythmias. Although its effectiveness is supported by data from several large-scale, randomized clinical trials, its psychological impact is less favorable, mostly because of the shock mechanism by which the device corrects arrhythmias. Patients with ICDs are vulnerable to depression and anxiety, including panic disorder and avoidance behaviors, as a result of device placement and experiencing an ICD shock. There are only a handful of randomized, controlled trials focused on enhancing the psychosocial functioning of ICD recipients. Computers are becoming an increasingly useful tool in providing psychological care due in part to their accessibility, convenience, anonymity, and cost effectiveness. There is ample support for using computerized interventions to successfully treat psychiatric dysfunction, including depression, panic disorder, generalized anxiety, and phobias. There are currently no computerized interventions in the literature aimed at the psychosocial fitness of ICD patients. Our study is a pilot study of a psychoeducational, computerized intervention for ICD recipients entitled Patient Assisted Computerized Education for Recipients of Implantable Cardioverter Defibrillators (PACER). We hypothesized that the PACER program would increase patient knowledge about their ICD, decrease anxiety, and increase device acceptance, as compared to usual care patients. PACER patients were also hypothesized to demonstrated equivalent scores of anxiety, device acceptance, and quality of life compared to patients from a similar, in-person intervention from a related study. Thirty patients were recruited, and half were randomized to the treatment condition. At one-month follow-up, there were no differences in scores between treatment and control patients on an ICD knowledge test. Increases in ICD knowledge were associated with increases in device acceptance, but only among treatment patients. There was no impact of the program on anxiety. Compared to participants from an in-person treatment, PACER patients demonstrated similar scores of mental quality of life and device acceptance, but worse scores of anxiety and physical quality of life. A user survey demonstrated overwhelming support of the PACER program by participants, suggesting the utility of future testing amongst a larger sample.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Emily Ann Kuhl.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Sears, Samuel F.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0020624:00001

Permanent Link: http://ufdc.ufl.edu/UFE0020624/00001

Material Information

Title: Patient Assisted Computerized Education for Recipients of Implantable Cardioverter Defibrillators (PACER) A Randomized Controlled Trial of the PACER Program
Physical Description: 1 online resource (82 p.)
Language: english
Creator: Kuhl, Emily Ann
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: computerized, icd, implantable, psychoeducation, psychosocial, web
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: The implantable cardioverter defibrillator (ICD) is the treatment of choice for preventing and correcting potentially-lethal cardiac arrhythmias. Although its effectiveness is supported by data from several large-scale, randomized clinical trials, its psychological impact is less favorable, mostly because of the shock mechanism by which the device corrects arrhythmias. Patients with ICDs are vulnerable to depression and anxiety, including panic disorder and avoidance behaviors, as a result of device placement and experiencing an ICD shock. There are only a handful of randomized, controlled trials focused on enhancing the psychosocial functioning of ICD recipients. Computers are becoming an increasingly useful tool in providing psychological care due in part to their accessibility, convenience, anonymity, and cost effectiveness. There is ample support for using computerized interventions to successfully treat psychiatric dysfunction, including depression, panic disorder, generalized anxiety, and phobias. There are currently no computerized interventions in the literature aimed at the psychosocial fitness of ICD patients. Our study is a pilot study of a psychoeducational, computerized intervention for ICD recipients entitled Patient Assisted Computerized Education for Recipients of Implantable Cardioverter Defibrillators (PACER). We hypothesized that the PACER program would increase patient knowledge about their ICD, decrease anxiety, and increase device acceptance, as compared to usual care patients. PACER patients were also hypothesized to demonstrated equivalent scores of anxiety, device acceptance, and quality of life compared to patients from a similar, in-person intervention from a related study. Thirty patients were recruited, and half were randomized to the treatment condition. At one-month follow-up, there were no differences in scores between treatment and control patients on an ICD knowledge test. Increases in ICD knowledge were associated with increases in device acceptance, but only among treatment patients. There was no impact of the program on anxiety. Compared to participants from an in-person treatment, PACER patients demonstrated similar scores of mental quality of life and device acceptance, but worse scores of anxiety and physical quality of life. A user survey demonstrated overwhelming support of the PACER program by participants, suggesting the utility of future testing amongst a larger sample.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Emily Ann Kuhl.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Sears, Samuel F.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0020624:00001


This item has the following downloads:


Full Text
xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20101208_AAAAIB INGEST_TIME 2010-12-08T09:32:21Z PACKAGE UFE0020624_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 2110 DFID F20101208_AAAKWB ORIGIN DEPOSITOR PATH kuhl_e_Page_25.txt GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
1fcf00deb9f047992065fa2116b07359
SHA-1
f26298977b4f99b5762649017233db1c0bc7c3a7
35057 F20101208_AAAKRE kuhl_e_Page_17.QC.jpg
4c84d22528879c3181e75b455c12897a
cf255bc20f20400a34a9ddff38d25976bf1bc2a1
1053954 F20101208_AAAKCM kuhl_e_Page_23.tif
f99b890116f3375945e3671c321e42c7
de9362f8edbbac391187d29c865315980e061cc1
F20101208_AAAKMH kuhl_e_Page_15.tif
2dcb178c6b59aa5f5c640e1633eae8c4
f9cb9f7a20dc84a5387f60155d81e0642d43d307
1996 F20101208_AAAKWC kuhl_e_Page_48.txt
4a23d0e2a68184446b5dd762c5debf4e
869859daabcffb0988a4fef480e8969b64eaeb42
7262 F20101208_AAAKHK kuhl_e_Page_69thm.jpg
adc01fda0f9ab42b5c04aaf6c1902dce
fee6947ffe9e27957f516b5d7153a4731becdd8d
126185 F20101208_AAAKRF kuhl_e_Page_80.jpg
23d4fd4bbc473b6a663081f3d76d4c89
cea6f0a8e3ab55a19dfc3d90cebf58835aab980e
15093 F20101208_AAAKCN kuhl_e_Page_60.jp2
ccb1d41784c7d4e55587daf500387d05
ee31893a4414cf8729903d08b1423d9eb1d50f29
2250 F20101208_AAAKMI kuhl_e_Page_59.txt
f3b8aaf12c55dae42694b87c2814f5bf
56d0de27cd6438206a65372b1335f1e9a6a797a0
882 F20101208_AAAKWD kuhl_e_Page_49.txt
c43a7eba58461dd6e579a35ae626a84d
4d4474e100b5ed09cc690f1bf47d3d3df2036f62
2177 F20101208_AAAKRG kuhl_e_Page_32.txt
e56778f348f6582efb14d62b8a82ef6f
efcd15609c50d85f2ccc5297538cf450b5f9efed
F20101208_AAAKHL kuhl_e_Page_54.tif
4a2879e0a4acfe9c5ce0006a50687d92
cc10defa0fbc9b3c19601517f526317809b10b6f
54493 F20101208_AAAKCO kuhl_e_Page_38.pro
028b9cea9943c51b4f9a4da951455d33
47a7f6ddc896a549cf475a0cf5571f39ee0d89c2
2233 F20101208_AAAKMJ kuhl_e_Page_03.QC.jpg
349c2aad10b65370b9166ba6fd234f7e
2eb69f41b92954c0bbc1271a9c1effd3c0e6c986
2129 F20101208_AAAKWE kuhl_e_Page_52.txt
61c87ebe9f472c6ff69267b67a6182c2
7dd241d819f1723cfa30d3f09ccdab7857afbad9
431 F20101208_AAAKRH kuhl_e_Page_35.txt
902d29e455b0128f9e9224fbea26f58f
634f15e0256027e41335223bce1048df1ee59ec5
F20101208_AAAKHM kuhl_e_Page_09.tif
bf1bdbb7e95701ada379e7df7ce094f7
605cda8a139c31b05f43b0ec0628e9f750685ce2
36715 F20101208_AAAKCP kuhl_e_Page_34.QC.jpg
725735f6959f6ed1ff4811729903209c
85f6b953c1cada20cceb7792aa4417cb298cb83b
971 F20101208_AAAKMK kuhl_e_Page_51.txt
0367f43d4bc0cae64e3cf44166028075
e9eb88d40156b536dbdad5fffd8e2b97b869faf3
1949 F20101208_AAAKWF kuhl_e_Page_57.txt
d78119eb63d5a0723374d9f0b506513c
25345f5aa5728ba3d530c275b0d4d7a34a7b82c7
112997 F20101208_AAAKRI kuhl_e_Page_27.jp2
405ebd5c9f431e4105e7927cbedb74f2
e87684ca32223269c108df2025d8cdc5b6fa27df
107466 F20101208_AAAKHN kuhl_e_Page_04.jpg
9caa0149b2ad9c22c80bf74e36f9d50a
e56118f452c75f470360b4b836084146189d3e7f
632 F20101208_AAAKCQ kuhl_e_Page_62.txt
54f293a51fa2786f56642c3273c8bc39
ea47acb390af100ab1c698c606620c363e51b0d4
32671 F20101208_AAAKML kuhl_e_Page_01.jpg
be3ad3656a3eedb424f77651ffb2df1f
779221c613fe5bc6ec6f3b6fd80c5bd33df114f9
2246 F20101208_AAAKWG kuhl_e_Page_58.txt
027662cdb977c49be5a97aae6908bef5
0ebfb0b4c7d37ccf57224ec3e1cfbbe60285b62e
2125 F20101208_AAAKRJ kuhl_e_Page_36.txt
e1b6bb9c1f714bb2270774c6ac41a3de
5bdc084cee1dc3055acd84769d07129bacd3557c
53707 F20101208_AAAKHO kuhl_e_Page_25.pro
cf0e328b0bfed5545e03730e8e26df34
6a7e928b2bb267ff25dcb9f0ae7b3af6fd5b65b2
2194 F20101208_AAAKCR kuhl_e_Page_26.txt
4bd1e9b0bd2237206eba2c18a60a4430
d9fb389a6dccfeeab890a10aa4b6e648dc50d43d
F20101208_AAAKMM kuhl_e_Page_12.tif
8677ae3f1a03f55652f3fd465c7d972d
6113bb6982295f53029f52d4f5d53c956994f10b
220 F20101208_AAAKWH kuhl_e_Page_60.txt
29ff257d3609c91774a256e022225af2
95dffb87aa839436294cf1b8780298f8970db8c7
56210 F20101208_AAAKRK kuhl_e_Page_33.pro
d3c22d77c28704efcdf6b8b087b917f5
208c7fc5b50d967ef969f7d111001f65079ecb7f
5173 F20101208_AAAKHP kuhl_e_Page_73thm.jpg
2f053651a9a18e3a6f68fdea48c778a7
74ceab1c70575559d2fab2f182895b3e5c61eee8
6352 F20101208_AAAKCS kuhl_e_Page_48thm.jpg
7a7f833de8165734f6f5283fefee3b66
5badb7b97b9f925061779487dc6128e4550674a8
33182 F20101208_AAAKMN kuhl_e_Page_15.QC.jpg
572ec0414ed98ccd387d7329ac4e5dad
e91beaf598ee99b46b06d366e7558ae5dcc8bcd8
2183 F20101208_AAAKWI kuhl_e_Page_61.txt
9060a5789af866f9b1b654e21c3bd4a2
1cc4cb7a7d7d86d99ace85ca353c96516f5a6439
2206 F20101208_AAAKRL kuhl_e_Page_33.txt
75813e08bbe3d0cd6eb76892a4dbff9a
5c11c68b560e59473a2d490681bd85960244d888
15578 F20101208_AAAKHQ kuhl_e_Page_51.QC.jpg
8fe614c3f2f26055ba522c15f56d60bb
227939dcbcfbf9cad88e8c65e835568a94bed108
F20101208_AAAKCT kuhl_e_Page_50.tif
bc0b4ecddadcc289c8f34e08ba5c83d1
5645564185e2bf70fe26e7a7252e2c745c459113
F20101208_AAAKMO kuhl_e_Page_42.tif
fbc8ce112ded73144b61738332c8d57c
8951942c7da176ba8d4727d26796d56b5a1124de
1704 F20101208_AAAKWJ kuhl_e_Page_72.txt
a152bd67924bd6d1399f46919f8444ec
e1f5946ba773e1cd1ae5f68e6e2c6f453fa1cf31
1935 F20101208_AAAKRM kuhl_e_Page_45.txt
fcadcc4d9a59ebd033a2444fe0dd1977
c22c4428d18ba67d04b2b745e302b6cc2f130d5c
2170 F20101208_AAAKHR kuhl_e_Page_38.txt
014790656b7b5d91bb1766180521ff7a
88321ea7e190399d991305da358efe6c82d8107e
6406 F20101208_AAAKCU kuhl_e_Page_05thm.jpg
89219271615906cbfbafed8520065847
e80a54b00ba501c682ff9fcbd4df90103b565831
2746 F20101208_AAAKWK kuhl_e_Page_75.txt
0ae3b20e16fd6a819d910edd8ab859e5
190b0ca2a2d4f1f28b52bebd16d64de4513e1193
121334 F20101208_AAAKRN kuhl_e_Page_33.jp2
6b80ef10aabc32ed34b2848786a2ab6d
4b073e441916aaded2a75a4e46e3369e5df1bdf0
2143 F20101208_AAAKHS kuhl_e_Page_10.txt
bed42dad46dd5575142fdf98b75be6ec
27869859e2d19666747ce9b699709064348d0a87
112728 F20101208_AAAKCV kuhl_e_Page_59.jpg
14b7d91a025bdbfdc171fe4aa1b61102
19fa878416fb3647df60eeb300e0d1a68e4c32f1
998 F20101208_AAAKMP kuhl_e_Page_20.txt
8af898f6b2d1b5eec5a86a24cdc5d09a
fe86ec4a66ac1ef481e6b9c93161481e98a8e1e2
2676 F20101208_AAAKWL kuhl_e_Page_79.txt
6979c794180b8c83363e7082b7344660
d444824c983c076bc4ec911fa95b8dadc392a804
F20101208_AAAKRO kuhl_e_Page_69.tif
40445b3e21fe16b2f8d6d54bcfdcce25
b31cad58d1e7f9d9f752fc3867553a8f452b43de
37267 F20101208_AAAKCW kuhl_e_Page_54.QC.jpg
505dc27bf771462997463003d95bf0f5
d9dbb0f486bf5b4a1d91d64ff5886e91ae0490f6
454 F20101208_AAAKMQ kuhl_e_Page_50.txt
9afc8984d3f0143c8f7532046cd42cad
0dc9e1e2aa1b5ef1734ec67632d01aa63e83eae5
53592 F20101208_AAAKHT kuhl_e_Page_12.pro
37eb778ac98e8da33744609ce99050b9
b95768661088ba8704694a17079e8739863f76d4
2030 F20101208_AAAKWM kuhl_e_Page_82.txt
eed6479831e09f1b49d94214eab3eb82
26f882b81a135220b100d141b8dc873be82c120a
118268 F20101208_AAAKRP kuhl_e_Page_11.jp2
c651fc0a5d6cc467dee39d31eba34413
c35a4bb68c60c5cbd500b05fe4ff8157ce6eddf1
2178 F20101208_AAAKCX kuhl_e_Page_24.txt
7b86cbc452f79cc869b9a396f77a2c49
f9174fe28bc888067f832eae1ee15facc849164b
50610 F20101208_AAAKMR kuhl_e_Page_51.jp2
64a12a2b6646907146fe02bffdd325f5
a623a8f11778ce81058f452825c4f3e8bd93c1a5
1685 F20101208_AAAKHU kuhl_e_Page_73.txt
5b998abd277dfb88b5437abd6157446c
9c5d164532e1211b2a549343f33ab0171915f228
288554 F20101208_AAAKWN kuhl_e.pdf
f0625fc90b4c014fd203d83800661611
be3a4e9e9c2dd2e2d55067c98ed6a55f0accb495
5783 F20101208_AAAKRQ kuhl_e_Page_47thm.jpg
299ee197eee28bc6242a68f1db0735d3
cd763f23da1584976731a539291f6893e806af19
F20101208_AAAKCY kuhl_e_Page_80.tif
51dbda3f6938a0566293c19f16058294
d40d7ba7e9a632ec75985a549ecc83795140696a
56946 F20101208_AAAKMS kuhl_e_Page_30.pro
938f425c4484b5b9396c52cf85c2592c
83403589b24850915415b6e8ae1b4fc96626a066
111651 F20101208_AAAKHV kuhl_e_Page_41.jpg
19355bbea304b9a19b02c45d33dad5eb
a1943bf591eb04a2024b9fb5a57abbeb1b2e4590
8630 F20101208_AAAKWO kuhl_e_Page_04thm.jpg
bb95df2eb22dfb837edee26071d9d382
1420e1a5137e39bc68cf4ec8b558b57a2a707621
26241 F20101208_AAAKRR kuhl_e_Page_35.jp2
24cf958eae1c37d23fbd060e54dd5450
fb225e76c89ab2a6a55151f5e66c1782ba667ada
122063 F20101208_AAAKCZ kuhl_e_Page_44.jp2
3d16a35de6ca14b75f2883f1eb3726f3
979cf3089cf778ebc7e8851b80625184e49773bf
F20101208_AAAKMT kuhl_e_Page_10.tif
8886401f4f1225e65606fa9b8699d466
83a11afe5b846f063e3341ce8bca577634d00087
9084 F20101208_AAAKHW kuhl_e_Page_76thm.jpg
7fe1cacb2dc33532f11887a666980452
9bc7cd1a9419eac620dcbabca02ca9984163d3ab
35231 F20101208_AAAKWP kuhl_e_Page_04.QC.jpg
847af19d125e9ed62f7daba416e89f21
be525355180ffd85bc44e1fde4667f6dd3095bd6
27313 F20101208_AAAKRS kuhl_e_Page_69.QC.jpg
8f7f655d3af04abdf484c344e2facc48
dbc8fdbd8490984178d864a8fd3590df74380dab
115580 F20101208_AAAKMU kuhl_e_Page_42.jp2
69ddfa76cbc3b14d50a5c80ed160ec30
ac9564ef9ab73fef9cfde97bbd6717f3a2a04aca
71684 F20101208_AAAKHX kuhl_e_Page_81.jp2
f923e1ce1838230c29d986d223182947
a0df7c3d41d3da32d849eb4e3d0acd841ceaeda4
26515 F20101208_AAAKWQ kuhl_e_Page_05.QC.jpg
3aef4ea054e501959d80e8a1c436a73d
0667089092bb3f95c7a0683de84f1a5e6482b4a3
2070 F20101208_AAAKRT kuhl_e_Page_31.txt
c2199793ea5b01e74ad4e125e3780eba
686a4d2b8b65f3f4b597431668e968f3607da4fe
9825 F20101208_AAAKMV kuhl_e_Page_03.jp2
8aa0af592354da01b8016e920468723c
ecf50a841fa48b5726f5894ba52e1a18205e4d2d
F20101208_AAAKFA kuhl_e_Page_38.tif
23b67c11562a9cc3a4813c74142a9095
260e85597097757b4213bfac60c8795a981e3b81
103409 F20101208_AAAKHY kuhl_e_Page_27.jpg
39d2fcffd65a43c6ef3f1b4a72d8502c
89d1c7e311770396eb31fb5b6044b4fb327df5ac
25451 F20101208_AAAKWR kuhl_e_Page_06.QC.jpg
105f574e00dbffa9bd413c99e7a6af56
fabcbbc93c2db9f9d573e3bace980368ba198d03
5250 F20101208_AAAKMW kuhl_e_Page_72thm.jpg
3b46e173f30b97915accca5a66a4e7b5
92544a1bd8d83a155dafc4c50b27d921d0e86a18
7733 F20101208_AAAKFB kuhl_e_Page_08thm.jpg
d560adfa954a9e764f025f87899d91ce
5214c42a9bd19d113b752a1b12191414b402a8c6
10796 F20101208_AAAKHZ kuhl_e_Page_35.pro
8486e186609c34af6c06a7e0cd259133
6b0419f408205897595bb44f9d2276c9af87d590
31108 F20101208_AAAKWS kuhl_e_Page_08.QC.jpg
8fdd4164658e8fd9160b091c9f043499
0a26451c99000caa2c3905e42753e30e90a5c071
F20101208_AAAKRU kuhl_e_Page_01.tif
efe842b600e391bc934970c2d47f9523
3b116e15eee033ab606cdb5618f99578e7d21e98
33760 F20101208_AAAKMX kuhl_e_Page_31.QC.jpg
191177692e74a11297d3fb58e446e4e8
8a913397f88f9a85597ae423ba3e10c10ec87e44
36605 F20101208_AAAKFC kuhl_e_Page_49.jp2
7ac73d2e4353610d553dfa8587ae6739
e800fc53e81b963b387539eeb5b77d760a5a7051
8409 F20101208_AAAKWT kuhl_e_Page_10thm.jpg
64691c83eef7eb4095f1338228cdfbba
d85a5daeca8d0b701d2c514919bddbe98319e52d
56676 F20101208_AAAKRV kuhl_e_Page_18.pro
07e2ed5d170cc895e311e226c26c48be
982fa308fd1926cb5ea84f88ec8a617613b621a9
F20101208_AAAKKA kuhl_e_Page_78.tif
b5c7129f11a905df2c58fc08ac534ced
5655edfe71840661cc1e26aa03567a4d11ad4648
103295 F20101208_AAAKMY kuhl_e_Page_36.jpg
8966f89518dca603023a5bb45aff7813
1f4db2f8080647ff1cc7bf2ec74d0bd484def691
106534 F20101208_AAAKFD kuhl_e_Page_10.jpg
6eef2b8557ef151ab3ff3be771b99034
1d5fe08023a7d4aa87d23b153b03a6ddb9a9d99f
8622 F20101208_AAAKWU kuhl_e_Page_12thm.jpg
66e3c0f6cd7457396526d553a27eeea8
60eeccd741bdf773b10f7be3422212f005244bc8
2238 F20101208_AAAKRW kuhl_e_Page_28.txt
57b3ff18604c7127a0452f3ed66e54c1
e6d35228d3c8fd2cd84857c788f0240d8cba75d9
67530 F20101208_AAAKKB kuhl_e_Page_78.pro
ecf73905fa0d712acd53cb71bb0a043f
7a0ceb098d4f61fdfbfff8bf129b465571591da9
125490 F20101208_AAAKMZ kuhl_e_Page_19.jp2
41ce18e2a57ab73932617d21568496aa
01a0d216bb253e39e143e546bc70327877ece842
F20101208_AAAKFE kuhl_e_Page_61.tif
0144700f088924bc2285f522a2c85bbd
2a1543d87dcc0b57b5b9050ddb91245f48cf36aa
35484 F20101208_AAAKWV kuhl_e_Page_12.QC.jpg
7e9b3afb00982bd212f01a7e6adaf718
708eb610a744dc31193778986b0b0be94db35b23
132886 F20101208_AAAKRX kuhl_e_Page_78.jpg
0529a332a59efc6c0242fb29c2ac9fb7
af798ca8e67dae3c366f490b20c37727813ecf3e
F20101208_AAAKKC kuhl_e_Page_66.tif
ca2319a87e6b1e7762a0927caa3e0fb4
c646377960df8f29c9ef98afc5f4ee98eb0cd23d
36674 F20101208_AAAKFF kuhl_e_Page_42.QC.jpg
fefd1130c92ad29dc4186eff6707f797
2a0e25d37822c35bf49ff6dfa91850084774257b
34878 F20101208_AAAKWW kuhl_e_Page_14.QC.jpg
d4c7c84c57552a3d15dcb69eec5fa40b
53a3d48a8cc43ab44a9f10b45a98b920f6950f2f
39953 F20101208_AAAKRY kuhl_e_Page_64.pro
203e885343d6cddd786d4599da6d821d
7336ba15c92abfcb7eb554a8b3d4a9494a67e767
52798 F20101208_AAAKKD kuhl_e_Page_17.pro
8aea83999cebe8ef00f58be7f34236be
e1a32e418248e5e34f05a681b0b6210d5f04faac
F20101208_AAAKFG kuhl_e_Page_60.tif
d568ae9112f77d48d68e5120277025d2
44e044d719364dbc59650169ffa5b31bbef61242
101945 F20101208_AAAKPA kuhl_e_Page_08.jpg
54401cf43bc1b0565b9fab70e00e6064
a0f203518457a7a7ff308cdb370f4955f22254ce
14335 F20101208_AAAKWX kuhl_e_Page_20.QC.jpg
c325156d5f1218c098b14fc4f252e2bf
31b50187ae217f8d485030126f92002041f8355d
F20101208_AAAKRZ kuhl_e_Page_48.tif
ff51348a3dd4886dbc81065c56d42527
b62b7f918199e52e48bcf41bdae703fae4f2093c
2144 F20101208_AAAKKE kuhl_e_Page_56.txt
3d7771f2bfc55fbd41261caaefb161e1
b197294d131b7bbb1d910ca54eb48fb99b095676
2169 F20101208_AAAKFH kuhl_e_Page_34.txt
760dec94686e28e833476a29700c63a8
abe84aba6e27f1223414ca788044240c03a3e2f7
F20101208_AAAKPB kuhl_e_Page_39.tif
551f8348ab11858bccd2bbefe747d554
f8f3aab0e2f01df4af88dce2cbdc15584f80d642
8598 F20101208_AAAKWY kuhl_e_Page_23thm.jpg
c3daf76e3c381881f26b14c2d9e12f48
4b6473fced568093ff31960119328761c24d5fc8
2533 F20101208_AAAKKF kuhl_e_Page_76.txt
4f0c81b6c21b4f5851b29adaab7f704c
33382e8d497cdf6100216b45392ed3e913ae245f
2126 F20101208_AAAKPC kuhl_e_Page_12.txt
989c8afea284a67ba097067b7cf76bda
5651eadaf5bf33b9e6df7993c5915bc1dd3a445c
53909 F20101208_AAAKUA kuhl_e_Page_65.jp2
8eb8aafe76b7d49248c52ac6d2b54752
4ab3c8df810d60bcc37e0382e12ec6553219a341
3302 F20101208_AAAKKG kuhl_e_Page_05.txt
6e3900feaa5d2b75630d3cf23924b1f3
b1d713d766254409d5c958cbd0fc9534a784144d
1383 F20101208_AAAKFI kuhl_e_Page_02.QC.jpg
d46af88d4d18c52301ecdd4ac2e772b7
d336c2132595ef023a55000f06f0811e2a03f348
F20101208_AAAKPD kuhl_e_Page_52.tif
620205de32183ec7ad94374da5e4809c
749532155002d6b09dbea5981f772af65c66deb0
8925 F20101208_AAAKWZ kuhl_e_Page_24thm.jpg
8b49a5ba13edab9bafe5c9dd52147535
98fa916207577589370ede9761263162133db598
55723 F20101208_AAAKUB kuhl_e_Page_66.jp2
2b569ffe709c34a6efcd854ab0ff2261
525de0b5b935de9af5a05e001eedd1c019b9610a
24769 F20101208_AAAKKH kuhl_e_Page_66.pro
5ef459a8a6163e7c689e1014cda5f17f
c81805217e42ce4f531ba5f995bb0a87f22661d0
47829 F20101208_AAAKFJ kuhl_e_Page_08.pro
b24e3734ae181080725e5c9cc38b7ffd
5b6bd9d68baa2a9ae769a4bb6a82d95e103c8418
3923 F20101208_AAAKPE kuhl_e_Page_06.txt
e62ba3e5661b9e9004b79fa9d5140d9d
de3cbc91898ccb3d50d30c9b81ed11949fe03d0e
60995 F20101208_AAAKUC kuhl_e_Page_67.jp2
8b2e6407bae7d02eab8aceeaac3c8485
8458fdb141a0e07cf9e58479427a5833c986658b
66584 F20101208_AAAKKI kuhl_e_Page_47.jpg
8d5770df94e514fb59048daad1c4759c
8fa0ab5697d1dc66dcaf8ed6df5aa1d1ba8fe1d5
9103 F20101208_AAAKFK kuhl_e_Page_80thm.jpg
f92ca81b271bb8d2646a806f94e8872a
842f05825bda5b3ba9b1a6ec4bfd82638699a3fa
25271604 F20101208_AAAKPF kuhl_e_Page_07.tif
c3966160fa13ee043e0f504b0e625635
14658488f167346f8d335bbe16e03da52531d54c
65350 F20101208_AAAKUD kuhl_e_Page_70.jp2
2d254cc73bfe49dd83af94cba988ae51
8d4f9b500ea9a50a118a1f5e00928c39c3a54989
49090 F20101208_AAAKKJ kuhl_e_Page_45.pro
dae6aa2ee0ed4a0fc23a186d19ba5963
576317e2f8fd0765ec4d448d00fc065fc33f368e
806 F20101208_AAAKFL kuhl_e_Page_02.pro
45a588bd1b16c0c54f1664aafc5f3f15
f081f7807b5647e1f1031de1d29281e1453565db
36237 F20101208_AAAKPG kuhl_e_Page_22.QC.jpg
700bfcb3944d74d9d1369e16c2c8e64e
5f9950870241f1e67f233e419972b2df0fc77a6e
64628 F20101208_AAAKUE kuhl_e_Page_72.jp2
2e5bfbd7dc2ddb574803e4ae91ee4fa3
d73ce6c2049b556cd4107bbab9400a0666000a17
104739 F20101208_AAAKKK kuhl_e_Page_14.jpg
c21bff6a7b515f79b39d95b9a858b86f
ab6daf0685b73f6bd920ee3657dbf8d345926881
2681 F20101208_AAAKFM kuhl_e_Page_80.txt
7ee8429aa25a129e19eb59a99ef9524f
6df151519039ba16e02140cbdc97641d102f5f7f
36247 F20101208_AAAKPH kuhl_e_Page_23.QC.jpg
94dbc5da84d008b14cce7b4318037dab
2ef0616f1add0de30e94d8e9e38b89c33b5b415e
129760 F20101208_AAAKUF kuhl_e_Page_76.jp2
d80ef6e6012bdb248e6f0dde668e1435
531f25f6df1565929f78989dd746a22fe7ee3224
64479 F20101208_AAAKKL kuhl_e_Page_09.jp2
8c5412e59c85a88ee4d862a58aebfee8
c5a08368c6eb858720669164b495eb5f5c565832
28178 F20101208_AAAKFN kuhl_e_Page_71.pro
53efc8303bbcf18a3b62eb2436ac1074
d8d4943ec86f2fedea22dcc8843770d64be8edd5
8205 F20101208_AAAKPI kuhl_e_Page_29thm.jpg
86b3d292fbfe423ad5f7f21fee29fbbc
b2c770b668b7f47a5c452eeba075b480dc91c06f
1051979 F20101208_AAAKUG kuhl_e_Page_77.jp2
bfe1d07f4b6eb0794284cec93af41c10
1389e12dca82760718ff68fed76c073b0df9c612
2023 F20101208_AAAKKM kuhl_e_Page_29.txt
bb54cfa4cbd92bd951209ff1bcef54f1
5900db635dd7a3e086e125a8c73d82e8d6246411
F20101208_AAAKFO kuhl_e_Page_21.tif
ab85922452771425b7a307e6219a2430
dbf3c9924e0162879611a2074bcc5593a3b8d770
F20101208_AAAKPJ kuhl_e_Page_43.tif
3a5a56d03554e999c22a25c6fd83a88f
f7f25d93b1599ffd0185ec0200a577c9013e2d55
135126 F20101208_AAAKUH kuhl_e_Page_79.jp2
c10dc2a9248343c842391a25970b855b
d885f9ba23ef4390894d631782d0bb7d665d399a
55350 F20101208_AAAKFP kuhl_e_Page_24.pro
5cc6f6eb991704a19219835477453930
d828f69362729553cc86db76b146944d77d3f3f7
111358 F20101208_AAAKPK kuhl_e_Page_52.jp2
9fb24926c64826782a445d559e957cbc
5f5265830dbd89ebe975bb96b4b5921ea0322a1f
F20101208_AAAKUI kuhl_e_Page_06.tif
a1b82a373bbdcd34af0776d89a0b7afe
545e25679dbfb1ce2e3ea40b1761a84c0bfa3c7b
3145 F20101208_AAAKKN kuhl_e_Page_62thm.jpg
90dac9caae567478b22530ca92d6a072
4c14980f7ee18c4f2ab848415a1d31d3a6c3f240
37387 F20101208_AAAKFQ kuhl_e_Page_26.QC.jpg
0090a013a71ba6d11c1c50965bc344e6
99ebb5e5326f71887fe0dbbda68389223dfa3877
18875 F20101208_AAAKPL kuhl_e_Page_67.QC.jpg
d8d04906277ea3479ced0c1b44533c89
d68dd871ad8563220fe9e76d7c356f1b9848812c
F20101208_AAAKUJ kuhl_e_Page_08.tif
786c86b71ce956c1f74fb005441a6102
b5a80264aad1c7525236a15a8a27f1ea539adebe
62596 F20101208_AAAKKO kuhl_e_Page_73.jpg
1b3a5faf48e47292bbec828972ec9d33
92a25c6ed63debac935a924492e86bd09f36cbc3
6929 F20101208_AAAKFR kuhl_e_Page_64thm.jpg
f71415991f8fb74ea2bd2406a8fb1cb5
3b0c47e02d453ee3078569971d0b8cd31049c6c4
32461 F20101208_AAAKPM kuhl_e_Page_68.QC.jpg
3643cf3e37114d5f1f4c5b550ca944a5
8f498e5c3ea676d6a45ddbb0ea86e489f1290ad5
F20101208_AAAKUK kuhl_e_Page_16.tif
f73776fbc2dbeb6371bd4acd106a5b8b
8aa11bee9a606edf7478e7f31437cd82b8571959
8840 F20101208_AAAKFS kuhl_e_Page_19thm.jpg
ba29530fea696cdb10a40c1eeaaaa92f
45a5e421dca711243f59ca7476a53248895216d7
8533 F20101208_AAAKPN kuhl_e_Page_31thm.jpg
0129b045a0925e35be3f5992bf60ee7a
254904eb9c3d8411edbc7b02355b05d83c18d2a6
5590 F20101208_AAAKKP kuhl_e_Page_66thm.jpg
659ae6bde72da115e0abbeb7266ffe19
7bf21f294d5ffc59e79d170c608e4445be13caf1
F20101208_AAAKUL kuhl_e_Page_17.tif
834e4d2a6c55bd6c227f82c510e8c1b7
4a8248a3992fe1a702b920ae0d0dbad4b5358639
107681 F20101208_AAAKFT kuhl_e_Page_42.jpg
2ff0671189a87525e59f8b9bbeef4109
5c6d7bf5b4d2db17e18c8f44e678a3347d2c384e
9044 F20101208_AAAKPO kuhl_e_Page_22thm.jpg
29878617b69530f26e4f275128d13d05
6d5290dfc095702bf91150a0145622aef7b206de
1241 F20101208_AAAKKQ kuhl_e_Page_67.txt
49fd115d075e910e4684098af8b9f3b0
7958497cf6ab27c956bf13c43d1445147aa9c471
F20101208_AAAKUM kuhl_e_Page_20.tif
1f5f1e3b54c9f05384ec6124abb8c1fa
02342820f67207b0606ddd794367074f23f16076
2076 F20101208_AAAKFU kuhl_e_Page_08.txt
52dd6c9a2e1f874b4ebabce81983e106
cc2a425f20dd735fde7dfc3f3102b8ba0b40d27d
F20101208_AAAKPP kuhl_e_Page_40.tif
9b295da6f6d44f1244b4daaef57e156a
c81119aa59645c99a9f8d5742b3d38d8dfecf2c9
F20101208_AAAKKR kuhl_e_Page_18.tif
3e913e7501673c15c3809602336d8ded
bac3af7593fa4b9e9363e91036a55a9625839d00
F20101208_AAAKUN kuhl_e_Page_35.tif
3294cdbfbfd41c7a4cd4e9d2d2b4de2b
02c1b9c2bd9afbac75d68b9931e872d674c367c4
98409 F20101208_AAAKFV kuhl_e_Page_15.jpg
39fba2371727d3dfb2dab95575ce3fc5
e07c26d0496232784f2729612cce63df5aa2644d
19041 F20101208_AAAKPQ kuhl_e_Page_73.QC.jpg
c2d011472ea396c19f804676d1d14e76
b4480f1474dbd45d7f27a780733fd6324904f934
34443 F20101208_AAAKKS kuhl_e_Page_74.QC.jpg
b71a132b5e450e22b848cf2d00d11064
ffbf6d4199fbbc2396e18e550e63963b6f53470d
F20101208_AAAKUO kuhl_e_Page_41.tif
fe6e215d9d1ece68990a61900c474fd4
236533483df96cd0333df935087a31c411b8a384
3714 F20101208_AAAKFW kuhl_e_Page_20thm.jpg
f47e0495139d7dc0875e8584d96ef243
a959d43e74325bd9c17f21a27d21c52393ae35fe
139226 F20101208_AAAKPR kuhl_e_Page_75.jp2
8aaa971baecae7063715e545a3bfe609
99e6a0c908839ca5d260a5af79f33e4e15331f0d
67573 F20101208_AAAKKT kuhl_e_Page_13.jpg
2c514d047689fcd2bf71a5e318e972fe
e80438f8a7cbc3187e440f0b75cee2fe2372ccd1
F20101208_AAAKUP kuhl_e_Page_45.tif
d4104b95050368eb2d5bf784b12e751a
82ba93058a93c5b561e8d07f4fd3f684be665c30
F20101208_AAAKFX kuhl_e_Page_73.tif
957d6483470f1d6ce1dd365eefdf03bd
fbcdc5e0bf0c0244eb7e974206f46e6772f3d05a
14207 F20101208_AAAKKU kuhl_e_Page_60.jpg
ef8afcd81fd42400a8c6cd4b5a86e9a1
e8ca34a06f720dd4c6919056cc773460e03b3b80
F20101208_AAAKUQ kuhl_e_Page_47.tif
84b72eb2ea8f662a6dd5251c9c5b2c1a
4cc567f3b0a672b55bb2348d3a1689658a30d98e
35776 F20101208_AAAKDA kuhl_e_Page_25.QC.jpg
1089c9a43b9e026c9fb776402d1b83a6
56d6b97d2f6decff062311e320c7728888149a14
32606 F20101208_AAAKFY kuhl_e_Page_57.QC.jpg
fc13778e0ac2b0de5d6ce93b7e89d988
5b3ff346fccaf527f93b95f303e95013cf2fc8cb
1703 F20101208_AAAKPS kuhl_e_Page_71.txt
e86193eb5661125f22541581f11a346e
344a855167e71f8e10912fc7f02adab16303f8ab
7522 F20101208_AAAKKV kuhl_e_Page_49.QC.jpg
a1470e393c511239272a08f00b108057
bbcf83d2a15fd7776540feacd707c1fc5ddfb65d
1054428 F20101208_AAAKUR kuhl_e_Page_49.tif
dd426566dd5485ce62b0138208c5e729
1635bbcda7b4d7033e468753927816185ae611fa
2108 F20101208_AAAKDB kuhl_e_Page_42.txt
d247798497c64f85fb3ec716c84d8121
18af9970819d387f806ebd8bf57ad05d856ec756
8867 F20101208_AAAKFZ kuhl_e_Page_26thm.jpg
cf199f92fe77c5c3c3673b8b952e0fb1
8d0e17c95c18546f77068cd2d39f83ea758ad8bb
36036 F20101208_AAAKPT kuhl_e_Page_16.QC.jpg
4d1f5d789f632c1cb52364b3ae1242b0
72b07cf0922bdd294160283540869d97aa766705
38074 F20101208_AAAKKW kuhl_e_Page_30.QC.jpg
b0559599dff94be6dba07b0c32eb45b4
9cee4f2a4d69510206f391d7d2877d1332bd5dc7
F20101208_AAAKUS kuhl_e_Page_51.tif
cc6f5a412c75e24252c051d5298f333b
468427627c506ca5b7bb50eb7e503be864dbf09c
59777 F20101208_AAAKDC kuhl_e_Page_09.jpg
83ca94c30f785ee69ffdd4fb5212f8a1
fa70deeb0d4e9726236e0ab163f8d0a63cdedd14
1597 F20101208_AAAKPU kuhl_e_Page_46.txt
d92471d19f7287ceb4a8692792a13a35
f6c340d67260cb5e930b4208fa532dc0474df15a
64933 F20101208_AAAKKX kuhl_e_Page_79.pro
aa9e5695f67982545a7a1896c8945922
9a2e3f034bca40d6c6b34c1c1668b5ac3a4c7c28
F20101208_AAAKUT kuhl_e_Page_53.tif
c414de22e91656eef83be1ae6734ae5b
fd9aecbd89d010a5961ed507a36fe070839ab37a
115677 F20101208_AAAKPV kuhl_e_Page_44.jpg
cceb5917ca44d5288c963c4fe1c66b15
66f422cd3ee64a362df7b1002b7373a3bcac8941
105331 F20101208_AAAKIA kuhl_e_Page_52.jpg
026a3b0e636dc713d7e482bfa351762e
fd11b1b0b502fb5b9e31bb33a0ef55daee7a4ec1
F20101208_AAAKKY kuhl_e_Page_03.tif
3cc460deab31c18bd51467574d19f3f8
a1761ffb8ec11e1fcab9a5fdeb98a55d9551c437
108790 F20101208_AAAKDD kuhl_e_Page_45.jp2
359c4e18c6dea170d3dc0271d1d2ca47
eecddbb03ea5b02bb429f8887113beedb786d8a0
F20101208_AAAKUU kuhl_e_Page_57.tif
b70dbd69670ce028e5dea8593ef62bb8
2538a24e798d7512c07bb00369b2e9a32bb54282
F20101208_AAAKPW kuhl_e_Page_33.tif
89cd9d99272f502c8ec07064cbbddb1f
46636ea1f545cc57f8a5addaf1977abb33548632
34414 F20101208_AAAKIB kuhl_e_Page_36.QC.jpg
11661b245b69fb0ccdcbbc0a5ad36861
9cdcdc691e06ac7d9ec1710dcaa2aa511862314b
8711 F20101208_AAAKKZ kuhl_e_Page_32thm.jpg
8b654db873457c003b15f762f70b0992
f3c83ed66c7134c8b98971577fc8fa90ec623c86
105928 F20101208_AAAKDE kuhl_e_Page_08.jp2
df5dd7a40ee9c34d7778ad0e4ed14b56
10085dcf5601e430af961a53ec80bee5772396e1
F20101208_AAAKUV kuhl_e_Page_65.tif
3e3cf78031f3b8ab210224fc19cb8664
0d15079066925d3b40011fb2ce0414b852c9f353
2358 F20101208_AAAKPX kuhl_e_Page_49thm.jpg
fbfac792a96655633b6facb6fed09a79
047b473d4959ce573da5a952a1dbb94e0f25638b
82674 F20101208_AAAKIC kuhl_e_Page_63.jp2
4fb0148f871fdfafcca3b7f324197b68
45e61721d7c5bbb02c7928f8892e9e9b0fc86077
117395 F20101208_AAAKDF kuhl_e_Page_06.jpg
3e605bf3b20ed060df716dfaf671fa25
4de62474f4a37f8d0565fe5411d906041d4b449c
F20101208_AAAKUW kuhl_e_Page_71.tif
1e43d1e7b33d207c21c63e002d3388ad
14809da1bef13093836c1b4a0b9f17d48983a7b5
20415 F20101208_AAAKNA kuhl_e_Page_48.QC.jpg
381aa7cc2bee0f95b8276c2e0fee6147
3dac4e58bbbc7913aa263afbb885c0910813cc96
8729 F20101208_AAAKPY kuhl_e_Page_42thm.jpg
b0126cf8e4f933cc7c752dec350a69bf
c84476522e5179ed34217aed66b7b2065242edec
140655 F20101208_AAAKID kuhl_e_Page_78.jp2
e387a20f79568a99c87ba16262dd2319
317c409e4a641105d881cf15b7dfa32f95f54d8a
51366 F20101208_AAAKNB kuhl_e_Page_27.pro
ae8a876fcc39de80c293653cc9951c24
f53013627caa9c2d472fd5fc2e5bc9a77a8d1145
34778 F20101208_AAAKPZ kuhl_e_Page_76.QC.jpg
1e43782fe152246a49e322724340252c
d8e90a15b2c53205079ea6315d4de4a62dfb2020
58616 F20101208_AAAKIE kuhl_e_Page_71.jpg
93d62b5cafec610536c8345bd06b24d8
6ba2d5b951b9d66f9ec1bf72d81450b6c8ee0c1a
123384 F20101208_AAAKDG kuhl_e_Page_53.jp2
b4b671b5b3cd497b92d6a4e66af49cfb
4fc70b1c17eac3fa858347a5037418aeca5f0122
F20101208_AAAKUX kuhl_e_Page_76.tif
9eda49c52fd9469f75375b28c475786d
244fbfe727e46ac1d337d28011f0f9031dac9d75
114800 F20101208_AAAKNC kuhl_e_Page_28.jpg
210fa61aa95e1a13603ee1facde1e569
510a81887f42456ba984aa6a67838b13615da681
F20101208_AAAKIF kuhl_e_Page_70.tif
4917da6cd2b9afa9b2e2d7e21a2923d7
cd1f2ff5a6d5afcd92e60b57ee0ed99fdfd96375
F20101208_AAAKDH kuhl_e_Page_74.tif
da6ae1bef07146121204bf6d09015530
bb8ad7f9395bb3683c5f8f49b5ed8687c60fdf47
F20101208_AAAKUY kuhl_e_Page_79.tif
67b6e9a4012c3d8f9e98d0ad5bc5e5c1
3e6fc2aeb971e32ae76737c38d3fb6d08b70ae72
33721 F20101208_AAAKSA kuhl_e_Page_21.QC.jpg
d8b2d1c90a5ed8f91c88e9863360030f
433a1ba0179ff83fa72c37494a17e1e6b1a6cf8d
55207 F20101208_AAAKND kuhl_e_Page_66.jpg
a3b29e76b1746e53b3fb74f15ad63dba
d4310d9f52ec78a21ec9961c41ab6b0eb45d997d
F20101208_AAAKIG kuhl_e_Page_11.tif
c1047b4e977d2a02d648eb3b8fd328bb
ece9a215f42506dd9d1532bc9efb923c3f0d6732
1991 F20101208_AAAKDI kuhl_e_Page_64.txt
ee68ce6c7ab1e8f24c944e101d91adf3
f54aae7e37027d2903823632f8f177d74f378b97
F20101208_AAAKUZ kuhl_e_Page_81.tif
a9df20b25850415e1d4be192740c6524
1a0564561d11ec5ac258bd69bfe7941313bad19e
113630 F20101208_AAAKSB kuhl_e_Page_11.jpg
f4b7c8b27b1223f852144c5ac514a3a2
eada8b70a51344a9c6e2045c2c0ca801e8c89b46
4757 F20101208_AAAKNE kuhl_e_Page_09thm.jpg
b6c2b93e408fb0e50cdc088e51698cd4
7bff585624c2674ed23983d077abd8fa7c05da67
18708 F20101208_AAAKIH kuhl_e_Page_72.QC.jpg
d2a03ff46107443d896128899d234468
feaba899796e34285b52da2fa38582a42ca84195
52079 F20101208_AAAKDJ kuhl_e_Page_10.pro
bc9f50588a9f300a10696608925109a7
6002f8bd8514a7e1f9a11f687a8c3d0f852860fa
F20101208_AAAKSC kuhl_e_Page_26.tif
693e5a9c8326595d23a9485958fb2900
4fc85a5f2eab1ef80d50157a8dcaac547d0b6342
F20101208_AAAKNF kuhl_e_Page_25.tif
72dc6997b77fd675e879ba3f54948449
14a52f6166fa80819850232ead06965b5f97309e
57364 F20101208_AAAKII kuhl_e_Page_53.pro
8907c7e577f06c731fb66a2d5467e43d
eeaadee88d3b0f4c6a7f6aa8f2f61e810e75838b
8847 F20101208_AAAKDK kuhl_e_Page_38thm.jpg
750e59c85c512aae9976e55561e087cb
5697c123e4c619abeafd108d1feb8ada2042b331
37562 F20101208_AAAKXA kuhl_e_Page_28.QC.jpg
6f4e84e20097264f890cbf1e6d2fcc26
844b3c6fbdd3a3f59fb25e2dca345f948361bbf0
2075 F20101208_AAAKSD kuhl_e_Page_21.txt
85042b2fb140c200a06b913883cb54bc
611d36f01d8dc7517e887043369f24325c4aa66a
38178 F20101208_AAAKNG kuhl_e_Page_11.QC.jpg
60f4b1247ca1fb346542fd1dfa7becd6
487cc610592a3dcd07d8348348d21f91acfd2e2b
50035 F20101208_AAAKIJ kuhl_e_Page_68.pro
c712a9f0bc2dd8b05391119c12d22bd6
6401c5b8ac01382b3fb9f40a66d13d75c6e82be1
2111 F20101208_AAAKDL kuhl_e_Page_17.txt
cf57d6033df40dc089ab5da32de00804
d087d71ac88fb16a79d660f17f25e9ebd5f8f079
33494 F20101208_AAAKXB kuhl_e_Page_29.QC.jpg
be98476c97f93b91d1a17993859bbab3
6cc1515c1e886f4a4d75612569b3ba931cc2348f
F20101208_AAAKSE kuhl_e_Page_36.tif
6e249c1133c3896a71a0bcc6c6ca37f7
826cab63755ffb2b92b03c1d1657da4bafbb5b5e
1051967 F20101208_AAAKNH kuhl_e_Page_28.jp2
c80e0649474e444775a09796c311f329
b787b7a220dc21641b017858084a275cd45652d0
120890 F20101208_AAAKIK kuhl_e_Page_38.jp2
aaaf528b9ad7dd212485ea21ef2f4cd3
b0b9ecf021b24c23b1d8e3cb72e494cf4a8e0b98
121438 F20101208_AAAKDM kuhl_e_Page_54.jp2
4228f11151920aea30003032c81be790
f6086a2795cc873b2e5ac1c8f98657cf72ad141a
9073 F20101208_AAAKXC kuhl_e_Page_30thm.jpg
1475db00cff73165e4ee006da645a64d
27f1d8573c26c59471a803319bb1225b697a120a
8641 F20101208_AAAKSF kuhl_e_Page_68thm.jpg
c40cbab7eabc49610a4d17409b6f7af3
5f01906951de9abaef6e9a88c0f04a4169694ec4
91813 F20101208_AAAKNI kuhl_e_Page_68.jpg
fd2e80aefb35703476df44cf5f4481a8
7e4412b94b411d27763cea06705e56ca6e315271
59161 F20101208_AAAKDN kuhl_e_Page_67.jpg
147758c860343572142342a066bcf624
22c5f1adf1099cf207d4e3d0e2428cc03e58adef
9159 F20101208_AAAKXD kuhl_e_Page_33thm.jpg
b7dc6846ff1d60ec14913a5709474def
ebda754f742ae64c4933c55b048610a1685012b5
32518 F20101208_AAAKSG kuhl_e_Page_81.pro
17f7551b167ba97154c11aff9997247b
817d21d1d8433fcdbe4fb12df9544bde21ae220f
2752 F20101208_AAAKNJ kuhl_e_Page_63.txt
2b5df18e1516a3b3ef6d368f58e03289
b61aa2507ac6b458ca4cfbb40a7d546faf46db8c
55103 F20101208_AAAKIL kuhl_e_Page_11.pro
f3a339ad6762143d56d111c9a7797369
688cffbc471a14220d76da7850b834c56d4039e2
111551 F20101208_AAAKDO kuhl_e_Page_38.jpg
f58b8b4e819a0a7da285e4552e7215f5
f851ed3c92e4d67c088ce45902804d59253ee611
2173 F20101208_AAAKXE kuhl_e_Page_35thm.jpg
c239eeaa37ebcc60f2c1dea0207d2b48
84b56870a23da677a79f297f970bb650206ba0bd
112208 F20101208_AAAKSH kuhl_e_Page_10.jp2
dee5946c962ecb2355b8e30972e6eca2
da11b0a099dfe204b059139e445405553215ff2d
F20101208_AAAKNK kuhl_e_Page_59.tif
d42c8393e22e02503c0f29d8aa52627f
0502333d8d7a986a150f1d7e3ebb4c7528467ef7
5308 F20101208_AAAKIM kuhl_e_Page_60.QC.jpg
ee37f675427d70fd6fc923d9f61b1b9d
83a48c0300b371d8eca0de0aa6c0e080c06ac561
57060 F20101208_AAAKDP kuhl_e_Page_28.pro
f980c383455efa97a3a352e2cd3141a3
d0de90986124f0744b43b902a675c80b5c0a7bfc
8823 F20101208_AAAKXF kuhl_e_Page_37thm.jpg
1118dfff6a721f5f55e68625f5e692d7
7bd373ddb9640637de599000f7b01f9bce20cab0
F20101208_AAAKSI kuhl_e_Page_31.tif
bd311d439ffb3d1198113f607b843b9f
9a03a158ab606c9340f99195716859f12553912f
15677 F20101208_AAAKNL kuhl_e_Page_62.pro
17466c9f0a6ca9c86f51da4103d7d0b3
04fbe8cafbd54f08181ac553eff934bc0c586152
8865 F20101208_AAAKIN kuhl_e_Page_59thm.jpg
a0f2d53690575d6670cb24dabcee34e4
ded4bfcac0ee67ba7972c41144703d875a89e9bb
9201 F20101208_AAAKDQ kuhl_e_Page_28thm.jpg
488256461dd59b03b138712036807af9
b8df97f3236594ab62cb4bd9ac9b53ac8f6fdf1b
36021 F20101208_AAAKXG kuhl_e_Page_37.QC.jpg
81197acfacb4bf2e4105811ac071625f
8a6c161462bb0da986e11ad5edc90c141ff8a4c7
F20101208_AAAKSJ kuhl_e_Page_72.tif
da1a670fa530e41344503550c3f565fe
ad97a8090769718cae9205e0508efd3b11301220
F20101208_AAAKIO kuhl_e_Page_58.tif
99cf6a203a5af9ea1a501e5655566497
47c730b032141e22af4205c7248a8d11b5323017
12467 F20101208_AAAKDR kuhl_e_Page_62.QC.jpg
73167673190e55a07e02e6d91e222d14
593e826c187aadd7f97463f45b61c33edea99e20
111416 F20101208_AAAKNM kuhl_e_Page_82.jp2
6f7b1b0706ffce91ff9126c9ae521f3a
b005c029b32303dfe0a69a5be49499636e523108
37765 F20101208_AAAKXH kuhl_e_Page_38.QC.jpg
2cb48d5553ad315ded5ab05e117d4424
3bed57d29f818880a7e6c5ae6a537e5b3bc4c3fd
48035 F20101208_AAAKSK kuhl_e_Page_15.pro
468ee8e845a781d1537d3374dca06128
508ffed292340c81a27d5fd19cd054cc8120c832
25544 F20101208_AAAKIP kuhl_e_Page_50.jp2
db40620ead2c9cc867459ba8d477e55c
7d3c1f58af72f89853b561ac2ea5c87edc8f0800
35831 F20101208_AAAKDS kuhl_e_Page_24.QC.jpg
626b9aaaa75d15af420f73eb81a58b12
7f54180f7060d99dd8ad45692c9a1ec7b3e92672
120405 F20101208_AAAKNN kuhl_e_Page_59.jp2
50afdb0aabf6fda7c312c04908ef07ee
259421a66fe4930a11184527830358c514cc90a7
36851 F20101208_AAAKXI kuhl_e_Page_40.QC.jpg
e98e9e06093a079bc6f70323c21cf65a
aae70f363ae4c0fba06c238ab53a1ae77dcfd077
F20101208_AAAKSL kuhl_e_Page_55.tif
f4f4cf07c089c3b36df5bea59d2d448f
117b4022329a72a739057296873322c46a18f8a8
113909 F20101208_AAAKIQ kuhl_e_Page_33.jpg
3bbd7ce1fa17e62a328cc1e593706ad3
d579e60913a8a444985f287f0f333f626055bbae
9559 F20101208_AAAKDT kuhl_e_Page_77thm.jpg
8aaac094529f5864999182c26d74e02e
b1b45816effb9da5d359bcadc3637f6a8b3221d5
53722 F20101208_AAAKNO kuhl_e_Page_22.pro
6e34f8c04fd436a54097d3edc0515ec7
e428fac76940af27062a6588a1ddf48410f76a27
8099 F20101208_AAAKXJ kuhl_e_Page_45thm.jpg
c48035f9fc8d6ab4a839d3deca02ef79
b3f6a83ec4c15cd3b574ed3cd5380be18113ec6e
129966 F20101208_AAAKSM kuhl_e_Page_79.jpg
c7cd733be3d8197cde649f554c2c7846
e174e7e1e69a971226936660254cd3cf44525733
65764 F20101208_AAAKIR kuhl_e_Page_73.jp2
dbf707f2387a8c1cd7411f01800e777a
2cfddf77b5f39822a5aec8fe67d1fc38b409b6d6
21830 F20101208_AAAKDU kuhl_e_Page_13.QC.jpg
a53793aec86220298e69c275f2a4a7bf
f480c51d35b395f14d54782fddfe2406ac23a40e
3320 F20101208_AAAKNP kuhl_e_Page_07thm.jpg
4680694da8d09c644a851cf2ecbeab44
b68356def76f090b24220c7e1273bb44c77a677d
32886 F20101208_AAAKXK kuhl_e_Page_45.QC.jpg
84a53e16c24c88d93a54f31f6ec29816
0b80b01885ee673deeaddca5b008163bffe2bb02
49553 F20101208_AAAKSN kuhl_e_Page_51.jpg
2f27b78a90b1b33cb7236edd2f69b128
40fbc83cf45dc69c39a99dea7a96f16cbe20b1c5
29267 F20101208_AAAKIS kuhl_e_Page_01.jp2
1fa3cd865bfa71e2c46f216623916d53
35901f7b52285b7c73f99ff93434e9947568cf33
2213 F20101208_AAAKDV kuhl_e_Page_54.txt
3854091b2c5f7e2245a668fc4adca080
ebba855685ee6e1abe620c9d93f1ab2fc753be22
22236 F20101208_AAAKXL kuhl_e_Page_47.QC.jpg
11cc15bf696c3263237a97f3c1f1331e
447936ae828067386f476398913e3007d7959b0b
123060 F20101208_AAAKSO UFE0020624_00001.xml FULL
0cd92c74ed7ea12a1dfa753c74ea28f4
c49879b5ff321eabfff32a461128a829b4630b30
32977 F20101208_AAAKIT kuhl_e_Page_43.QC.jpg
b16a963ba65c6f061298be904755bc5d
965cafa1524279cc466817d41eef5a636a44ce60
51736 F20101208_AAAKDW kuhl_e_Page_31.pro
3fa089d4e01eee9788264fa5f346cbf4
686589098d73506af364c155ed106066f5e119eb
F20101208_AAAKNQ kuhl_e_Page_77.tif
e34e4a4d62a867e38c9b03cdc7351e87
d97a712148921130e72b3795cb5457851343964c
2563 F20101208_AAAKXM kuhl_e_Page_50thm.jpg
ac641091f42314f055f294d2a99316bc
e13648506b207744e71c6c3cf63e676094aa0e9e
24157 F20101208_AAAKIU kuhl_e_Page_20.pro
9611d40ff51bb2cb518ac3cb5f2e1842
5c68a28b70fb722f2e6573cd49f4bbe840a439e7
120136 F20101208_AAAKDX kuhl_e_Page_56.jp2
2c9d2f9418f3271bf8a659b27e929231
024ebe1ddb80495596bda746872eefd73a271425
118674 F20101208_AAAKNR kuhl_e_Page_32.jp2
744bc2bb7638927be2cf1bf547c738e5
7dfcf85943db3e17ea33c731c10c23bdbdf31ee6
8345 F20101208_AAAKXN kuhl_e_Page_52thm.jpg
52e806538f46c2532f5d4cec0eb2b326
612636fde9818b115a9faf3a4a1a47acc89c2e5d
116521 F20101208_AAAKIV kuhl_e_Page_34.jp2
d51b6ff8b7b47b547a6036b78715453a
483a4ac1d07d91bcd200aaa26603ddf000a3f165
114878 F20101208_AAAKDY kuhl_e_Page_58.jpg
94d317f82dd9a3b38faf22810c19a317
9d0ed58eb6966afd0bfdd62bf9f8d51ddd38d6f7
F20101208_AAAKNS kuhl_e_Page_27.txt
d831a3299d77fe4f510713e37cc6f70f
24f84ab043c961b04de2a1c062882a5b331005a3
36690 F20101208_AAAKXO kuhl_e_Page_55.QC.jpg
60dd4ba46c99c2cd722d132e0370c183
fcf597e379c318e0adbfe5adc7b51ab20430e33f
8924 F20101208_AAAKSR kuhl_e_Page_03.jpg
9720247d569a033cf670770fef79ab01
41dbe310c8a7fa978c83e8c17d3b0192bdeca424
108787 F20101208_AAAKIW kuhl_e_Page_34.jpg
e3e0f46f56a236adf2723ab35244e01f
483c869049319f32e6b4af5611b9c697ea59840f
61384 F20101208_AAAKDZ kuhl_e_Page_48.jp2
48fdc680672daf62a46ebf74dfa39329
dc476c724b838cd892047ce5de905340bf0d2111
8365 F20101208_AAAKNT kuhl_e_Page_27thm.jpg
8da1a65220c0331963097afe82463d67
5ca2428bf99f9e48cb41fa3411693f7e184b4810
37466 F20101208_AAAKXP kuhl_e_Page_59.QC.jpg
035de2e45ce7b99b8068c2b32346b3b4
cadea1631ad2402a8986e699000a90dea8779033
109434 F20101208_AAAKSS kuhl_e_Page_16.jpg
b6c789d43d711d77aed3beb5ac050ded
07c55f7899b7f1813101051ca49cb44f03722bda
1689 F20101208_AAAKIX kuhl_e_Page_70.txt
93a678b5e8a0a6eb9be391dd966f35b9
e8a4c8497ac96cf03132ae7f4f9642ffecf995a9
53383 F20101208_AAAKNU kuhl_e_Page_04.pro
18bc853aea047874b4ec315c2b0676b7
78c7cf873de6a380b23099cf341792135c2eddab
1398 F20101208_AAAKXQ kuhl_e_Page_60thm.jpg
8d43c454bfdd84bcd12d7b90ca97d7a8
cc1b151ac40b9887e68be5d33ead4a7e4b468de0
108176 F20101208_AAAKST kuhl_e_Page_17.jpg
7c76aa08caca7cc7c25760f68a6b9cb1
66814d33901a5180440c861959c12ef836b228c5
8898 F20101208_AAAKIY kuhl_e_Page_44thm.jpg
c20a55ca8ea05ced9939122bf60c3e79
2306a86375740eda5f6a60fa52ea556cf72f6a2e
29599 F20101208_AAAKNV kuhl_e_Page_72.pro
3dc347d9396048ae901fa8ed54a9bcbc
75937c5da1012b2c2386bf77e00d8068fb240a3e
37043 F20101208_AAAKGA kuhl_e_Page_58.QC.jpg
c30931e5616b6f73caaf445678ee56e8
32b054e14ba7f406fc9dd89648bf5de24a6090c7
8596 F20101208_AAAKXR kuhl_e_Page_61thm.jpg
1d64eb927621e1c40220d999b51cef6a
5b8aaecb765acae8e58070d05d1dc52749abf90a
113330 F20101208_AAAKSU kuhl_e_Page_18.jpg
2bbdde48ebd54df8d0b99881ba7c148f
e45feae8bd2a8f489da283a6c7b1abacaad01144
105733 F20101208_AAAKIZ kuhl_e_Page_15.jp2
c745aa628cdc7c147af4c3225e540c91
a34f205cf1bc69412cc656e764d0477211ed42f0
48636 F20101208_AAAKNW kuhl_e_Page_57.pro
535862ff563433b9d16bfcdf7e2a425b
f79c2697a34cfa8e7d20339f7e8a0fc240c3bc8c
84607 F20101208_AAAKGB kuhl_e_Page_68.jp2
9d22f835a26d976bd91b86af1d193559
144737a12cc61e2a2015e23b6df569afccb7357a
5920 F20101208_AAAKXS kuhl_e_Page_65thm.jpg
de079799ed2fd7377a6d3a85c372e726
3b916d0e650f56c8af764194ab8cf2ff5b2b799f
22230 F20101208_AAAKNX kuhl_e_Page_49.jpg
b65e5a3ba8d7829722021ab6741ac938
30af3d25d344b645d79e52199ff3a40b86a95c91
8969 F20101208_AAAKGC kuhl_e_Page_11thm.jpg
9767abaa79ad5cae20aed9cab03898b9
8b97b86ebd99fff2375dfbe98069f26e8ae7611e
21971 F20101208_AAAKXT kuhl_e_Page_65.QC.jpg
72f1c0f7a4c7541bd3a3255a980b2838
d4202e8df2c636b1b4de16623a2b119736306a20
110533 F20101208_AAAKSV kuhl_e_Page_24.jpg
60be2d19fdc9c583a85462482753bb19
3fe914d9af6535a25cbd5d2980c3e2470da88114
108832 F20101208_AAAKLA kuhl_e_Page_55.jpg
9536338ac0f65182b83638a34e4565ed
dea4698b93f4d9f624f4627b333b275c246d4fb3
115017 F20101208_AAAKNY kuhl_e_Page_19.jpg
dd360653d413540d5f4f449156c525d6
d0dbfbcb9e6dffabae7a127aea2859a77dcef520
5436 F20101208_AAAKGD kuhl_e_Page_60.pro
117c42526d0cd3108b8583b4eabed78e
ec926fc7c3dc582f7d8d1a47be2e1e07c705b413
17871 F20101208_AAAKXU kuhl_e_Page_66.QC.jpg
113713a9b01bdc14d350ef6e4759407d
119150dc0153be2a8875829b2503d064e8c8dc02
102005 F20101208_AAAKSW kuhl_e_Page_29.jpg
5ecb8ac8b080a1f0973954ea7b29ea88
63e32039c68201447e0653f785392b489131bbd9
102218 F20101208_AAAKLB kuhl_e_Page_21.jpg
d239510f9fc72afe281a754870594b23
fb628ce79822802ea15e7ddd4512f556cec3159a
49671 F20101208_AAAKNZ kuhl_e_Page_43.pro
adf8db95f23203a4b2f7fd2959e8a5e9
81488d84d608be2b1d4848e81eb10d0deb35f1b0
F20101208_AAAKGE kuhl_e_Page_22.tif
9b23050390933a2738ca114b055f8514
65a1e769bb44de314b1fae540d999c696cf2fec6
18208 F20101208_AAAKXV kuhl_e_Page_71.QC.jpg
dd4d8781a2782494e1b4d98ca3f031b7
1443c8c0a4eef72a1d3ad4278ba29202f8b11206
106229 F20101208_AAAKSX kuhl_e_Page_31.jpg
dab6462b971345050b16646c718c73cf
b4e7124bf4c04a9ca03f6afbf79eddfd535a1705
35467 F20101208_AAAKLC kuhl_e_Page_80.QC.jpg
64a937c5a3235bd78ef8d1e36a9cf063
087bd75ef41422230242d465323bffb3ca1f0135
F20101208_AAAKGF kuhl_e_Page_34.tif
d12bfaccb967ac37d44fc0593d700167
3dc65eb786e606b0e014cc19b237f68c637447f8
37793 F20101208_AAAKXW kuhl_e_Page_77.QC.jpg
8415829614f8c7d36587cc925bdadd2e
a82a269b0e99332c796c0cafa52c7720959914a1
110695 F20101208_AAAKSY kuhl_e_Page_32.jpg
952fe3ab802e809ef82d6f660a09f51d
55b8d1ce4806abefc6c750f3f0ac8c99f6f80d05
2159 F20101208_AAAKQA kuhl_e_Page_41.txt
a167f9afd6bd8f36ea9355f2861ee808
7de292e39b0f619c437ca6417f46b375dc4e99f9
116551 F20101208_AAAKLD kuhl_e_Page_25.jp2
6c96bb7b0527cd191dc8c38a079ca4cf
00b7fad233d02bbfb8f768dd0539b0c147d4ef17
12584 F20101208_AAAKGG kuhl_e_Page_07.QC.jpg
0c545c54ea2828647941cdd79b4c3fd8
cf1d7901462e811429bb3adcbafd8e63af905fb8
36627 F20101208_AAAKXX kuhl_e_Page_78.QC.jpg
c7460bd1c2cdbe28d63442d8f0b693cc
b158f6a59172e6d543929a0c2d785f317d5c24af
24626 F20101208_AAAKSZ kuhl_e_Page_35.jpg
80dc74a484a917a587db77368b7d3ef4
ba0b6c0096fd5fed86538afb15026c417e0b251e
1819 F20101208_AAAKQB kuhl_e_Page_65.txt
87719207d500d2fda62eace0b4c371f8
2f39d503882c8255f1e8b771bea6b26f69e580f5
56910 F20101208_AAAKLE kuhl_e_Page_48.jpg
88a2ee8169d5818986caeee0aa86d79b
8004184aeb28c3aabc6426278e259b7cce8b0464
61785 F20101208_AAAKGH kuhl_e_Page_76.pro
5023b76dc9426b8e8ad56d97a4e38629
619cc80cc36422299f6fb86d1d742f073016cd0a
19155 F20101208_AAAKXY kuhl_e_Page_81.QC.jpg
a42fdc3d7135179c0ceb16b1169d6a97
0d8a2da15b5b25cca7ced74a08e6ca4ed8ddc2c2
F20101208_AAAKQC kuhl_e_Page_62.tif
1f9ff5b8b9d84bd727b451567c7f182e
7e3660fab82e20b1bc801ff096b226a0411bca57
111980 F20101208_AAAKLF kuhl_e_Page_04.jp2
5ecd08e0891155741b70723a0d4f046f
1eef8e6c332634003258d708f009037296e78d9a
6044 F20101208_AAAKGI kuhl_e_Page_06thm.jpg
40e91484cc48a4ad5370fb9424c7985c
a8a6e9f78ecbaefe36fa23532658ca06af023dc9
34216 F20101208_AAAKXZ kuhl_e_Page_82.QC.jpg
33edd92b71128db8929b0238fd5807a8
00d5a8a84a59a41d9169cf5063a6480ee78c9ee5
96575 F20101208_AAAKVA kuhl_e_Page_06.pro
994a8aa3954c4de6c0bd839b44cc9a87
a1030bab5282e3f224ed409520f40758017302c2
7913 F20101208_AAAKQD kuhl_e_Page_15thm.jpg
efdb4c673831b23aca89e7405830bc52
f854ee322c885b022ec144db283fd8ddd8457aa0
F20101208_AAAKLG kuhl_e_Page_44.tif
22f8afafbf945be7da4862dd95a7050f
b4c741ce9cce073805a05734757df7fbbd589df5
50717 F20101208_AAAKVB kuhl_e_Page_14.pro
7a772467bd4dc803b8944f4f7f5e410f
6f2de2eaebefec77a063f4875a85d4d6de19317d
946 F20101208_AAAKQE kuhl_e_Page_03thm.jpg
bff9dbe448d18d1593c31575e41eea4a
f18beb8c55ff2aedc3a833d0fd0022867ff68a0f
105810 F20101208_AAAKLH kuhl_e_Page_82.jpg
c933eee500507fe382b0a8ef02f3e5d1
acc9aee58410aa670c3aeab20a625081e451c36a
8166 F20101208_AAAKGJ kuhl_e_Page_39thm.jpg
09fde9047e40e34fd3a2ddc3dc191922
792d87f2f606f907f98336bcf8b34618855befe1
50167 F20101208_AAAKVC kuhl_e_Page_21.pro
fd3acd961cb1291f7f91de2b6859c9ef
b9bad2a5aa4b926ebb58c926e82ecc35eaabcc90
73083 F20101208_AAAKQF kuhl_e_Page_69.jp2
c75db7c31a13356625fa543cdf461ade
2b0b2215bd9b6a7b09a3a52c1bb1a908c32e8dd1
50571 F20101208_AAAKLI kuhl_e_Page_82.pro
9b36b164967801fe3b9d19e7664546d4
fbfda3f83011dc11ffcc450292dad315960e4259
80181 F20101208_AAAKGK kuhl_e_Page_64.jpg
e7d85aff6c96c9dff613985d8247f35b
0129d090dbb980f8867c992dfda571bfa28b301f
56027 F20101208_AAAKVD kuhl_e_Page_26.pro
bf26f2055c286553b55a1e1aec78af7e
b0787942e9c77a782e0e7a60774e96b590d0a959
37399 F20101208_AAAKQG kuhl_e_Page_53.QC.jpg
998cd5173195d909bf83bb81d90721e7
c44725b3a76b785742914dba0f19c3a80c36347c
137301 F20101208_AAAKLJ kuhl_e_Page_80.jp2
6badeb78b3e023e749a894d4f0ab98c9
7de58e1c852628ff2cb87444eebf1a106c2c08d4
98862 F20101208_AAAKGL kuhl_e_Page_39.jpg
30c5405ca2b50bc9b10a63c53c2daa1c
6c9efc6a6f2aa1ed00d8f725c3b2effc85854b5b
50781 F20101208_AAAKVE kuhl_e_Page_36.pro
02cf04007ab1ad9c4050493bc819000c
a3cd660e46cfaec9f93706642bbd7658ab4dc9e8
9123 F20101208_AAAKQH kuhl_e_Page_40thm.jpg
8a825f31c5774afd31d2ba6b15d9ee08
e181c7362dbbc31a065316a8adf3eefcb81bb860
4833 F20101208_AAAKLK kuhl_e_Page_02.jp2
4be6f80a01bc5f799c5a64c7450a018f
1dfa05ddb8ad9c0efbd584b9bb255c8688e3e233
34278 F20101208_AAAKGM kuhl_e_Page_39.QC.jpg
e86333bfaca7ce434edd106ce5c3c4f3
582e1ae5dda901aac6e2c832b0e452666ab3a74c
48629 F20101208_AAAKVF kuhl_e_Page_39.pro
aa3f9988fa541fc3c8d467f433f7349c
e17eabd49ca7282fb2b2fb87fbe246fd1ad4dfde
F20101208_AAAKLL kuhl_e_Page_63.tif
bf7f3188e9f03262914a7ca3df4d7876
e72658a6c6550870884ce2d35a000beb14905f8d
54754 F20101208_AAAKGN kuhl_e_Page_37.pro
6f98c41de52f576933dece2fe379b46d
300595dc8521c85cad95e72613262dd5879969f7
63227 F20101208_AAAKQI kuhl_e_Page_46.jp2
ffeb324feb0541a402eb4f74b258b9ed
79ffc5f59b2528e1a20d73840973124f7bf9b7b6
55674 F20101208_AAAKVG kuhl_e_Page_40.pro
97dc75f3dbfafb77535c718d151a9a97
2b44f5ef44e1d4d89026cc11f76a41a58c0baef5
34760 F20101208_AAAKLM kuhl_e_Page_69.pro
d82850af001930f03e071f50fbe27a2f
7e90302da539b1046c9637788aaa200fce419ba5
36688 F20101208_AAAKGO kuhl_e_Page_33.QC.jpg
81452955ab5244a961802295ed3b6733
c7ce094363e406f265a2689975af487f3c052b42
116636 F20101208_AAAKQJ kuhl_e_Page_23.jp2
00acc70533fe15354d5cfee02426f835
c157913df1b3510c8937cf8957c40b0cd4a6c554
54901 F20101208_AAAKVH kuhl_e_Page_41.pro
44d63f0f7c9bf9183760ac910f496e64
bc181051ad0aaadb15fab009c28635eb805f22c3
110360 F20101208_AAAKLN kuhl_e_Page_22.jpg
08a866725ae7c247e85d234bfa5373f3
e92831ead381edde601d5ba38cceecf330db1c2a
9715 F20101208_AAAKGP kuhl_e_Page_01.QC.jpg
2966cc2462ab22d3a46573bef86bf065
e032af6ad819faa7a0fba7a3cc5487776ba32b25
F20101208_AAAKQK kuhl_e_Page_05.tif
10ca0291e1605ff9063bd5eeeaf37f8e
cec367d2cdc56cc2edb21b54f62a3084828b5488
56572 F20101208_AAAKVI kuhl_e_Page_44.pro
d9cbed218ad8ff40255bc0516b16594e
dfed071a298f22d8eaf97f9771ec6ce25b844fcd
9013 F20101208_AAAKGQ kuhl_e_Page_41thm.jpg
5210ca6c226fe38d94e689c1a5adc420
981020b8917b1704658f7f5d43c45dfc667a4161
4781 F20101208_AAAKQL kuhl_e_Page_71thm.jpg
b3c47e4ce5b61b6cf91b8d3171cc11ce
431e330d08c08cb14c2cb3af7bb9e234c2836635
32127 F20101208_AAAKVJ kuhl_e_Page_46.pro
6aaa8fb1f15d5065086403a34b288521
8531d01d8c4143450c97bcc10fb00c9e218d30f9
37580 F20101208_AAAKBU kuhl_e_Page_44.QC.jpg
c6dc57bd610b52fb12e0aab6d8a9020e
1d6767ba06b7661ea6e9836fdd092f0f8ef54349
43596 F20101208_AAAKLO kuhl_e_Page_07.jpg
6034c2e6f9db178fa4f45c78d37dd860
a429dcb1a6f98dc559e0177674bec9a56ac472c3
2189 F20101208_AAAKGR kuhl_e_Page_11.txt
a8fdcd363e81e9dad09e226791bdf83b
c94900331520ffd4d2191975a5a6e7d7220da9c5
108828 F20101208_AAAKQM kuhl_e_Page_12.jpg
adef9ef1343f3966fe06771aea94366b
326824f4739e5d62238464c55722bacae8ce7fc4
31463 F20101208_AAAKVK kuhl_e_Page_48.pro
4e06d667409c7334ed273e92c798abbb
03ed51a232bdc932807bd078cd04234073c61c42
30615 F20101208_AAAKBV kuhl_e_Page_70.pro
5fd26e8b912a17df998924de19dcaf14
89a0f957f66caf74370100c89630cfa2514b7b59
10027 F20101208_AAAKLP kuhl_e_Page_01.pro
d2453343f5f01421a3649991b02d262f
3b078e73335ffe365902712467339d7ca30208b1
2165 F20101208_AAAKGS kuhl_e_Page_55.txt
10bbb935889dc9774f46a5f569ca9271
a519d9f9fdaf35a7e937cc44757703cdf6e37e97
83773 F20101208_AAAKQN kuhl_e_Page_69.jpg
986f6a880350bd983fd3f482e6eb6c0d
08d8a3aaeb341341a4f75be92da332522560f182
9819 F20101208_AAAKVL kuhl_e_Page_50.pro
991275c87d2cd06b579e36f7129aca35
1cd454c8a7496a08a02b62b008d43bcff6d975ac
F20101208_AAAKBW kuhl_e_Page_67.tif
7c19baeb7f9a13a90d1d5b5d4057ca01
8c8f0368c224cd71a8b0d7fd16c6093d09f87e6e
36687 F20101208_AAAKLQ kuhl_e_Page_56.QC.jpg
3e0d8156e1b3c1ddf3b113904da6f98e
a725b85dc5205e6c4c7c4e3bb5cc93e9fe09c2c6
108660 F20101208_AAAKGT kuhl_e_Page_43.jp2
fa81ae0515f1ae63843383394494eae8
98af0261315f7b77e49e65e0e467ef3f9bfd1f5d
61067 F20101208_AAAKQO kuhl_e_Page_74.pro
169140b8354e582726f851fc0a3af42b
5c2c53c1a1688f53bb51f752e41f6a4f60c93145
20732 F20101208_AAAKVM kuhl_e_Page_51.pro
00a184cccd9625d71909be2775da6d87
29c3ec4cc29279afef36f8ab0bf213297751b66d
117242 F20101208_AAAKBX kuhl_e_Page_30.jpg
83d645dffa67a32a1eaf248b84f6f02d
1cbd15be1b0d7edb2e6e0911e7be80185b23993e
116340 F20101208_AAAKLR kuhl_e_Page_61.jp2
43a0edc38f0d3aa607c82feb8c2d87a6
868d7ebbecf5a8002565fbfccf16284dc079aa67
1032 F20101208_AAAKGU kuhl_e_Page_66.txt
706d2975e4f2df432872e18ae9e5b677
cb53afbde03977c93f18541d973b523f8885720d
109860 F20101208_AAAKQP kuhl_e_Page_36.jp2
e4c14c3beb4cc1e75faa3b5e6ea7ad58
725f79c25188f86fd468f6d019a769d7f3ee99cf
51433 F20101208_AAAKVN kuhl_e_Page_52.pro
55ea6af9253017645743f45031f96b5b
c15890e57b516fb1ff981d6cc68d3b48ac1cb469
122944 F20101208_AAAKBY kuhl_e_Page_58.jp2
5a61809830e259d81c7f52c22a530695
04df881d0eb18d7b9c6e3400ad9c3c0be81f483e
2508 F20101208_AAAKLS kuhl_e_Page_74.txt
a4ec9e4b230c90a6df30aca5a4ddf770
631397dec8f73b0a57a4fcce40f10d15c7404574
32278 F20101208_AAAKGV kuhl_e_Page_13.pro
1fecebadd1f973e200eb4b0ae3808071
97d8bde67f5f7c781c91274f5cb0d88fe8259eed
2258 F20101208_AAAKQQ kuhl_e_Page_30.txt
914687096c2dc36e79389fa9e91e2040
b0dd33eb2bc8c3a7817ea860dadad6535e207452
55946 F20101208_AAAKVO kuhl_e_Page_54.pro
95682d6cb517bbbd5e4ff6e50c7dac80
86c19430cd27a3ef19810f9cf559e40eddd99cd2
5730 F20101208_AAAKBZ kuhl_e_Page_46thm.jpg
ada6fad6e2b10f0dbabd296bc5a0eea2
2cae0fcdd9e926698e638920280d1543635615fe
F20101208_AAAKLT kuhl_e_Page_64.tif
824d3a3ce358e7ee094d1218fa8e7bcd
3f9dcd4cb76c0ad110c62e3729f784948a87857f
4287 F20101208_AAAKGW kuhl_e_Page_51thm.jpg
dd8410e1b3ee5a50e0b6b82a21986cd7
394eaaf7b31a8ba1e02883a1e4dfd23721135cfa
4774 F20101208_AAAKQR kuhl_e_Page_81thm.jpg
2b14ea8bf0613871dd94876f7c5bae6f
c649ad2dfd43989fb9aeea0865068c8e10e90ca9
54390 F20101208_AAAKVP kuhl_e_Page_55.pro
372afddd188a08fc68e3b07306b5d2f7
e43f3661b7cc75f291664b09ef816922ff0749f7
F20101208_AAAKLU kuhl_e_Page_82.tif
f31ae7009bc4c701b38bbb16f20715ee
3873829155f029f79d35d38c96aee5285e91c570
F20101208_AAAKGX kuhl_e_Page_46.tif
91f9d1abb49f712129f02d04af4dbf17
84938427a7e64e3d0475ee1bcbbdbffea533ef5e
8607 F20101208_AAAKQS kuhl_e_Page_16thm.jpg
2bc33aca1871dd0de7af7d96d4249dea
dbd38c86185e8c4ac00b6700c9b884f5eea3eb30
56694 F20101208_AAAKVQ kuhl_e_Page_58.pro
c6eb1cc769dd1dbdba65667164b19792
13da2b68e045919ac01e1a9a0c80e96ec4175f9a
8832 F20101208_AAAKLV kuhl_e_Page_25thm.jpg
fc58d960a54f69aa532a8101e339fbe8
481d18edfd0591c3803c856f031309b31340ef25
2335 F20101208_AAAKEA kuhl_e_Page_01thm.jpg
5a0e8809ccf7f2b9b618a483cfde75ea
aaecc70f91f152926ba9d0e1a7d34d2732061403
555 F20101208_AAAKGY kuhl_e_Page_01.txt
34e30c56c19b3abbcb98e3b7e246b67b
8c12749943321c014f34679a676ce1f61844b483
53439 F20101208_AAAKVR kuhl_e_Page_61.pro
5491f492ad59c3b33c7bda6e45abcdd6
016293564437adb67a4f8b145b8f152fa4635b7e
2141 F20101208_AAAKLW kuhl_e_Page_68.txt
da732e38de6ddbad9d044f942ee31d45
6270452127e7df8bed66a5b68dd455a163c8c19f
34710 F20101208_AAAKEB kuhl_e_Page_61.QC.jpg
e2b80c678814ae94ba3b9d81d64ca2d7
064b9657fff355eaa4efd0165f96aaffd9551d39
1939 F20101208_AAAKGZ kuhl_e_Page_15.txt
882705f19bfd7e37e17042f46def3877
a9ad8769800ae63c6782a7f828a7bcc33b9ec22c
62814 F20101208_AAAKQT kuhl_e_Page_71.jp2
6d62b3d5ca2614f1afe4d1f0e05a1528
3e962e99a6d07b043bfc561008727b98f9a929d3
34696 F20101208_AAAKVS kuhl_e_Page_65.pro
0d1f3646f6d1f7fd3629f99e90c92f04
3306f054816223f64ca4b8fa354536c6795eec05
50521 F20101208_AAAKLX kuhl_e_Page_29.pro
062cced6457b95cefb11e55e3855a9c3
5f1972162c7c1ef5af9af05cdfec301eb5aa24fb
601 F20101208_AAAKEC kuhl_e_Page_02thm.jpg
639834729abb158a28fd9d1c2f5eb08f
1cffec0ba19898e6031c22c7876a406b741b277c
9356 F20101208_AAAKQU kuhl_e_Page_78thm.jpg
00af6094b20aea3ebed9da598004d340
aba7a6a9262eca6e3c22c1bfc6b720ef01833f9a
68670 F20101208_AAAKVT kuhl_e_Page_77.pro
c7811b92366cdf8f4c13cfcd67474f85
24871827f54f910b251a556d8e7f8dab4b7cb71a
F20101208_AAAKLY kuhl_e_Page_56.tif
b2e8aeaed37e60d3f0ebc9d6afd1480e
fb1619f034c18ec926102ac69996aa546d55bd1a
F20101208_AAAKED kuhl_e_Page_02.tif
1d0833bbac43bc5f75a5c2215ff71a93
5fc2d91bffb07b8dc1eb593b74a9e45a4f1daadb
35551 F20101208_AAAKQV kuhl_e_Page_62.jpg
2c2fe76cd6d173733fd4a17812841e09
6cc470957f14cbb0e710c52627c75136a1f25d07
51247 F20101208_AAAKJA kuhl_e_Page_63.pro
345ecf1f5ed31bcbf788e8c5f0bdcc06
c7d6581d1d89a5c2beac6c1425aeb5b946b246ff
65171 F20101208_AAAKVU kuhl_e_Page_80.pro
57eedd5e67d6ea6b9a51ce4224c8ba1f
28f12be30d96e95d6023f794eb36bd8c97a5a131
F20101208_AAAKLZ kuhl_e_Page_24.tif
391cecb3819e5993a6a2f0967e5b8547
8ef1147865fb553407c8996013fef47fd1b36479
53616 F20101208_AAAKEE kuhl_e_Page_42.pro
54854876a0e10f392249d3da2e4b467e
dd8aff2c0631ca5d4f81fbb6fd2625573ab1981b
33467 F20101208_AAAKQW kuhl_e_Page_27.QC.jpg
23f50c13dd1126b666d54ad63649481f
8c326a361ab876dd9d59f853fee6fbd90e368573
52931 F20101208_AAAKJB kuhl_e_Page_16.pro
cf1d34d565fd353fbe5624eb44ac2a1e
d75b15bbe3b4a4928121565938485737ada74401
79 F20101208_AAAKVV kuhl_e_Page_02.txt
af308059dc8789ce7ccbfe6dfef3ed66
a0f23b156ddabaaf2e8a0b8e8d2af47dd4e3af78
6122 F20101208_AAAKEF kuhl_e_Page_67thm.jpg
3b4ed6726d01434f2672e1bedcffcad8
aa6e94bc9e6316490fee8288469d4a9ddd4c5bda
67040 F20101208_AAAKQX kuhl_e_Page_75.pro
4e36b246dfc32c8084e505fa431dc460
4f5f4b5b90931180385231bde5e70e0eda9b53ab
131708 F20101208_AAAKJC kuhl_e_Page_74.jp2
440f4453fa127e804a63956e0b4ed782
0ec2a7b7e65ee1468f27c7dbe49bfc9ef24f2620
213 F20101208_AAAKVW kuhl_e_Page_03.txt
670ea8cc59790e2c338b5c147976e579
525a529166bbfb45714622c49fc74a1d569c2950
20145 F20101208_AAAKEG kuhl_e_Page_70.QC.jpg
64b647dccbb4ade010ef964e01a1fc6f
80de69114b29bc2293b8b9747f263c912a959013
8226 F20101208_AAAKOA kuhl_e_Page_43thm.jpg
5ee7bb92a75047e44b4de80d9364944b
1e028e4b071e3764fe95be998ba61633517c74a4
109173 F20101208_AAAKQY kuhl_e_Page_23.jpg
7db665b8184e943e662c549bad30ecfa
0e7a39c759657e50f347abd31c3f1185d6a33b67
2119 F20101208_AAAKJD kuhl_e_Page_23.txt
f3f0420e162b9582e7ab95cb09470ab7
d5535c464cb5c8d866f71a4a45829e845c7a5967
2148 F20101208_AAAKVX kuhl_e_Page_04.txt
f0624c52bbc4f219fa203c76acae33f8
80eb6b30f420d491b97756c9b756d3a03b449c30
118703 F20101208_AAAKOB kuhl_e_Page_24.jp2
faf2602e393335d32d9d39984f25d78d
bf31382cdeb2fa59b1deb422c39510fca22842f9
F20101208_AAAKQZ kuhl_e_Page_68.tif
559cffaf8d3150a8c4fed8cbe821ebf1
fb129a6143fa91860623ae4f84e493fe5b5a65f5
8805 F20101208_AAAKJE kuhl_e_Page_79thm.jpg
0141e078855fce11008293afcc29175b
98266d6c92590885f9ff3c30fd28f2ba72630517
F20101208_AAAKEH kuhl_e_Page_13.tif
da652a0cf202eda96790b5bf5ed16d6d
bf71223966357e3a95bb648619c6d995f64698c4
83425 F20101208_AAAKOC kuhl_e_Page_63.jpg
50ec58cccdb79c8d6cd444bcb7f8b23b
0fde33f835abaf5927c08c9b0dde2f76819b8a90
19209 F20101208_AAAKJF kuhl_e_Page_46.QC.jpg
2c8c5faf2938202468b00088321b7d8b
2c36c274335a46b07a1cc1e7d88e97b34c831da8
1285 F20101208_AAAKVY kuhl_e_Page_13.txt
863341c4d3dba81d89138a05cb50567d
6567f1d2788eea60cb1bfea5b2f2a3a3bc46acac
112103 F20101208_AAAKTA kuhl_e_Page_40.jpg
97845ede0d38c4541ef884c7e855638c
5e5b6e130f67b7fb188fe8b13af31bd204594b31
8132 F20101208_AAAKEI kuhl_e_Page_35.QC.jpg
2a93ed55f33affbbf9de65c32696c785
dcaa70b5684e275b531e7fbb3b47122d5e17e657
3842 F20101208_AAAKOD kuhl_e_Page_02.jpg
df3e988af7723ce0f4c1faaac61bf642
70b5a08e5e6b6955fd18c9092858fab21a2fcf04
35277 F20101208_AAAKJG kuhl_e_Page_10.QC.jpg
c13aa32da2d4ac9473e399ed65e1e72a
d76600dbc36fed5d72855e99a86fac7a584af34d
2400 F20101208_AAAKVZ kuhl_e_Page_19.txt
bd2c90e02ca8240bcc7797507cb3cb01
4539b8364950f29cf99c3800af6a6e1504f44f23
59548 F20101208_AAAKTB kuhl_e_Page_46.jpg
814ae301f56ecd57f81ba5e86482d9f1
c266b2a6fb72aeb09adf91507811a9a52d60c817
119858 F20101208_AAAKEJ kuhl_e_Page_74.jpg
4acdf589bb85c25c4cf4d2fccb16e680
cf4a26bee5518abf7f3dc193b41b5b8eff2216ba
35297 F20101208_AAAKOE kuhl_e_Page_19.QC.jpg
4b6976d17418572fd459d8d7607ef286
ee459474d1027c5a6c0b52de68074ec18603c368
2179 F20101208_AAAKJH kuhl_e_Page_40.txt
b9b12a8083fe2eb04fffed24a4f11987
046e3193f6bfb44d547fcb6f34504610fab859a5
115033 F20101208_AAAKTC kuhl_e_Page_53.jpg
4470e33d167beba84e52169a091dc72a
75c40b8e2a26a1ebd98ecd77a7c26a8d114644a6
8450 F20101208_AAAKEK kuhl_e_Page_82thm.jpg
7d67588ae3dc03b4d7f6eaa1f1e6c51e
b1e578aeac065c79860928f0ad63c352a6b55be9
20091 F20101208_AAAKOF kuhl_e_Page_09.QC.jpg
1d31ca603b823301f2cc8cce52258138
99ad0cee506e0796ae62b83de48ebfd9981f7165
16640 F20101208_AAAKJI kuhl_e_Page_49.pro
82765d70db2362dd70c98de29c219d5f
9a6734d9a4eb35326043e5bfe30c6beb7fd141df
95392 F20101208_AAAKYA UFE0020624_00001.mets
d62847a10b6af1f42c49fe8e0aa38085
7999997e4dca0a0d84e35b13a4cbb74b70faf8ca
113196 F20101208_AAAKTD kuhl_e_Page_54.jpg
2b3d162051e0ce6acb8e0c2a750e4f4a
90dbba6817dc2de85cc5420277161c0ab3d82897
8692 F20101208_AAAKEL kuhl_e_Page_21thm.jpg
7b7a95e5958d203336ffa03b5cbdf78c
92c6a643a5485122bf8e35787c0bdb84fa580802
1966 F20101208_AAAKOG kuhl_e_Page_39.txt
cc9544156787ce10a23310e68f66485c
5b9ce7260393ce0f4a089dea13c065602dd782ba
2040 F20101208_AAAKJJ kuhl_e_Page_43.txt
396c31126ef62ad8e6551ff9e4e2014d
be1264b3fbc8da8b4f58e55b493a39f6cdb8e0f1
108883 F20101208_AAAKTE kuhl_e_Page_61.jpg
8d6b4613811fce19d609443fa93db69c
4e9803c174c5d4288af124250ba5721e2249bb45
114085 F20101208_AAAKEM kuhl_e_Page_17.jp2
7ce59f8b4af8e1076571c8ca242ae64d
8f203f27baf61b0c57e8a265b53ca06bdde9dcc9
36186 F20101208_AAAKOH kuhl_e_Page_32.QC.jpg
ecf926bd35a4116c58641229f5169d52
6a1e78c74a9553b3144178e46aabf0ec303d1086
2244 F20101208_AAAKJK kuhl_e_Page_53.txt
066ef72a9531cd322116aae10136d230
6ab1bfd6aaa3673f493b8e7ef41570c751c4ba99
65768 F20101208_AAAKTF kuhl_e_Page_65.jpg
a84273f14327af974f15128683f408ca
b0c8168e9b283a831af16c75ca53630e27c2601b
1358 F20101208_AAAKEN kuhl_e_Page_81.txt
fee6550e4f64837e08b186a3a4a9beac
5fc9a6666d9e918c4bddb633af15a4222c435da6
25223 F20101208_AAAKOI kuhl_e_Page_50.jpg
5d641c0dcd05c5457ea631c69d2b3307
e3779494bce0fb0d3c0ae55dcbe79a4f03b42a89
25644 F20101208_AAAKJL kuhl_e_Page_64.QC.jpg
4abc830f8d00247a13fa626837638ec2
54dbc4a7096b064288f9a14545a4e06a2cc90834
64289 F20101208_AAAKTG kuhl_e_Page_70.jpg
6763974154747d569c068870428bafa7
a53a12aa38da0ac699ab9233c0e0b6430e9ca5f6
2924 F20101208_AAAKEO kuhl_e_Page_03.pro
008524a82f96e5e0973667bc7c3a2562
7b2453edeaecf7d52eaf25b09e2b46c6058cbb1c
8477 F20101208_AAAKOJ kuhl_e_Page_36thm.jpg
0f521f49bb6c5f554d2b97339a58d1e2
31dc3cc4d57f642cec1532889bb302932fbf6d63
129077 F20101208_AAAKTH kuhl_e_Page_75.jpg
b480d0454b7cab93f2008d8456d05c6d
bdd19055a2010ef317ca95371620cb065ec838bd
1519 F20101208_AAAKEP kuhl_e_Page_47.txt
2aadcb7547dc6a300f19cb1bc06c5191
c1a9fcc205048053fdd2d37a2ff60f88440077b0
981 F20101208_AAAKOK kuhl_e_Page_07.txt
f07734a10db159c96e2e48cdc7e9f0fd
80ca1c4f0fc890268b8d43a9cedced47b599a0bc
1051978 F20101208_AAAKJM kuhl_e_Page_06.jp2
29ce33283eeae459b34293c16b3ad161
155a4926d81407d2d7db643d1fc9b5d07d3cb2ca
119203 F20101208_AAAKTI kuhl_e_Page_76.jpg
57ea59ef70206fd02a897d82fa49c874
e54e50da0034741cff43bd4057149e197fe859f5
F20101208_AAAKEQ kuhl_e_Page_29.tif
b2dcb71877720d5ef2f0667969a7ec6b
ffbf865e295034146fe1163d873b0ec85e5fcf3b
23532 F20101208_AAAKOL kuhl_e_Page_07.pro
ef3534849cb243b9e9365562c17a434a
6213b10c8e658373edb38424caef91e160237b70
27379 F20101208_AAAKJN kuhl_e_Page_63.QC.jpg
23537c59b00c179aa8b4009a35cbafe1
64cd84fc6ee86454037abd3ad310e8ead676fe90
135838 F20101208_AAAKTJ kuhl_e_Page_77.jpg
4944053228125584bf65777cba995586
fd7da63f87200c49f6bb1156f58b825d04c6f2dd
F20101208_AAAKER kuhl_e_Page_04.tif
9ff0ca05e8c52fd8abb4cfce95d27ca5
b2b438d217eb13dd283f45a622c1b78106d9940e
7613 F20101208_AAAKOM kuhl_e_Page_63thm.jpg
c88e4551ff0a458625b114102cd64ecb
435a0d05697dedce5d8bd630b32a9caec29fdec5
2081 F20101208_AAAKJO kuhl_e_Page_16.txt
81db6b77d9f2de6e46558477d11f0e9a
2a7e6dc1b077586812aca4b55dec27ed6bc810b0
1051971 F20101208_AAAKTK kuhl_e_Page_05.jp2
4776cde4b180c35bd9c45607f5203638
09e315f13eac15c8898b98246b282e264937f9ce
112610 F20101208_AAAKES kuhl_e_Page_05.jpg
22344793829a948c270daacc0bbc9afa
aeb0f368b95a6bc10b54c83ee08f409499fe219d
F20101208_AAAKON kuhl_e_Page_14.tif
b064ee938935878bd7c2e90c6b466276
fd208cb88551c410c394a418b5c5485b6d248194
28042 F20101208_AAAKJP kuhl_e_Page_67.pro
8c00e91ecd0f10f3ff734dce597e01d9
09f96d74823962fd4660db6eb90d278fd5b2e0b9
117668 F20101208_AAAKTL kuhl_e_Page_12.jp2
56453fdc9e0e0381a07bf05abc9c87fb
a4f9eb9337d0f4c0777bc7eb7a5ba94f68583dc1
53923 F20101208_AAAKET kuhl_e_Page_23.pro
70989d63fc06dc8c98d1a977712ffe95
a57c2c1937ccf13beb3d544802fa35735eda18ff
34061 F20101208_AAAKOO kuhl_e_Page_52.QC.jpg
af1ef75ca00fdbdc26e5d45b9ff8824b
9a9e0261bdf1eba22dbc82ca3092e91cb612d700
58891 F20101208_AAAKJQ kuhl_e_Page_19.pro
e3be3e617bcb8fe05f55ddc9aa340044
9d6240d233d3031f01fc0c026bf076a78885d835
71222 F20101208_AAAKTM kuhl_e_Page_13.jp2
8a57efdaf1fadcbc6e55cd3b8e9404ca
24552ff50b67b4a6c2667c9e709eef06483186cc
30134 F20101208_AAAKEU kuhl_e_Page_73.pro
e67e0ac032c3f5d2cd5276515224057a
b5fd06a578756bd8fc465993985dfb0bd8f57a36
9188 F20101208_AAAKOP kuhl_e_Page_53thm.jpg
c3b6291945493606afbb4c9d520ae2a8
144a4fc3c0c232ae14740c213e98f0494c3b09c2
77754 F20101208_AAAKJR kuhl_e_Page_05.pro
f8fb67dbc4e3a9c421f58134ea7fe158
e706680ab71aaf6a8add3207b66b669890f6b104
110699 F20101208_AAAKTN kuhl_e_Page_14.jp2
9ca2335632b150d336fe5e58c87abc40
8ce8ef078bae6ee5b822127be843b1b0cabb4d5d
1601 F20101208_AAAKEV kuhl_e_Page_69.txt
6a875c93aa0aa19c4ef8981a226d78e0
597ecd83ac19e82b8e1e97d12cb257b9c1605519
64620 F20101208_AAAKOQ kuhl_e_Page_81.jpg
8a4d895f9d59f783931be60fcc33095e
c8e9ceaca3cf02fcf79c3d06736fd033d1553d34
68833 F20101208_AAAKJS kuhl_e_Page_64.jp2
907497be486868525cadb0008b8ac1ef
4efd47b2c32caaeb1f1ea55851d29996b20a96d4
115248 F20101208_AAAKTO kuhl_e_Page_16.jp2
353bce2e208f0e1dce132c6aa4a6b586
d96238960f2f488f459bb01e2765271e22b109c1
113847 F20101208_AAAKEW kuhl_e_Page_31.jp2
9a87ac476f2b67782b140f7c585436c8
3521c54858ec388123506ef265043da163586d95
F20101208_AAAKJT kuhl_e_Page_37.tif
b0ad1304c1830b348266b3d7ac9f6298
2031fb7386d6d67ab64b2ef0264f2d55d705bf94
52109 F20101208_AAAKTP kuhl_e_Page_20.jp2
cd25ea63b95c850f7823a6eb964ca660
f38ceee2aa6a65674fc70be70fce7adb68a24e9b
56271 F20101208_AAAKOR kuhl_e_Page_59.pro
f448d46981832d84fae5e978b58a75b4
09413239f8717bab857e56eece377f13fb524e3b
8997 F20101208_AAAKJU kuhl_e_Page_54thm.jpg
e8015d593c02f550200ec48e3fbf086c
fd63f5d78b5a2873e26eaec4ef2de334329c9641
36753 F20101208_AAAKEX kuhl_e_Page_41.QC.jpg
4449aca7269d8642852e0906d5db359f
affc1c1cac13050aaffe9c4454c72baffbd464f2
109683 F20101208_AAAKTQ kuhl_e_Page_21.jp2
6546514af0e03214d124d19e8d1542f5
1cd4f8ccac9c03bf724be41856ea15a067cf9381
37949 F20101208_AAAKOS kuhl_e_Page_18.QC.jpg
4a1ea54bcf0ede2910fc74780ba883ec
6d490f3887fe457a2ca9500cf68ce28ed1e1ded3
F20101208_AAAKJV kuhl_e_Page_30.tif
89de715ab1cac78cd22a49f89abe0f06
31a562de142b44afdc00e8a73f140affcae3f282
8546 F20101208_AAAKCA kuhl_e_Page_17thm.jpg
f208e98aff6d880a0806bc4fd22d3072
6019d95da4732434a3bee80aa581e5fc5962ac74
2099 F20101208_AAAKEY kuhl_e_Page_14.txt
92054ad31fb2e90c8768f3500e31dad5
c502a2dd4b8340e2e2cedcc15891df10825fdad0
117812 F20101208_AAAKTR kuhl_e_Page_22.jp2
57ba937c7f6c0cf22884f4a71a726ad6
78876beb8d178b0980ead3a032f5e5fa1d9cc6ac
5559 F20101208_AAAKOT kuhl_e_Page_70thm.jpg
d73c3b28184390878df6b49e1a602085
544e583793d8660b86dda128ff42b51d3e28b97f
2249 F20101208_AAAKJW kuhl_e_Page_18.txt
8cda6436868527fea25ea27ea83987f8
e72fa145b2533dd0666b9925993097b9691ee317
100937 F20101208_AAAKCB kuhl_e_Page_43.jpg
0a13ecdf43f960fe7de446cde83d229c
38abd07b60262ef2cf84fa6f98faa1da8e2e94f4
F20101208_AAAKEZ kuhl_e_Page_19.tif
cdf01eb07ba0db730939511708a823b9
aaad68eec4bbb5b91b5ebd937d0fafe312bc288e
120383 F20101208_AAAKTS kuhl_e_Page_26.jp2
7b581fc7399705da790c784c331ea60c
7f96ad36142fb78d0fac8b475afb7180c2b6371b
8493 F20101208_AAAKOU kuhl_e_Page_14thm.jpg
c2fc23892d2fc34fa7bc06a701923867
330a2b9402002b9ee2364a379e5bb0006ee467b2
64604 F20101208_AAAKJX kuhl_e_Page_47.jp2
1e1f14e4369e243706814c6acc0771d4
2bc2af1ea445d790875af03c9427509af05ace10
762586 F20101208_AAAKCC kuhl_e_Page_07.jp2
00e7543fdb87079267bbc851f0f56c33
07023aa62d3dbd68796a5ab2eccf0004e785eeec
111025 F20101208_AAAKTT kuhl_e_Page_29.jp2
31ce7ce34f26c2f7e46cc9aebc05a5ea
3fefa03fa5656933880ec455b6d38e96278672bd
36642 F20101208_AAAKOV kuhl_e_Page_75.QC.jpg
468dc7219dad973796fb5eb4a048425b
45a4b72ad8773a5c235b88ab01deba3c7cf791bc
8844 F20101208_AAAKHA kuhl_e_Page_56thm.jpg
6998978e0ba956a128298ad4d99dcaf4
4bc5b83391b986eaddf4566863b311b962da53a3
8964 F20101208_AAAKJY kuhl_e_Page_58thm.jpg
06331ed176030a6358a087f70b7488db
26c66617e39e67d03b6fbeec6e0ed997760d0903
113738 F20101208_AAAKCD kuhl_e_Page_26.jpg
703ed5bb712934975af5d94e658e53e9
ec600cbe1bf32efc81d723c753d768ffb25b12bf
124189 F20101208_AAAKTU kuhl_e_Page_30.jp2
474096fe8c724f469a109977decaeee8
6b73ee3402e86dc306ddd5fa1fcd95850a04c4d3
8686 F20101208_AAAKOW kuhl_e_Page_74thm.jpg
456aea923f3f6af8d861e7d14bcad953
5f72c94578be33bb315834d65c6157fffb31e12f
112981 F20101208_AAAKHB kuhl_e_Page_56.jpg
095e84e83eb07d5478c26811d489c7f4
68194c1c3bf7b80919e84e8c21f176c68609eb89
2812 F20101208_AAAKJZ kuhl_e_Page_77.txt
a43bc2ca33c7b5b890ceee2071f39b0b
1e5a0c28fc59e807aa0626e85dd2ccf50d007a5a
2753 F20101208_AAAKCE kuhl_e_Page_78.txt
2fc0739db6ee7063db2d6f4ca21f854c
6ca2d14b1535407bf232f74d0aa11268e005e735
121004 F20101208_AAAKTV kuhl_e_Page_37.jp2
fd1dcaf225b75eeccce42a84532b37ef
f2b14e2f4695def4f047faae83a6c20cf280ab9a
F20101208_AAAKOX kuhl_e_Page_75.tif
d41af84ce038366ecf913ff87ce57265
d29689294e1961c4e859d2d98584df7f4faed0ea
8720 F20101208_AAAKHC kuhl_e_Page_50.QC.jpg
d148c4c0ea985363d5c14d82295d2a3a
d076ae9776143e8d60851fcce2c1f50015f4364a
F20101208_AAAKOY kuhl_e_Page_32.tif
85780ab3beb3724b237d0e7c7972d757
76fe2050dda1b997cee93d681011fb157938fd2f
28218 F20101208_AAAKHD kuhl_e_Page_09.pro
8c9a62a4a763d1f56aaad9ce5acdea9b
8b24d9d4903c81a18f7e0454a50374cea61fa933
F20101208_AAAKCF kuhl_e_Page_28.tif
7d52a869662c6631b82cdd8433a93111
b32792ffc7228d9ceb03976056e9aeae140f88c8
8601 F20101208_AAAKMA kuhl_e_Page_34thm.jpg
610ff433e229be58b02f1f2d18121f2b
cbab6cae9e97b9e2be6c17e0c3c61192145636a9
108345 F20101208_AAAKTW kuhl_e_Page_39.jp2
bb35abf09e252b55358100054f5abe0f
0583185608271dc607283d51e2aaa5940e4726bd
1118 F20101208_AAAKOZ kuhl_e_Page_09.txt
e7bdfa2ae3a15924de4fc92e3f0a5e65
35dc64d671953f1f5936ab45404b95d9c509ffad
F20101208_AAAKHE kuhl_e_Page_75thm.jpg
df77e0bc1f9fceb8e4f8668617a2d365
b94b2f770707311b06c03721cb8657781cb8bf2b
54779 F20101208_AAAKCG kuhl_e_Page_56.pro
b2df4544f98edc8fe211a2d124ccb7fb
ad57bc3b7eb3b60f787c860e5a97541668459d45
35734 F20101208_AAAKMB kuhl_e_Page_79.QC.jpg
d6f80aa29d234194d7aabbb189cc27cc
3d6b911d03833ec17d9c1756a625ad5c1bd4f7bd
117400 F20101208_AAAKTX kuhl_e_Page_41.jp2
163e0066437df6f589fc280a79b875d2
a3fe38a9ab5347c516e312646094550703e5c3c6
2150 F20101208_AAAKHF kuhl_e_Page_37.txt
34e90d65e0e4b5a33d2c5e38490c2845
5bdc22ba9504495f8a9527c1e020ca541b1a0d4a
9116 F20101208_AAAKCH kuhl_e_Page_18thm.jpg
b54f35187df4fdece6a0d6a0ae890567
b84ddc8ce5a5f1d91ae8c4b2a8e47d69ef057c9f
2217 F20101208_AAAKMC kuhl_e_Page_44.txt
74c9e35ecf835cec459655a216428b9f
2f2f5db25f38fc49196dfd1694d79fdad4283707
106769 F20101208_AAAKTY kuhl_e_Page_57.jp2
5397979fadf40bb06c97019073b8891d
d45d949ce492a5db21091390402178bcafe97efd
120753 F20101208_AAAKHG kuhl_e_Page_40.jp2
0be2aa550a75c79884a176322045ad6b
f52c25917dc9c954fa724cf135f84bcbf0f8180f
29975 F20101208_AAAKRA kuhl_e_Page_47.pro
77c07c6237ee83098f7355722d925baf
8c88b65f88a97dc4e66ca87f7af19acf03c0cce3
8737 F20101208_AAAKCI kuhl_e_Page_55thm.jpg
f306bb7a2b9741adad58520457fe9559
23a3eee38310792ceb684907580765c940370ad2
117081 F20101208_AAAKMD kuhl_e_Page_55.jp2
3ea5afb0aea1bacba8a6046cbd7c2280
e7f4c85f5315966865a596f308c233cfbfbf96cb
38224 F20101208_AAAKTZ kuhl_e_Page_62.jp2
d0e34bb0052965f93d55448e5a91719c
17a5121a37556d941d31081a5a957b04724087c5
99993 F20101208_AAAKHH kuhl_e_Page_45.jpg
3aac66c200061401eaf8cb6cdcf9ff5b
870e498fad56a73b66e86a13c3bc07523e0652b7
55321 F20101208_AAAKRB kuhl_e_Page_32.pro
d80eca191565f6dd8d2bc42fb10a76e3
eb7db12e5ed4dd58f390dab91d19daffda343f17
111257 F20101208_AAAKCJ kuhl_e_Page_37.jpg
169f3f5b4b8949e7d9a3baac9d98520d
2da0a79daed376103bd20f96c9f25a263b002fb8
109007 F20101208_AAAKME kuhl_e_Page_25.jpg
fff86fc49ab043d7772508982cc02680
b4dce562e01a159eff301b4b790e38bbc5238cdc
99599 F20101208_AAAKHI kuhl_e_Page_57.jpg
4f356722eb1969ee90960f137191896e
28bb847ad39f4def4ca2395b1dd61960bac54333
F20101208_AAAKRC kuhl_e_Page_27.tif
fb3ccba72bd9114b90f91cd7dc22241d
2c048e3e714030d243d2db2d5fdbc836ec1ff22c
8266 F20101208_AAAKCK kuhl_e_Page_57thm.jpg
31fdf7a35bb8ccc5521e34a4a77146c9
fa42292bf96359f449d5560fb558acbf077b2e5d
53326 F20101208_AAAKMF kuhl_e_Page_20.jpg
05d26faff60c4de7b6af82b27ab9532c
3081b0c1af189b5a1dcc1bafceb89f99aaf9682e
F20101208_AAAKWA kuhl_e_Page_22.txt
617ebf52c6572a9bd5def6a57f6c613b
f619f47757007eb87da2078edf32a54193106c5a
54349 F20101208_AAAKHJ kuhl_e_Page_34.pro
d4a337accea00499209ead1d6e59a4d9
fe2b3e613c0229570b74a70009c398ffbcad299e
62007 F20101208_AAAKRD kuhl_e_Page_72.jpg
7c4edfa7076fb7707bfdc8db57ac89fb
b3b53c5fd0afd41a54bb878b82cd1c09e3038bde
121372 F20101208_AAAKCL kuhl_e_Page_18.jp2
f78d5927836b263f8edc8f61602f0c90
98b53a315036132d1f1421606962c059dab2883f
5313 F20101208_AAAKMG kuhl_e_Page_13thm.jpg
da670e1edd23869d0b028686b63fe199
c2c16741495ee270b1844835f435de1f98e9e69d







PATIENT ASSISTED COMPUTERIZED EDUCATION FOR RECIPIENTS OF
IMPLANTABLE CARDIOVERTER DEFIBRILLATORS (PACER): A RANDOMIZED
CONTROLLED TRIAL OF THE PACER PROGRAM




















By

EMILY ANN KUHL


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007





























2007 Emily A. Kuhl






































To my friends and family who have been by my side throughout it all; my successes are your
successes.









ACKNOWLEDGMENTS

In order to fully reflect on the time and effort that went into this project, I must first

acknowledge Dr. Samuel Sears. These pages are a manifestation of his unwavering support,

enthusiasm, and generosity, and they are undoubtedly the most sincere and gratifying forms of

respect a young professional can be lucky enough to receive at any point in her career. Beyond

this, though, they speak to an even greater meaning his integrity as a colleague, a friend, and a

fellow human being. He is, in short, an inspiration.

I wish to thank Amy Lazerson; even if I did have a choice, I would want her to be my

sister. Without family, enduring the most painful difficulties and celebrating the most thrilling

joys are simply events in time, a thousand tiny images that seem randomly thrown about. Family

strings the events of your life together with purpose so that when you step back, you see that the

tiny images make one big picture. Without her, there simply would be no big picture.

I wish to thank Tricia and Larry Beach, who personify the meaning of the word home and

remind me that I will always be someone's daughter. I will spend all the days of my life, all the

love in my heart, all the breath in my body thanking them for their endless devotion and

guidance. And still, it won't equal half of what they have given.

I wish to thank Tracy Montauk, who is the person I most want to be like when I first wake

up in the morning, and the person I am most grateful for at the end of my day. To only call her

my friend discounts the many thankless roles she takes on: my never-ending confidante, my

unquestioning defender, my keeper of secrets, and all-around supporter.

Finally, I wish to thank my parents, who had the unenviable job of having to support and

nurture and develop my talents when they were at their most raw, but never got to witness the

payoff of their sacrifices. It is one thing to be loved and cherished, but it is something even

greater to be honored and missed.









TABLE OF CONTENTS

page

A CK N O W LED G M EN T S ................................................................. ........... ............. .....

LIST O F TA B LE S ............................................................................................. ............

ABSTRAC T ..........................................................................................

CHAPTER

1 INTRODUCTION ............... ................. ........... ................. ............. 10

Utility of Implantable Cardioverter Defibrillators........................ .............. .............10
Psychological Sequelae of ICD Implant....................................... ........................11
Com puterized Psychosocial Interventions................................... ........................... .. ........ 12

2 M A TER IA L S A N D M ETH O D S ........................................ .............................................14

P participants and P procedure ........................................................................... ....................14
Instrum ents .......................... ..... .......... .................... ........... 15
ICD Device Knowledge: Florida ICD Knowledge Questionnaire ..................................15
Patient Acceptance: The Florida Patient Acceptance Survey (FPAS) ............................15
Shock Anxiety: The Florida Shock Anxiety Scale (FSAS) .............................................16
General Anxiety: State-Trait Anxiety Inventory (STAI) ............................................. 16
H ealth-Related Quality of Life......................................................... ............... 16
Short Form -12 (SF-12). ................................. .. .. .... ...... .. ............16
Intervention P rocedure......... .......................................................................... ..... ............ 17
T heoretical B asis for C hange......................................................................... ...................18
Q questions and H ypotheses ................. ......... ........... ...... ... ... .. ... ............... 19
Question 1: Does the PACER Program Provide Improved Device-Specific
K now ledge A cquisition?..................................................................................... ... 19
Question 2: Is Increasing Device Knowledge Related to Increasing Patient
A acceptance? ............. ..... ...................................................... ....... ..................19
Question 3: Are Increases in Device Knowledge Related to Decreases in Anxiety?
(Shock-related and Generalized)................................ .... ...............19
Question 4: Does Independent, Self-directed Use of This Program Produce
Comparable Outcomes of Psychosocial and Quality of Life Ratings as an In-
person, G roup E education Setting? .................................................... .....................20









3 L IT E R A TU R E R E V IE W ........................................................................ .. .......................2 1

Psychological D stress and the ICD Patient ........................................ ....................... 21
D escriptors and Prevalence .................................................... .............. ............... 21
Theories of Distress Among ICD Patients ................. ...........................................23
A nxiety and C ardiac Patients ................................................ .............................. 26
Interventions for IC D P atients........................................................................... .... ... 27
P patient A acceptance and the IC D ..................................................................... ..................29
Cardiac Patients and the Internet ...................................... ............. ....... ............... .30
P psychology and the Internet.......................................................... ........ ............................3 1
N eed for Further R research ............................................................................... 34

4 R E SU L T S .............. ... ................................................................36

S a m p le ............................................................................3 6
D descriptive A analyses ................................................................... 38
H y p oth esized A n aly ses..................................................................................................... 3 9
H y p o th e sis 1 ................................................................. 3 9
H y p oth esis 2 ................................................................3 9
H y p o th e sis 3 ................................................................4 1
H y p oth esis 4 ................................................................4 2
User Survey Data ................................................................. .........43
Post-Hoc Analyses.................................... .................... ........ 43
Effects on New Recipients versus Previous Recipients ..................................... 44
Effects of Knowledge on Quality of Life ............................................ ............. 45

5 D IS C U S S IO N ...... ........................ ............................................................... 5 2

Acquisition of Knowledge Between Groups ............. .................................... 52
Relationship of Knowledge to Device Acceptance ........ .........................................54
K now ledge and A nxiety .................................................................................... ............... 55
Computerized versus In-Person Treatments ............................ ......... ...............57
N ew versus Established ICD Recipients ........................................................ 58
L im itatio n s ...... ........................ ................................................................5 9

6 F U T U R E W O R K .............................................................................................................. 6 1

A PPEN D IX : M EA SU RE S ................................................................63

LIST OF REFERENCES ............................. .................. 74

BIOGRAPHICAL SKETCH ............................................ ..... .............. ... 82









6









LIST OF TABLES


Table page

4-1 Social and demographic variables by treatment condition .............................................46

4-2 Psychological variables at baseline, by treatment condition ..........................................47

4-3 Baseline Psychological Variables of New and Previous Recipients ..............................48

4-4 Independent predictors of device acceptance at follow-up, among treatment
p articip an ts ...................................... .................................................... 4 9

4-5 Post-intervention psychological variables from the PACER Study and the in-person
study......................................................... 50

4-6 U ser Survey of PA CER Program .......................................................................... ...... 51










Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PATIENT ASSISTED COMPUTERIZED EDUCATION FOR RECIPIENTS OF
IMPLANTABLE CARDIOVERTER DEFIBRILLATORS (PACER): A RANDOMIZED
CONTROLLED TRIAL OF THE PACER PROGRAM

By

Emily A. Kuhl

August 2007

Chair: Samuel F. Sears
Major: Psychology

The implantable cardioverter defibrillator (ICD) is the treatment of choice for preventing

and correcting potentially-lethal cardiac arrhythmias. Although its effectiveness is supported by

data from several large-scale, randomized clinical trials, its psychological impact is less

favorable, mostly because of the shock mechanism by which the device corrects arrhythmias.

Patients with ICDs are vulnerable to depression and anxiety, including panic disorder and

avoidance behaviors, as a result of device placement and experiencing an ICD shock. There are

only a handful of randomized, controlled trials focused on enhancing the psychosocial

functioning of ICD recipients. Computers are becoming an increasingly useful tool in providing

psychological care due in part to their accessibility, convenience, anonymity, and cost

effectiveness. There is ample support for using computerized interventions to successfully treat

psychiatric dysfunction, including depression, panic disorder, generalized anxiety, and phobias.

There are currently no computerized interventions in the literature aimed at the psychosocial

fitness of ICD patients. Our study is a pilot study of a psychoeducational, computerized

intervention for ICD recipients entitled Patient Assisted Computerized Education for Recipients

of Implantable Cardioverter Defibrillators (PACER). We hypothesized that the PACER program









would increase patient knowledge about their ICD, decrease anxiety, and increase device

acceptance, as compared to usual care patients. PACER patients were also hypothesized to

demonstrated equivalent scores of anxiety, device acceptance, and quality of life compared to

patients from a similar, in-person intervention from a related study. Thirty patients were

recruited, and half were randomized to the treatment condition. At one-month follow-up, there

were no differences in scores between treatment and control patients on an ICD knowledge test.

Increases in ICD knowledge were associated with increases in device acceptance, but only

among treatment patients. There was no impact of the program on anxiety. Compared to

participants from an in-person treatment, PACER patients demonstrated similar scores of mental

quality of life and device acceptance, but worse scores of anxiety and physical quality of life. A

user survey demonstrated overwhelming support of the PACER program by participants,

suggesting the utility of future testing amongst a larger sample.









CHAPTER 1
INTRODUCTION

Utility of Implantable Cardioverter Defibrillators

Each year, approximately 350,000 Americans experience sudden cardiac arrest (SCA)

related to the occurrence of cardiac arrhythmias, including ventricular fibrillation (VF) and

ventricular tachycardia (VT; American Heart Association, 2004). Ventricular tachycardia is

characterized by heartbeats in excess of 160 beats per minutes. Ventricular fibrillation is

characterized by both excessive heart rate and poorly-defined contractions wherein the heart

manifests a fast-paced, quivering motion. The result is a failure of the ventricles to completely

fill and contract, sending insufficient amounts of blood to the lungs and body. In the event of

SCA, treatment by defibrillation to shock the heart back into rhythm is necessary to prevent

death, which otherwise occurs within minutes. Individuals who experience SCA may be treated

pharmacologically (e.g., antiarrhythmic medications) or via implantable cardioverter defibrillator

(ICD), an internal device that detects, paces, and defibrillates arrhythmias including VF and VT.

Modem ICDs are equipped with multi-therapeutic pacing and graduated shock delivery, as well

as additional lead placement and algorithmic programming to differentiate ventricular from

supraventricular activity.

When an irregular rhythm such as VT or VF occurs, the ICD may send a small shock to

slow a fast heart rate (cardioversion), or a larger shock to stop the rhythm completely and

essentially "reboot" the heart's electrical system defibrillationn). Shock is not a rare

phenomenon, with 40-42% of all ICD patients experiencing one shock within the first year post-

implant (Credner, Klingenheben, Mauss, Sticherling, & Hohnloser, 1998). Twenty-two percent

will experience more than one shock during this initial year, while 17% will experience more

than three shocks. Although the shock mechanism means that a patient with an ICD is not likely









to die from SCA, there are secondary complications that can occur with ICD placement, such as

the development of congestive heart failure (CHF) can continue despite reduction in cardiac

arrhythmias.

The ICD is the treatment of choice for ventricular cardiac arrhythmias (Anti-arrhythmic

versus Implantable Device [AVID] Investigators, 1997; Moss et al., for the Multicenter

Automatic Defibrillator Implantation Trial Investigators, 1996), and nearly 60,000 Americans

receive an ICD each year. Previous recipients include Vice President Dick Cheney in 2001.

Several large-scale, randomized, controlled clinical trials have compared the effectiveness of the

ICD versus standard care (e.g., medications). For example, the AVID Trial paired nearly 500

ICD recipients against 500 patients placed on antiarrhythmic medications (e.g., amiodarone,

sotalol), and found a 27% reduction in mortality from the ICD at 2 years. These results were

impressive enough to prematurely terminate the study in order to provide implantation for all at-

risk patients. Throughout other studies (Connolly, et al., 2000; Kuck, Cappato, Siebels, &

Ruppel for the Cardiac Arrest Study Hamberg Investigators, 2000; Moss et al.), the ICD has

repeatedly outperformed medication management with mortality rates ranging from 31-74%. In

another such study (Buxton, et al., for the Multicenter Unsustained Tachycardia Trial

Investigators, 1999), patients randomized to medical management had mortality rates

comparable to those of control patients receiving no treatment at all. While patients who take

medication for SCA can reduce their risk of recurrence within 5 years to approximately 50%,

those who receive an ICD have a mere 5% risk. Data such as these highlight the strength of the

ICD in helping patients live with potentially life-threatening ventricular arrhythmias.

Psychological Sequelae of ICD Implant

Although the ICD has demonstrated impressive mortality rates, the device nonetheless

presents as a potential instigator of psychological maladjustment in recipients. This is primarily









due to the shock mechanism necessary for the device to cardiovert and defibrillate potentially

lethal arrhythmias. Another factor that may make an individual more susceptible to poor

adjustment is lack of understanding and knowledge about their device (Sears, Burns, Handberg,

Sotile, & Conti, 2001), implying that the need for sound patient education is great. Significant

rates of panic symptoms (Godemann et al., 2004) and avoidance behaviors (Lemon, Edelman, &

Kirkness, 2004) have been documented among this population, as have difficulties with

depression, interpersonal functioning, and stress management (Sears & Conti, 2003). It would

seem, therefore, that health care providers should consider issues related to quality of life, rather

than just quantity of life, among these recipients. Unfortunately, there has been little published

in the way of psychosocial interventions for ICD patients. What studies do exist (Frizelle et al.,

2004; Kohn, Petrucci, Soto, Baessler, & Movsowitz 2000) suggest that cognitive-behavioral

techniques, such as helping patients break classically-conditioned cycles of avoidance

surrounding fear of shock exposure, may be of particular benefit.

Computerized Psychosocial Interventions

In this new era of psychological treatment, the Internet is becoming an increasingly

common venue for reaching patients. Indeed, with nearly two-thirds of all Americans having

Internet access (Lenhart et al., 2003), this appears to be an appropriate arena to which

psychologists can extend themselves. Web-based interventions (WBIs) represent the current

interface between modem technology and psychology. Already there appears to be much

support for the use of WBIs in creating behavioral change, such as in treating panic disorder

(Richards, Klein, & Carlbring, 2003) and eating disorders (Winzelberg et al., 2000). Similarly,

Web programs that address cognitive components, such as with individuals with depression, also

have been supported (Christensen, Griffiths, & Korten, 2002).









To date, there have been no published studies of WBIs for ICD recipients. In fact, there

has been relatively little done for cardiac populations in general in the way of Internet

interventions. An online intervention that utilizes documented cognitive and behavioral

techniques to improve patient acceptance and adjustment would be desirable. However, the

reality of whether such an intervention could achieve any success is unknown. Clearly, there is a

need for feasibility studies to determine whether computerized interventions are usable for the

ICD population in the first place. Therefore, the main objective of the current proposal is to

examine the effects of a WBI (The PACER [Patient-Assisted Computer Education for Recipients

of Implantable Cardioverter Defibrillators] Program) designed for ICD patients in terms of

increasing patient knowledge about their device, increasing patient device acceptance, and

reducing anxiety among recipients. A secondary objective is to determine whether participants

in this study display different outcomes (e.g., psychosocial ratings, quality of life) compared to

participants in a related study who utilized the same intervention but in a structured, in-person

group format.









CHAPTER 2
MATERIALS AND METHODS

Participants and Procedure

The current study lasted for two years. Participants were recruited from Shands Teaching

Hospital in Gainesville, FL. Initial inclusion criteria were that all participants will be newly

implanted (<3 months), be able to read and write English, and must have access to a computer.

Midway through the study, though, a change in the research protocol was implemented due to

low enrollment secondary to low implantation rates at Shands and recruitment difficulties (e.g.,

lack of patient referrals). The protocol was expanded to include all ICD patients and not just new

recipients. Permission was obtained by Institutional Review Board to contact these patients by

phone. Patients meeting these criteria were asked to participate either immediately following

implantation during inpatient hospitalization (new recipients) or via telephone (previous

recipients).

All patients were provided with a general description of the study and asked to participate.

After giving written consent, participants completed a packet of questionnaires assessing for

psychological functioning and device knowledge. Following completion, participants

randomized to the treatment condition received a CD-ROM containing a computerized psycho-

educational program (the PACER program) about how their device works and how to cope with

having an ICD. An Internet Service Provider was not necessary for participation.

At one-month follow-up, participants completed the same measures as at baseline.

Follow-up questionnaire packets for treatment participants included an addendum to the Florida

ICD Knowledge Questionnaire that contained a user survey to determine which parts of the

program were accessed and deemed effective. Control participants were wait-listed and at the

end of the study received the same CD-ROM as those in the treatment group. All participants









were allowed to keep the CD-ROM. Institutional Review Board (IRB) policies at the University

of Florida were followed.

Medical variables gathered include the left ventricular ejection fraction, history of

implantation, and other cardiac risk variables, medications, other illnesses or surgeries, length of

hospitalization, length of time since implant, number of rehospitalizations, and number of

medical procedures. Demographic information collected includes age, sex, race, educational

status, family income, marital status, and employment status.

Instruments

ICD Device Knowledge: Florida ICD Knowledge Questionnaire

This measure was developed specifically for this study, since no measure of this construct

currently exists. The patients' knowledge of ICDs was assessed using scores from six sections

including basic knowledge about the device and shocks; stress management techniques for ICD

recipients; improving cognitions and outlook; utilizing adaptive behaviors to increase

adjustment; understanding family relationships; and preparing for device shock. Questions are

multiple-choice with four- and five-choice answers. A utilization subscale was added to post-

tests given at one-month follow-up. This subscale is a user satisfaction survey determining how

often the participants accessed the program, how useful they found it, and what areas were most

helpful.

Patient Acceptance: The Florida Patient Acceptance Survey (FPAS)

This measure was developed to examine device acceptance in pacemaker, implantable

cardioverter defibrillator (ICD), and implantable atrioverter defibrillator (IAD) patients. It is

comprised of 15 items with four valid and consistent factors: Return to Life, Device-Related

Distress, Positive Appraisal, and Body Image Concerns. The FPAS total score and subscale









scores demonstrated both convergent and divergent validity with the SF-36, atrial fibrillation

symptoms, the CES-D, STAI, and illness intrusiveness (Burs et al., 2004).

Shock Anxiety: The Florida Shock Anxiety Scale (FSAS)

This scale was developed for a previous study to assess the fear and anxiety that patients

may have regarding the ICD and its shocks. This 16-item measure examines the cognitive,

behavioral, emotional and social impact of shock anxiety. Full psychometric validation is

currently being investigated (Kuhl, Dixit, Sears, & Conti, 2006).

General Anxiety: State-Trait Anxiety Inventory (STAI)

The STAI is a 40-item self-report questionnaire designed to measure both state and trait

anxiety (Speilberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). For the purposes of this study,

only the 20-item trait scale of this questionnaire was administered. Trait anxiety is defined as a

relatively enduring personality characteristic, or more specifically, as anxiety proneness. The

internal reliability of both the state and trait anxiety scales has been shown to be uniformly high

across samples of adults ranging from .89 to .96. Test-retest stability coefficients for multiple

samples of college students ranged from .73 to .86, with test-retest validity specifically for the

trait scale being reported at .73 for males and .77 for females. Concurrent validity between the

STAI and IPAT Anxiety Scale and the Taylor Manifest Anxiety Scale ranged from .83 to .73

(Spielberger et al., 1983).

Health-Related Quality of Life

Short Form-12 (SF-12). This measure was developed to gauge mental and physical

functioning and can be separated into two components: physical component summary (PCS-12)

and mental component summary (MCS-12). All scores of the SF-12 are comparable and highly

correlated with scores from the SF-36, from which it was derived, (ranging from .63-.97) (Ware

et al., 1995; Ware, Kosinski, & Keller, 1996). The SF-12 reproduced 90% of the variance in the









SF-36 PCS and MCS measures in the United States and on cross-validation in the MOS (Ware et

al., 1996).

The Left Ventricular Dysfunction Questionnaire (LVD-36). This cardiac-specific

measure was designed to assess the impact of left ventricular dysfunction on daily life and well-

being. Responses are dichotomous (true or false). True responses are summed, which is then

calculated as a percentage; higher scores indicate worse functioning (i.e., 0 = best possible

score). The measure demonstrated high internal consistency in a sample with chronic left

ventricular dysfunction (Kuder-Richardson coefficient = 0.95) (O'Leary & Jones, 2000). Higher

scores indicate greater dysfunction, and poorer QOL.

Please see Appendix for printed copies of all measures.

Intervention Procedure

The intervention in this study is a psycho-educational, cognitive-behavioral program

entitled "The PACER Program: Patient-Assisted Computer Education for Recipients of ICDs."

Accessing a CD-ROM program only requires the user to insert the CD and double-click on the

appropriate icon, and therefore involves considerably less experience on the part of the user. The

intervention program provides information about coping, mood, relationships, device

functioning, and other areas relevant to ICD patients' adjustment. As described earlier, it has

been theorized that cognitive appraisals and classical conditioning contribute to ICD patient

anxiety. Cognitive-behavioral techniques help dispel the cognitive distortions behind patients'

attempts to predict shocks and avoid activities. The current intervention teaches participants

about the unpredictability of shock; helps patients devise a plan to cope with shock, thereby

assisting them in feeling more prepared; and provides coping techniques that allow patients to

return to everyday activities and enjoy life again. The program is interactive and allows

participants to apply concepts and strategies to their own situations and concerns.









Psychological and QOL scores from participants receiving the PACER intervention were

compared to those of participants from a related study that utilized a similar intervention (Sears,

Vazquez Sowell, Kuhl, et al., under review). In this original study, ICD recipients who had

received a device shock were randomized to either a 6-week cognitive-behavioral stress

management program or a one-day workshop control group. Both groups received the same

information although the control group's information was abbreviated. The information

presented is the same as the information contained in the PACER program. Post-treatment

analyses indicate that the weekly intervention resulted in improved scores of mental QOL,

anxiety, and decreased diurnal salivary cortisol production, which is a validated biological

marker of stress. All participants demonstrated improved scores of depression and physical QOL.

However, it is unclear whether the information itself provided the basis for change, or whether

the didactic format of the groups was more influential. By comparing scores from participants in

the original study to those using the PACER program, we will be able to better understand where

to attribute outcomes. In order to control for the fact that the original study participants were

shocked, baseline scores of anxiety between both groups were compared to determine whether or

not anxiety should be used as a covariate.

Theoretical Basis for Change

Classic learning theory can be used to conceptualize how the PACER program will affect

participants. Learning theory is built on concepts of reinforcement, shaping, and self-monitoring

- all of which are addressed by this intervention. For example, participants are provided with

psychoeducation to reduce avoidance behaviors and increase pleasant activities. As they engage

in these behaviors, it will provide reinforcement for the notion that virtually all activities are safe

for ICD patients, that they do not need to actively avoid objects/activities, and that such

avoidance does not reduce their risk of shock. By encouraging participants to create a "shock









plan" in the event that their device fires, the program is shaping behaviors, such as preparedness

and active coping. Lastly, participants are taught various forms of self-monitoring, such as

relaxation techniques (which are directly built on the premise of self-monitoring for the stress

response), and identifying and reframing cognitive distortions. It is believed that these are the

primary pathways by which the PACER program is likely to produce changes in participants'

thinking patterns and behaviors.

Questions and Hypotheses

The following questions and hypotheses are proposed and comprise the apriori analyses to

be conducted after data collection is complete.

Question 1: Does the PACER Program Provide Improved Device-Specific Knowledge
Acquisition?

* Hypothesis 1: Treatment participants will yield greater change in test scores from baseline
to follow-up.

* Analysis 1: Descriptive and repeated measures analyses of covariance (R-MANCOVA)
will determine changes in scores between the groups while controlling for the effects of
age, education level, and disease severity (e.g., ejection fraction).

Question 2: Is Increasing Device Knowledge Related to Increasing Patient Acceptance?

* Hypothesis 2: Gains in knowledge will be associated with greater device acceptance
scores at follow-up among both groups.

* Analysis 2: Separate hierarchical regression analyses will determine whether change in
knowledge scores predict scores of device acceptance within both groups. In the first
block, demographic variables related to knowledge acquisition including age and education
level, will be entered. In the second block, medical variables will be entered. In the third
block, change in knowledge score will be entered.

Question 3: Are Increases in Device Knowledge Related to Decreases in Anxiety? (Shock-
related and Generalized)

* Hypothesis 3: Knowledge acquisition is related to shock anxiety and trait anxiety, with
increases in knowledge being associated with a decrease in both types of anxiety.

* Analysis 3: Separate hierarchical regression analyses will determine whether change in
knowledge scores predict scores of shock anxiety and trait anxiety within both groups. In









the first block, demographic variables related to knowledge acquisition including age and
education level, will be entered. In the second block, medical variables will be entered. In
the third block, change in knowledge score will be entered.

Question 4: Does Independent, Self-directed Use of This Program Produce Comparable
Outcomes of Psychosocial and Quality of Life Ratings as an In-person, Group Education
Setting?

* Hypothesis 4: Participants in this current study will produce scores of psychosocial
adjustment and quality of life that are not significantly different from ratings of
participants in a related study that utilized the same program but in an in-person, group
format (Sears et a., in preparation).

* Analysis 4: Multivariate Analysis of Variance will be employed to explore differences by
treatment group in trait anxiety (STAI), patient acceptance (FPAS), and quality of life (SF-
12).









CHAPTER 3
LITERATURE REVIEW

The following literature review will describe how ICD patients adjust to their device, and

what psychological treatments are recommended for this population. Further, it will review how

the Internet has been utilized as a clinical tool by psychologists, and how Internet interventions

apply to cardiac patients.

Psychological Distress and the ICD Patient

Descriptors and Prevalence

With mortality benefits of the ICD well established, the focus of its impact has shifted

beyond the physiological outcomes of the patient and toward the psychosocial and quality of life

issues that coincide with implantation. The shock mechanism by which the ICD attempts to

correct arrhythmias is a unique experience to which few individuals can relate. Although most

recipients say this phenomenon is more surprising than it is painful, and rate it as a 6/10 on a 1-

to-10 scale of pain (Sears, Kovacs, Azzarello, Larsen, & Conti, 2004), it nonetheless is

sometimes an anxiety-provoking and fearful experience (Herrman, et al., 1997; Luderitz, Jung,

Deister, & Manz, 1996; Schuster, Phillips, Dillon, & Tomich, 1998; Sears, Todaro, Saia-Lewis,

Sotile, & Conti, 1999). Other common concerns among ICD patients include fear of shock,

device malfunction, battery failure, and sexual/intimacy concerns (Sears et al., 1999).

Approximately 15% of ICD patients struggle with psychological distress secondary to

device placement (Sears et al., 1999). A large-scale national survey from Sears and colleagues

(1999) found that ICD patients experience relatively high rates of anxiety compared to the

general population. Specifically, about 24-48% of ICD patients have anxiety symptoms, with

13-38% meeting criteria for an anxiety disorder. Rates of depression are more similar to those

seen in the general population. Approximately 12-24% of ICD patients describe symptoms of









depression, while about 9-15% actually meet criteria for clinical depression. Despite this, about

91% of ICD patients return to pre-implant levels of QOL within the first year of device implant

(Sears et al. 1999, 2000). Quality of life for ICD patients appears to be as good as, if not better

than, that of patients receiving pharmacological care (Sears & Conti, 2002). Irvine and

colleagues (2001) found that ICD patients' QOL was better than those patients receiving only

drug therapy, except in the areas of pain and social functioning. Although ICD patients have

device-specific anxieties and concerns that are worthy of attention, a majority of these patients

appear to experience good QOL.

Among the ICD patients who do experience distress, shock seems to be the primary

culprit. Schron and colleagues (2002) found that experiencing more than one shock within the

first year was associated with lower mental and physical QOL scores on the Short Form-36

questionnaire. Luderitz, Jung, Deister, and Manz (1996) suggest that five shocks may be the

"magic number" in determining whether an ICD patient experiences significant anxiety. Other

researchers (Kamphuis, de Leeuw, Derksen, Hauer, & Winnubst, 2003) emphasize time of shock

rather than number, finding that shocks within the first 6 months are significantly associated with

an increased risk of distress.

Regardless of whether it is related to when they occur or simply how many occur, the

incidence and impact of shock cannot be overlooked. A recent large-scale study assigned half of

post-bypass patients to receiving an ICD, while the other half was maintained via drug therapy

(Namerow, Firth, Heywood, Windle, & Parides, 2002). It was reported that the ICD recipients

experienced worse QOL than those taking medication. However, further analyses revealed that

the non-shocked ICD patients did not differ significantly on QOL ratings from those assigned to

the medical condition. The experience of shock solely accounted for the difference in groups.









Further, Godemann and colleagues (2004) studied diagnostic rates of panic disorder with

agoraphobia among ICD patients and found that, when shocked, ICD patients were more likely

to meet criteria for diagnosis (7% no-shocked versus 21% shocked).

While these studies clearly implicate shock in the advent of psychological distress, other

studies suggest different risk factors are at hand. Pauli, Wiedemann, Dengler, Blaumann-

Benninghoff, and Kuhlkemp (1999) opine that anxiety in ICD patients is not related to shock, but

rather to catastrophic thinking. Specifically, anxious patients in their study were prone to

somaticizing and interpreting changes in their bodies as negative signs of failing health, which in

turn can spiral into negative cognitions about one's health, life, and future. Sears and Conti

(2003) further elaborate by suggesting that there are multiple risk factors for distress, such as

young age (<50 years), female gender, poor device understanding, the presence of 3 or more

shocks within a 24-hour period (aka., ICD "storm"), and a history of significant psychiatric

distress.

Theories of Distress Among ICD Patients

How is it that some ICD patients adapt normally while others continually struggle with

anxiety and health-related concerns? Several theories attempt to explain the development of

psychopathology among some ICD recipients. Four such theories focus specifically on patients'

perceptions of their device and shock.

The first theory is that of classical conditioning, introduced to psychology by Ivan

Pavlov's research with his dogs. This theory holds that pairing a neutral stimulus with a negative

or positive event can create a resulting association between the two items. In the case of ICD

patients, the negative event is device shock. Pairing the existence of shock with an object, event,

or place can result in avoidance (Lemon et al., 2004) due to the newly created negative

association. This avoidance can subsequently lead to maladjustment (Sears & Conti, 2002). For









example, a patient who is shocked while gardening may associate being in the garden with the

negative experience of being shocked, and therefore avoids working in the garden despite the

fact that is a safe activity and possibly one that gives the patient enjoyment. Consider the same

consequences when an individual is shocked while being intimate with a loved one. Suddenly,

the conditioning of the patient to avoid contact with their loved one now not only affects the

patient himself, but also the spouse. This can also lead to social isolation, depression, low self-

image, and feelings of helplessness.

Similar to this theory is that of operant conditioning. Operant conditioning holds that

individuals are motivated to do or avoid doing things for which they are reinforced. An ICD

patient who believes they are avoiding shock by avoiding an activity is receiving negative

reinforcement. A recent example of a female patient who was shocked while eating illustrates

the serious consequences that this faulty reasoning can have.

Third is the theory of learned helplessness, developed by Seligman. This theory states that

when we are presented with an aversive situation from which we cannot escape, we tend to give

up and cease trying to find a way to avoid the negative consequences. In the case of an ICD

patient, there is no way to avoid being shocked. Shock is not predictable or directly controlled

by what a patient does, says, eats, behaves, etc. This clearly can lead to feelings of helplessness

and despondency. Patients who come to believe that they will be shocked no matter what they

do may give up trying to cope and adjust, feeling that they have no control over their lives or

health. This in turn can lead to feelings of depression, withdrawal, social isolation, and fear.

The fourth theory, proposed by Sears and Conti (2003), is the theory of cognitive appraisal,

also known as the sickness scoreboard theory. Patients who are shocked, and often times those

who are not, may come to view device firing as a sign of failing health. Over time, patients may









"keep score" of whether their health is improving or declining by tracking device firings. In an

attempt to gain control over their health, and therefore alter their score, they may avoid activities

that they erroneously believe will lead to shock. This "score-keeping" also gives patients a false

sense of control over their health, causing them to become hypervigilant of their body's changes

and physical sensations. The occurrence of shock does not indicate failing health. In fact, as

mentioned previously, shocks can occur for reasons unrelated to arrhythmias (e.g., lead

dysfunction).

More recently, some researchers have suggested that patient personality characteristics

may make them more vulnerable to distress following implantation, especially among patients

who experience shock. Dunbar and colleagues (1999) studied mood disturbance in 207 ICD

patients. Participants were asked to rate their levels of anxiety, anger, confusion, fatigue, and

vigor at pre-implant, post-implant, 1-month, 3-months, 6-months, and 9-months follow-up.

These scores yielded a total mood disturbance (TMD) rating. Statistical analyses determined that

the only significant predictor of shock was TMD at time points 1 and 3, which also predicted

shock at subsequent time points. Anxiety, confusion, and fatigue were all significant predictors

of shock. Further, they found that there was no significant difference between pre-implant and

post-implant TMD scores, signifying that the psychological variables acted as precursors to and

not consequences of being shocked.

Results from Dunbar et al. (1999) are consistent with another recent study from Shedd and

colleagues (2004) concerning device firing during the period immediately following the World

Trade Center bombings on September 11, 2001. The authors examined rates of device shock

among ICD patients at Shands Teaching Hospital and the Veterans Affairs Medical Center in

Gainesville, FL, in the 30 days prior to and following the terrorist attacks. During this time,









electrophysiologists in Florida witnessed a 2.8-fold increase in number of tachyarrhythmias.

Similarly, electrophysiologists studying ICD patients at six hospitals in New York City and

upstate New York also witnessed an increase in cardiac events post-September 11th (Steinberg et

al., 2004). As with the Florida patients, the New York sample experienced a 2.3 fold increase in

ventricular tachyarrhythmias from pre- to post-September 11th. Furthermore, there were no

reports of cardiac events in the 3 days immediately following the bombings, and patients

returned to baseline levels of events within a month. The authors note that this finding in

particular differs from previous studies of traumas and cardiac events, which have reported

immediate increases in activity. These fascinating data imply that not only can anxiety and fear

from directly experiencing trauma impact one's heart rhythms, but that experiencing an event

indirectly can affect cardiac functioning as well.

Anxiety and Cardiac Patients

As noted above, anxiety and depression have been identified as common comorbidities to

ICD placement, and there are several theories as to why anxiety in particular may transpire so

frequently in this population. This is particularly worrisome because of the devastating effects

that anxiety can have to both one's emotional and physical self.

Anxiety has been identified as a significant contributor to the pathogenesis of cardiac

disease (Kubzansky, Kawachi, Weiss, & Sparrow, 1998). Through activation of the sympathetic

nervous system and subsequent release of catecholamines, anxiety is implicated in platelet

aggregation, injury of arterial lining, and release of fatty acids into the blood all of which

promote the atherosclerotic process. Anxiety also may cause injury by decreasing heart rate

variability and increasing the incidence of ventricular premature beats, thereby contributing to

electrical instability. Finally, anxiety may trigger myocardial infarction due to the association

between hyperventilation and coronary vasospasms. Behavioral mechanisms have also been









established associating anxiety with health-compromising activities, such as smoking, decreased

physical activity, or poor diet (Haywood, 1995; Januzzi, Stern, Pasternak, & DeSanctis, 2000).

Myocardial infarction and sudden cardiac death are subsequently common outcomes (Januzzi et

al., 2000). Clearly, anxiety is an important psychological and physical contributor that should be

monitored in cardiac patients, such as ICD recipients.

Interventions for ICD Patients

Current research with ICD patients suggests that there is a great need for psychosocial

interventions to help ICD patients cope with comorbid distress. Unfortunately, much of the

research in this area is methodologically flawed due to problems such as small sample size and

the use of interventions, such as support groups, that are unstructured and predominantly provide

emotional support. While emotional support is undoubtedly an important component to patient

adjustment, the use of patient education and cognitive-behavioral therapy techniques should not

be ignored, and have been shown to be more effective in decreasing distress and improving QOL

than emotional support alone.

Structured interventions for ICD patients based on cognitive-behavioral techniques have

only recently been studied. In one landmark study (Kohn et al., 2000), ICD patients were

randomized to a six-week individual psychotherapy intervention, or standard care.

Measurements of depression, anxiety, and illness adjustment were taken pre-implant, and at 1, 3,

5, and 9 months following implant. The authors reported that providing individual cognitive-

behavioral therapy to ICD patients resulted in significant decreases in depression and anxiety,

and improved adjustment compared to a no-treatment control group. Even more notable, the

experimental group contained more women and reported a greater number of shocks, both of

which are recognized predictors of poorer adjustment.









An additional study (Frizelle et al., 2004) examined the impact of a cardiac rehabilitation

program fitted with cognitive-behavioral techniques for ICD patients. Participants were

randomized to a six-week treatment program or a wait-list control group. The intervention

consisted of psychoeducation about the ICD and its functioning, relaxation techniques (e.g.,

breathing exercises), and goal-setting to help patients increase avoided activities. Post-treatment

results revealed a significant improvement in anxiety and depression scores; improved QOL

measurements; and a decrease in ICD-related concerns. Intervention patients also improved

significantly on physical measures of exertional capacity (e.g., Shuttle test). Taken together,

these few studies highlight the early success of these strategies in aiding ICD patients.

Patient education is a reasonable intervention for medical patients, and may be particularly

helpful with reducing anxiety (Lee, Chui, & Gin, 2003; Poroch, 1995). Research has highlighted

the benefits of patient education beyond merely reducing anxiety, such as increasing quality of

life, compliance and patient satisfaction with care (Mills & Sullivan, 1996; Powell, Bentall, Nye,

& Edwards, 2001; Sturdee, 2000). However, three meta-analyses of studies on psychoeducation

programs for cardiac patients (Dusseldorp, van Elderen, Maes, Meulman, & Kraaij, 1999;

Linden, Stossel, & Maurice, 1996; Mullen, Mains, & Velez, 1992) reported positive results for

cardiac outcomes, but mixed results for psychosocial outcomes. Unlike the review from Linden

and colleagues, Dusseldorp et al. found no significant effects of psychoeducation on anxiety or

depression. The authors suggest that this could be due to various factors such as floor effects of

their population, sex- or age-specific needs that were not addressed, or use of psychoeducation

programs that were too general or vague in their content (e.g., group discussions of MI risk

factors as a stress management intervention). Similarly, Mullen, Mains, and Velez suggest that

individually tailored content focused on promoting behavioral change may help maximize









psychosocial outcomes. Given this, a psychoeducation program driven by patient-specific needs

(e.g., shock anxiety among ICD patients) that aims to change behaviors and cognitions, rather

than simply disseminate information, may be appropriate for cardiac patients and could

potentially improve psychosocial outcomes.

Patient Acceptance and the ICD

In addition to psychological disturbances, health care providers should also be aware of

patient acceptance among ICD recipients. Patient acceptance of medical treatment is a

complicated variable (Cleary, 1999) that is worthy of attention due to its association with

improved patient understanding and satisfaction with outcome, as well as adherence (McKinley,

Manku-Scott, Hastings, French, & Baker ,1997; Renzi et al., 2001; Roberts, 2002; Zimmerman,

1988). Patient satisfaction may be contingent on several variables including disease severity,

health-related quality of life, and, often times, patient-provider relationship.

Implantable cardioverter defibrillator recipients are confronted with significant burdens,

particularly during the first 6 months after implant (Kamphuis et al., 2003), which can impact

their level of device acceptance. Burns, Serber, Keim, and Sears (2005) state that ICD patient

acceptance encompasses an understanding of device benefits and detriments, the likelihood of

future recommendation of the ICD to other individuals, and an awareness of what benefits the

patient perceives are being provided by their device. As a global term, patient acceptance is

thought to be a construct of QOL, incorporating disease-specific aspects that may be lost on

other general or even cardiac-specific measures of quality of life (Burns et al., 2005). Therefore,

measuring patient acceptance in ICD recipients is crucial to understanding their unique

experiences and forming an awareness of how the device impacts their functioning.









Cardiac Patients and the Internet

Cardiac patients are a prime population for Web-based care. According to CyberAtlas

(Greenspan, 2002), there were 137 million Americans online in 2002, nearly one-third of which

were age 50 or older. The U.S. Bureau of the Census and the National Center for Health

Statistics reports there are 35 million Americans age 65 and older (Greenspan, 2003). An

estimated 20 percent (7.6 million) of those are currently on the Internet, but that number is

projected to more than double by 2007. Further, Harris Poll data (2002) suggest that men and

women were nearly even among Internet use, with women slightly edging out men. By racial

ethnicity, Caucasian users make up approximately three-fourths of all adults on the Web, with

African-American users totaling 12% and Hispanic users 9%. A typical cardiac patient is a male

Caucasian, age 65 or older, and therefore is well suited for a Web intervention. Moreover, a

2000 study (Dickerson, Flaig, & Kennedy) on Internet use among ICD recipients found that

patients readily utilized the Internet for supportive communication and information exchanging,

suggesting that the ICD population is an appropriate group for an online intervention, although

no specific intervention was provided in their study.

Web-based interventions have been scarcely applied to cardiac patients. A majority of the

studies conducted thus far concern enhancing professional development, medical monitoring, or

improving technology. There are considerably fewer studies aimed at directly impacting patients

via improved psychosocial and physical outcomes, though WBIs for cardiac-related risk factors

such as obesity (Tate, Jackvony, & Wing, 2003), smoking (Feil, Noell, Lichtenstein, Boles, &

McKay, 2003), and sedentary lifestyle (Napolitano et al., 2003) have gained attention. Studies of

tertiary care populations show hopeful results for populations such as transplant patients (Dew et

al., 2004), individuals with CHF (Delgado, Costigan, Wu, & Russ, 2003; Scherrer-Bannerman et

al., 2000), and secondary prevention populations (Gordon, 2004). Other research suggests that









cardiac patients may benefit from computerized treatment by increasing education and

communication (Delgado et al., 2003), as well as improving treatment adherence (Ruggerio et

al., 2000). Further, Southard, Southard, and Nuckels (2004) demonstrated cost efficiency with a

computerized nursing case management system developed as an alternative to cardiac

rehabilitation. Participants in the treatment condition exhibited improved, though non-

significant, outcomes in time spent exercising, fat intake, and cholesterol, along with significant

improvements in weight loss and body mass index. In addition, among the treatment condition,

there was a significant cost-savings per patient (net cost savings = $965) on hospitalizations and

emergency department visits. These studies indicate that, though still nascent in their

development, Web-based interventions for cardiac patients show potential.

Psychology and the Internet

Today's technology sees traditional psychosocial interventions merging with the world of

high-speed computer programming to form psychosocial WBIs. Web-based interventions have

been successfully utilized in various arenas including eating disorders (Winzelberg et al., 2000;

Winzelberg et al., 1998), diabetes (Glasgow, Boles, McKay, Feil, & Barrera, 2003), weight loss

(Tate, Jackvony, & Wing 2003), and toilet training (Cox, Borowitz, Kovatchev, & Ling, 1998).

Internet interventions are noteworthy because of their potential to reduce some of the barriers

encountered in traditional treatment (Ritterband et al., 2003).

There are four primary benefits to using WBIs for treatment. First, WBIs are convenient.

The Internet is always on and is always open. Internet interventions do not require patients to

make appointments, wait in line, or contend with scheduling. In fact, as long as the technology

is available, patients don't even need to leave their home to access services, making WBIs

exceedingly convenient.









A second benefit concerns accessibility. The Internet is easily reached at any time from

nearly any place. Although use of the Internet does require some equipment, much of this

technology now comes standard in computers today, and is available outside the home for people

not wanting to personally invest in equipment. Further, with the advent of updated technology,

such as wireless Internet cards, reliance on accessory equipment is becoming less necessary.

A third benefit is that WBIs can offer anonymity, which may be particularly helpful in

addressing highly personal and sensitive topics that patients might not otherwise be inclined to

address in face-to-face arenas (Tate & Zabzinsky, 2004). The ability to exchange dialogue or

view text anonymously is likely appealing to many patients and could encourage a sense of

honesty and openness that is not always easy to achieve in traditional settings. Individuals who

are sensitive about in-person settings (e.g., those with physical disabilities) may be more likely to

seek treatment from WBIs, which may gradually help them feel more comfortable to seek

treatment in person in the future.

Last, because of their reliance on computers, WBIs allow for individual tailoring of

treatments. Brug, Oenema, and Taylor (2002) write extensively about the benefits of

individually-tailored interventions, particularly in the realm of providing psycho-education, and

how computers adapt to those this method more easily than standard formats (e.g., pamphlets,

print material). The authors found that when patients received information more relevant to their

particular problem or situation, they were more likely stay engaged with the intervention, thereby

increasing the chance of treatment effects. Computers are more adaptable to tailored

interventions because of their capacity to create large databases of information combined with

programming technique (e.g., use of "if then" statements to direct text) to selectively produce

individualized information. In addition, a study of a computerized education program for cancer









patients (Agre, Dougherty, & Pirone, 2002) suggests that the CD-ROM format in particular is

highly beneficial over other modes (such as the Internet) and is readily accepted by patients.

Web-based interventions are still relatively new, and thus early studies have limitations for

future studies to attempt to correct and strengthen (Ritterband et al., 2003). For example,

researchers have continually cited compliance as a major problem in making WBIs effective.

Another important drawback concerns the disparity in access between different populations, also

termed the "digital divide" (Lenhart et al., 2003). Individuals most likely to fall into this gap of

non-users are ethnic minorities, residents of rural areas or residents in the Southern portion of the

United States, individuals with annual incomes below $30,000, and individuals with a high-

school education or less (Lenhart et al.). Other groups of people who are less likely to be online

are individuals older than 65 years of age, children from low-income homes, and disabled

individuals (Lenhart et al.). Other well-known concerns include lack of comfort with the

Internet, lack of security and validity of information accessed, and initial cost in developing a

WBI. Although cost has been suggested as a possible long-term benefit, in the short-term,

developing the technology to initially provide WBIs (e.g., Web site design; programming fees;

hardware costs) is expensive (Atkinson & Gold, 2002).

Despite the above-noted concerns, the Internet remains a promising option for which

psychology to transition its traditional treatments and techniques. For example, one type of

intervention that seems readily applicable to the Internet is that focusing on behavioral change

techniques (Cavanagh & Shapiro, 2002). One study from Gega, Marks, and Mataix-Cols (2004)

details three individual cases of psychotherapeutic change using three different WBIs to treat

depression, panic with agoraphobia, and obsessive-compulsive disorder. Although this is only

one study, and no definitive conclusions should be made regarding the efficacy of WBIs based









solely on these results, it does provide some promising and intriguing evidence on which future

research can build. Therefore, it is reasonable to continue conducting effectiveness trials, such as

the proposed study, to further investigate the viability of this treatment option.

Need for Further Research

The "structural," "plumbing," and "pumping" capacities of the heart directly impact its

electrical performance. The near-epidemic proportion of coronary artery disease and

cardiovascular diagnoses in this country ensures that, unfortunately, SCA will continue to occur

and ICDs will continue to be necessary. The psychological distress that can accompany ICD

placement is an important consideration. Anxiety in particular appears to be a common concern

among this population, and given the deleterious effects it can have on one's physical and

emotional well-being, it should also be of concern to health care providers looking after ICD

patients.

Education is one reasonable method for addressing distress among medical patients,

especially those with anxiety. A review of literature suggests that the application of WBIs to

cardiac populations has been poorly achieved. Further, to date, there are no published

intervention studies aimed at reaching ICD recipients via the computer. Although the typical

ICD patient is older and therefore less likely to have experience with the Internet, Pew data

indicates that this is a willing and burgeoning online population. Furthermore, CD-ROMs are

considered a reasonable and accessible method for educating patients (Agre et al., 2002), and

provide a good alternative for individuals without Internet access.

The proposed study's focus on ICD patients and computerized care is a unique feature, but

there are other benefits of note. The results from this study will help contribute to the growing

body of literature examining the usability of Web-based interventions in general, as well as

adding to the meager research on cardiac populations. Further, the ICD may be viewed by some









patients as more of a "life destroyer" rather than a "life saver" due to the shock mechanism and

perceived limitations it carries. This study contributes to understanding patient acceptance

among ICD recipients and may provide information that could help this population feel more

satisfied and comfortable with their device. This in turn should impact their treatment

compliance and future adjustment.









CHAPTER 4
RESULTS

Sample

All participants were recruited from the University of Florida Health Science Center, were

older than 18 years of age, and spoke and read English. Forty-six participants consented to

participate in this project: 39 completed all baseline measures and 30 completed 1-month follow-

up measures. Therefore, the total number of participants who completed all phases of the study

was 30. Compared to the number of participants recruited, intent-to-treat attrition rate was 35%;

attrition rate for study initiation was 24%. Known reasons for attrition included no longer being

interested in participating in the study and having significant negative feelings about the device.

Twenty-one participants were randomized to the treatment condition, and 18 were randomized to

the control condition. Of the 30 completers, 15 were treatment participants and 15 were control

participants.

Midway through the study, a change in the research protocol was implemented due to low

enrollment secondary to low implantation rates at Shands and recruitment difficulties (e.g., lack

of patient referrals). The protocol was expanded to include all ICD patients and not just new

recipients. Permission was obtained by Institutional Review Board to contact these patients by

phone. Therefore, not all participants were recruited post-implant during hospitalization, as

originally outlined. Of the 46 participants who consented, 23 were new ICD patients recruited

during the peri-implant period; the remaining half were recruited outpatient via telephone.

Regarding demographic data, 59 percent of the sample was male (n = 23) and 41 percent

were female (n = 16). Mean age of the sample was 57.44 years (S.D. = 14.28). Three of

participants (8%) identified themselves as African American, while 35 (90%) identified

themselves as non-Hispanic White. Regarding marital status, 69% reported being married or









cohabitating, while 13% were divorced or widowed. Thirty-eight percent (n = 15) of the sample

reported having earned a high school education or less; however, of those 15 participants, only

one reportedly did not complete a high school degree. Fifty-five percent had at least two years of

college education, including three participants who reported having completed post-graduate

work. Seven participants (18%) reportedly were engaged in part- or full-time employment, while

31% were receiving disability and 41% were retired. Three participants were unemployed. Five

(13%) of the participants reported living in household with an annual income of less than

$15,000. Most (31%) participants reported earning between $15,000 and $29,000 annually.

Twenty-three percent (n = 9) reported earning at least $60,000 annually.

Information was also collected regarding current and past psychiatric treatment, and

current and past psychotropic medication use. Three participants reported currently receiving

psychological treatment for either depression, anxiety, or both. Ten participants (26%) reported

currently taking a psychotropic medication, including antidepressants (sertraline, fluoxetine, and

venlafaxine) and anxiolytics (buproprion, escitalopram, alprazolam, and paroxetine). Four

participants (10%) reported having received psychological treatment previously, most recently in

2003. Two of these participants reported being treated for depression, one reported being treated

for anxiety, and one patient reported being treated for a non-mood disorder. Six participants

(15%) endorsed having previously taken psychotropic medications (citalopram, paroxetine,

buproprion, and diazepam).

Medical data on cardiac diagnoses, current medication, and ICD-related information was

gathered. Mean time since implantation was 11.77 months (S.D. = 21.53). Mean ejection fraction

was 29.87 (S.D. = 11.36). Respondents' medical history was significant for ventricular

tachycardia (28%), ventricular fibrillation (13%), coronary artery disease (56%), and myocardial









infarction (26%). Sixty-nine percent of the sample had been diagnosed with congestive heart

failure, with 31% in NYHA Class II, 26% in Class III, and 3% in Class IV. Five (13%)

participants had a history of sudden cardiac arrest, with one patient having multiple episodes.

Medication use was as follows: 56% endorsed taking aspirin, 28% Coumadin, 82% beta-

blockers, 13% calcium channel blockers, 46% ACE inhibitors, 23% angiotensin receptor

blockers, 44% diuretics, 8% amiodarone, and 5% sotalol. Thirty-eight percent (n = 15) of the

participants were implanted with a bi-ventricular device.

Descriptive Analyses

Descriptive analyses were run to examine baseline ratings of psychological, ICD-related

medical, and demographic variables. Except for the FSAS total scores and the follow-up physical

QOL score, no variables violated the Kolmogorov-Smirnov test of normality or Levene's test of

homogeneity of variance. The FSAS total scores variable underwent logarithmic transformation

and subsequently displayed normal distribution; the physical QOL score underwent square root

transformations. There were no differences on any measures of demographic or medical

variables by treatment group (see Table 4-1), nor were there group differences on any of the

psychological measures (see Table 4-2).

Given that the original intent of the study was to investigate new ICD recipients, baseline

analyses also included examining demographic, medical, and psychological variables of new

ICD recipients (< 3 months) versus previous recipients. In these analyses, all demographic and

medical variables were comparable. As shown in Table 4-3, significant differences were found

on all baseline psychological measures except on device knowledge and the Return to Life

sub scale of the device acceptance measure. Direction of effects were such that newer patients

reported greater trait anxiety, worse physical and mental QOL, lower device acceptance, greater

device-related distress, less use of positive device-related appraisals, greater body image









concerns, and greater shock anxiety. However, they also reported better scores on a measure of

cardiac-specific QOL that assesses symptoms of ventricular dysfunction.

There was no difference in number of months since implantation by treatment group (t

[37] = 0.35, p = 0.72). There were no differences in any variables by whether or not participants

were taking psychotropic medications, nor were there differences by whether not participants

were currently receiving or had previously received psychological treatment. Examination of

baseline ratings of drop-outs revealed no differences compared to completers.

Hypothesized Analyses

The following statistical analyses were performed to evaluate the proposed hypotheses for

this research project. The Statistical Package for the Social Sciences (SPSS) was utilized to

perform all the analyses.

Hypothesis 1

This first analysis was conducted to examine effects of the intervention on ICD-related

knowledge, operationalized by changes in scores on baseline and follow-up administrations of

the Florida ICD Knowledge Survey. A Repeated Measures Analysis of Covariance was

conducted to examine changes in scores while controlling for age, education level, and disease

severity. Examination of Box's M and Levene's statistic revealed no significant violations of

assumptions. The overall model was not significant (Pillai's Trace = 0.02, p > 0.50). This

analysis suggests there was no difference in test scores between intervention and control

participants over a one-month time period.

Hypothesis 2

Separate hierarchical regression analyses examined whether change in knowledge scores

predict scores of device acceptance within both groups. In the first block, demographic variables

related to knowledge acquisition (e.g., age and education level) were entered. In the second









block, medical variables (e.g., ejection fraction and length of time since implant) were entered.

In the third block, change in knowledge score was entered. Among treatment participants, the

full model was significant (F = 3.96, p = 0.04) and accounted for 69% of the variance in device

acceptance at follow-up (Adj R = 0.51). The first block accounted for 26% of the variance, while

adding medical variables accounted for an additional 12% of variance, which was a non-

significant change in R2. However, adding the knowledge change score significantly accounted

for an additional 30% of variance in device acceptance (F-Change = 8.71,p = 0.02). As shown

in Table 4, age and knowledge change score were both significant independent predictors of

device acceptance at follow-up.

Overestimated R2 values can result from having a small sample size relative to the number

of predictors entered into a model. Most recommendations suggest a minimum of 5, and as many

as 20, subjects per predictor in order to sufficiently power the analysis. Although planned

analyses included examining all five predictors, the above regression was re-examined using

only three predictors in order to investigate the possibility of falsely-inflated R2 values.

Eliminated predictors were determined by examining zero-order correlations between education,

age, EF, and length of time since implant with device acceptance. Based on lack of significance

with the criterion, there was not a need to control for the variables age and EF, and they were

therefore eliminated from the model. The analysis was run with education entered in the first

block, length of time since implant in the second, and knowledge change in the third. The full

model remained significant (F = 3.69, p = 0.04) and accounted for 50% of the variance in device

acceptance at follow-up (Adj R2 = 0.37). Although this represents a decrease from the five-

predictor model, it is nonetheless a significant finding. The first block accounted for 23% of

variance, while the second block contributed less than 1% of additional variance. However, as









with the five-predictor model, knowledge added a significant proportion of variance explained in

device acceptance (R2-change = 0.26; p = 0.03). In this new model, the only significant

independent predictor was knowledge (/ = 0.56, p = 0.03).

Among control participants, the full model fell short of significance (R = 0.54, Adj R =

0.21, F = 1.66, p = 0.26). None of the blocks accounted for a significant proportion of variance

in device acceptance; in particular, the knowledge variable accounted for only an additional 6%

of variance beyond the demographic and medical variables. Therefore, the hypothesis that

increases in knowledge would be associated with increased device acceptance at follow-up was

only observed among treatment participants. There was no relationship between knowledge and

device acceptance among the control participants.

Hypothesis 3

Separate hierarchical regression analyses examined whether change in knowledge scores

predict scores of trait anxiety and shock-related anxiety within both groups. The same

demographic and medical variables were entered into blocks one and two, respectively, as in the

previous analyses. In the third block, anxiety was entered. Among treatment participants, the

full model was not significant in predicting either trait anxiety (R2 = 0.59, Adj R2 = 0.36, F =

2.56, p = 0.10) or shock anxiety (R = 0.12, F = 0.26, p = 0.92). None of the blocks accounted

for a significant proportion of variance in shock anxiety. In the trait anxiety model, however, the

demographic block explained 54% of the variance in anxiety (Adj R2 = 0.46, F = 7.05,p = 0.01)

with age (/ = -0.57, p = 0.04) being the only significant independent predictor. In both models,

knowledge accounted for an additional 1% of variance in anxiety.

Among control participants, the full model was not significant in predicting either trait

anxiety (R2 = 0.14, F = 0.23, p = 0.94) or shock anxiety (R2 = 0.47, Adj R2 = 0.09, F = 1.24, p=

0.38). None of the blocks accounted for a significant proportion of variance in shock anxiety or









trait anxiety, and there were no significant independent predictors in either model. Change in

knowledge explained an additional 8% of the variance in trait anxiety and 7% in shock-related

anxiety.

Hypothesis 4

There were no differences of baseline anxiety between the PACER participants and the in-

person treatment participants, t = -0.73, p = 0.47, and thus no need to use anxiety as a covariate.

A Multivariate Analysis of Variance was employed to explore differences by treatment study in

trait anxiety, device acceptance, and mental and physical QOL at follow-up. There were no

violations of Box's M test of homogeneity; however, Levene's test statistic was significant for

trait anxiety (p = 0.00). Therefore, the more conservative Pillai's Trace was used in interpreting

the multivariate model. The omnibus F was significant (Pillai's Trace = 2.94, p = 0.04, partial

q2 = 0.28). Separate tests of between-subjects effects demonstrated a significant effect on the

dependent variable physical QOL (F = 8.71, p = 0.006), while the ANOVA for trait anxiety

approached significance (F = 3.23, p = 0.08). The direction of effect was such that participants

in the in-person study had greater scores of physical QOL post-intervention, and a trend toward

lower scores of trait anxiety (see Table 4-5). Given the violation of the Levene's statistic, a

separate ANOVA using the Kruskal-Wallis rank test for non-parametric data was employed to

examine scores of trait anxiety. In this analysis, no differences in trait anxiety between study

participants was demonstrated (X2 = 1.13, p = 0.29). Scores of anxiety for PACER patients

increased slightly from baseline to post-treatment (33.81 vs. 36.25), though not significantly (t =

-1.12,p = 0.28).

In order to examine whether there were changes in physical QOL and trait anxiety over

time, a repeated measures design was employed. There was no violation of Box's M test;

however, there was a violation of Mauchly's tests of sphericity (Mauchly's W= 0.38, p = 0.00).









Violation of the sphericity assumption can result in inflated F-ratios. Therefore, the Huynh-Feldt

correction was applied on tests of within-subjects effects. The multivariate model was

significant, Pillai's Trace = 3.87, p = 0.02, partial-2 = 0.28, and within-subjects time by group

effects were also significant, F = 4.69, p = 0.01. Parameter estimates demonstrated significant

group differences for physical QOL over time, but not for trait anxiety.

User Survey Data

Following completion of the follow-up knowledge survey, treatment patients were asked

brief questions about their opinions of the PACER program (see Table 4-6). Thirteen participants

completed this portion of the questionnaire. When asked when would be the most effective time

to receive the PACER Program, 10 said following implant and two said immediately following

their clinic visit.

Regarding ease of use, six rated the program as "easy," four as "moderately easy", and

three as "excellent." All respondents stated that they would recommend the program to another

device recipient. When asked to rate which sections were most helpful, four selected information

about managing stress, five selected information about the device itself, two selected information

about device shock, and one selected information on managing family relationships. Seven

participants rated the program as "somewhat helpful" and six rated it as "extremely helpful."

When asked about which topics they would want additional information, four selected stress

management, three selected device information, and two selected family relationships.

Post-Hoc Analyses

The following section addresses additional interesting findings and post-hoc analyses that

were conducted after the initial planned statistical analyses. Due to the addendum nature of these

analyses, caution should be utilized in interpreting this data.









Effects on New Recipients versus Previous Recipients

The original intent of the study was to include only new recipients of ICDs. As noted

earlier, recruitment difficulties resulted in new and previous recipients being enrolled in the

study simultaneously. A post-hoc analysis was conducted to search for possible differences in

scores between new and previous ICD patients, with length of time since implant being

dichotomized according to whether or not someone was a very recent recipient (e.g., < 3

months). Zero-order correlations revealed an association between dichotomized length of time

and improvement in knowledge score, device acceptance at follow-up, and shock anxiety at

follow-up. New ICD recipients had a mean change in knowledge score from baseline to follow-

up of 4.14 points (S.D. = 3.98), while previous recipients had a mean change score of less than 1

point (M 0.71, S.D. = 2.79); this difference was statistically significant (t = 2.64,p = 0.01).

Improvement in knowledge was dichotomized by whether or not an individual's score increased

from baseline to follow-up. Being a new recipient was associated with improved knowledge

scores (r = 0.50, p = 0.01), but lower device acceptance (r = 0.38, p = 0.04) and greater shock

anxiety at follow-up (r = 0.42, p = 0.02). A chi-square analysis indicated that new recipients

were significantly more likely to have improved knowledge at one month (2 = 7.04, p = 0.01),

accounting for 73% of the cases of improved knowledge scores. There were no differences by

treatment condition among the new recipients (p > 0.50).

Although at baseline new recipients differed from previous ones on nearly all

psychological measures, a MANOVA examining QOL, shock anxiety, and device acceptance

was employed because these were the only follow-up variables correlated with being a new

recipient. Further, at follow-up, the only variables that differed between new and previous

recipients were device acceptance and shock anxiety, with new patients having worse scores on

both measures. The overall model failed to reach significance (Pillai's Trace = 1.56, p = 0.22,









partial 2 = 0.21). Although the omnibus F was not significant, tests of between-subjects effects

were examined in order to inform possible directions for future research. These separate

ANOVAs revealed significant results for the dependent variables device acceptance (F = 4.35, p

= 0.04) and shock anxiety (F = 5.65, p = 0.02), with new recipients demonstrating lower scores

of device acceptance and greater scores of shock anxiety at follow-up than previous ICD

recipients.

Effects of Knowledge on Quality of Life

Two of the a priori analyses in this study examined knowledge as a potential predictor in

device acceptance and anxiety. Post-hoc, the relationship between knowledge and QOL was

examined. In this analysis, a hierarchical regression was employed to examine whether

knowledge at follow-up predicted mental QOL at follow-up among all participants. In the first

block, demographic variables related to knowledge acquisition (e.g., age and education level)

were entered. In the second block, medical variables (e.g., ejection fraction and length of time

since implant) were entered. In the third block, knowledge score at one month was entered. The

full model was not significant (F = 2.10, p = 0.11) and accounted for 26% of the variance in

mental QOL at follow-up (Adj R = 0.14). However, the knowledge change score significantly

accounted for an additional 13% of variance in device acceptance (F-Change = 4.03, p = 0.05)

beyond demographic and medical variables. Age (/ = 0.39, p = 0.04) and knowledge at follow-

up (/3 0.37, p = 0.05) were both significant independent predictors of mental QOL at follow-

up. When examined separately by treatment condition, both regression analyses failed to meet

significance. Further, when the same model was examined using physical QOL as the criterion,

all analyses failed to meet significance.












Table 4-1. Social and demographic variables by treatment condition
Treatment Control
Characteristics ndtin Conition Test statistic p-value
Condition Condition

Male = 62% Male = 56%
Gender Female = 38% Female = 44% 2 = 1.61 p = 0.69
56.05 58.72
Mean age (SD = 15.11) (SD = 12.10) t(1, 37) =-0.60 p= 0.55

Ethnicity2 = 3.82 p = 0.15
White 81% 100%
Black 14% 0%

Marital status = 3.78 p = 0.44
Single, never
10% 0%
married
Separated, 10 0
divorced
Widowed 5% 11%
Married/remarried 62% 56%
Living with partner 10% 11%

Education 2 = 5.88 p = 0.55
High school degree 43% 33
or less
College degree or
48% 50%
some college
Graduate 10% 6%

Employment 2 = 0.84 p = 0.93
Retired 43% 39%
Disability/ 33 28
government
Part time 10% 11%
Full time 10% 6%
Unemployed 5% 11%

Income (annual) 2 = 4.52 p = 0.61
Less than $30,000 10% 17%
$30,000-$60,000 33% 33%
More than $60,000 33% 11%










Table 4-2. Psychological variables at baseline, by treatment condition


Measure


Treatment
Condition


Control
Condition


Test statistic


p-value


M= 18.30 M= 17.76
ICD Knowledge (S.D. = 3.60) (S.D. = 3.09) F = 0.23 p > 0.50
M= 34.93 M= 33.76
STAI (S.D. = 9.80) (S.D. = 7.22) F = 0.00 p > 0.50
M= 14.80 M= 16.17
FSAS (S.D. = 5.98) (S.D. = 7.76) F 0.31 p > 0.50
FPAS
Return to Life M = 53.75 M = 62.87
Scale (S.D. = 20.16) (S.D. = 25.62) F 1.23 p = 0.28
M= 11.67 M= 14.70
Body Image Scale
(S.D. = 20.30) (S.D. = 18.87) F 0.19 p > 0.50
Device Related M = 20.31 M = 16.56
Distress Scale (S.D. = 19.36) (S.D. = 18.59) F =.31 p > 0.50
Positive Appraisal M = 87.50 M = 86.02
Scale (S.D. = 16.08) (S.D. = 18.69) F = 0.05 p > 0.50
M = 76.19 M= 79.22
Total Score
(S.D. = 15.25) (S.D. = 18.34) F = 0.24 p > 0.50

SF-12
Metl M = 52.31 M= 51.39
(S.D. = 8.71) (S.D. = 11.67) F = 0.06 p > 0.50
Physical OL M= 32.34 M= 35.00
(S.D. = 10.60) (S.D. = 10.15) F =0.53 p 0.47

M= 59.07 M= 58.16
LVD-36 (S.D. = 30.14) (S.D. = 27.86) F = 0.03 p > 0.50









Table 4-3. Baseline Psychological Variables of New and Previous
Recipients
Mean SD F Sig.
ICD Knowledge 0.72 0.40
New 17.29 2.93
Previous 10.93 30.62
Trait Anxiety 4.09 0.05
New 36.52 8.74
Previous 30.80 7.04
Mental QOL 14.4 0.00
New 46.42 10.19
Previous 57.93 6.15
Physical QOL 6.41 0.01
New 29.76 9.52
Previous 38.27 9.44
Device Acceptance 6.89 0.01
Total Score
New 70.88 18.23
Previous 84.66 9.536
Device Acceptance: 2.53 0.12
Return To Life Scale
New 52.57 24.71
Previous 65.41 20.30
Device Acceptance:
Device-Related 6.76 0.01
Distress Scale
New 25.88 21.45
Previous 10.00 10.52
Device Acceptance:
Positive Appraisal 4.22 0.04
Scale
New 80.51 18.99
Previous 92.50 12.98
Device Acceptance:
Body Image 4.71 0.03
Concern Scale
New 19.85 22.56
Previous 5.83 11.44
FSAS Total Score 4.33 0.04
New 17.82 8.33
Previous 12.93 5.58
LVD Total Score 19.50 0.00
New 41.99 26.25
Previous 76.48 15.91













Table 4-4. Independent predictors
Unstandardized
Coefficients


(Constant)


B
2.936


Age .032
Highest grade .203
completed
Ejection .023
Fraction
How long had
.002
ICD? (months)
Change in
score from pre .171
e to post


Std. Error
1.799
.014
.098

.019

.008


.058


of device acceptance at follow-up, among treatment participants
Standardized
Coefficients t Sig. Correlations


Zero-
order


Beta

.498
.461

.266

.065


.642


1.632
2.285
2.067

1.207

.263


2.952


.137
.048
.069

.258

.798


.016


.253
.484

.146

.182


.448


Partial Part


.606
.567


.426
.385


.550











Table 4-5. Post-intervention psychological variables from the PACER
Study and the in-person study.


Physical QOL


Mental QOL


Trait Anxiety


FPAS Total


Study
PACER
In-person

PACER
In-person

PACER
In-person

PACER
In-person


M
36.35
44.85

55.14
55.25


SD
7.96
8.74

7.38
5.49


36.25 11.60
30.67 5.90


78.23
83.43


15.93
11.12


p < 0.01


ns












Table 4-6. User Survey of PACER Program


Number of times
program accessed

Number of minutes
spent viewing program

When should PACER
be given?
Following implant
Following clinic visit


How easy would you
rate the program?
Moderately Easy
Easy


1.77
times

28.69
minutes



83%
17%


46%
31%


Excellent 23%


How beneficial was the
program?
Somewhat beneficial
Very beneficial


54%
46%


What areas of the
program were most
beneficial?

Stress Management
Shock Management
Device Information
Family Relationships
Other

Would you recommend
this program to other
ICD recipients?


What areas of the
program would you
like more information?
Stress Management
Device Information

Family Relationships
Other


31%
15%

39%
8%
8%


Yes 100%


40%
30%

20%
10%


I









CHAPTER 5
DISCUSSION

The primary findings from this pilot study of a computerized psychoeducation program for

ICD recipients were as follows: 1) Increases in device-related knowledge were predictive of

better device acceptance, but only among treatment patients; and 2) treatment participants using

the PACER program demonstrated comparable improvements in mental QOL and device

acceptance, significantly lower scores of physical QOL, and a trend toward higher trait anxiety

post-treatment, as compared to individuals in an in-person intervention.

Acquisition of Knowledge Between Groups

There was no identifiable difference between treatment groups in learning, as measured by

the ICD Knowledge Questionnaire. It may be that patients in the control condition sought

information on their own, or that much of the information in the program overlapped with

information all patients received from their healthcare providers or other resources encountered

during routine care. The PACER program is considered a psychoeducation tool because it

provides not only descriptive facts about the device and its functioning, it also relays

psychological techniques for returning to full activities. Because these are more complex

concepts, it may be that treatment participants failed to learn more due to lack of human

interaction to explain, teach, demonstrate, and answer questions.

A recent meta-analysis of online CBT programs for depression and anxiety (Spek, et al.,

2007) suggested that treatment effects may be strongly influenced by whether or not an

intervention is supplemented with minimal therapist involvement. The authors defined minimal

involvement as being brief, supportive, and facilitative, such as answering questions about using

the intervention or providing brief reinforcement for using the material. They did not include

studies that utilized clinician involvement that would be considered more traditional and









analogous to in-person therapy. Among 12 randomized-controlled studies, the authors found a

mean effect size of 0.24 for all studies examined. When analyzed by design characteristics, they

found a significantly smaller effect size for studies without clinician involvement (d = 0.24) than

for studies that provided therapist assistance (d = 1.00). It is hypothesized that treatment patients

in the current study may have failed to demonstrate a quantifiable difference in learning score

due to lack of therapist support. Previous participants (Carlbring, Ekselius, & Andersson, 2003)

have reported that while at-home, self-guided treatments are convenient, they require more self-

discipline in adhering to assignments and attending to information. They also note that a group

setting in which patients could discuss content and concerns with one another may enhance

motivation (Carlbring et al., 2003). Supplementing the PACER program with brief support, such

as random phone calls to inquire about participant questions and to provide positive feedback,

may be an easy and effective way to optimize the effects of the intervention.

Qualitatively, there was overwhelming support of the PACER program from treatment

participants. All recipients noted that they thought the program was worth recommending to

others, and described it as being beneficial. Research from Shea (2004) and others (Steinke et al.,

2005) reveal that patients often require additional education about sexual activity, driving, and

managing device shock. In this sample, treatment patients reported benefiting from and desiring

more information about stress management and about the device in general (e.g., non-shock

related information, post-implant adjustment). Because of its aversive nature, it is somewhat

surprising that more participants did not endorse needing and benefiting from information related

to device shock. While education about firings, such as making a shock plan, is arguably

important and necessary for patient adjustment and good QOL (Sears & Conti, 2003), healthcare

providers should not overlook the importance of other domains. In particular, participant









feedback about the importance of stress management speaks to the necessity of psychological

assistance as an integral part of comprehensive care in this population. User ratings from this

sample suggest that there is an audience for further testing of computerized programs in the ICD

population, which may help clarify how and in what ways these patients understand and process

information about their device.

Relationship of Knowledge to Device Acceptance

As stated previously, treatment participants in this study did not demonstrate a quantifiable

change in aggregate knowledge compared to usual care patients. However, the fact that they

demonstrated improvements in device acceptance relative to gains in knowledge, whereas

control participants did not exhibit this pattern, is important. It may be that while the intervention

did not substantially increase the amount of information learned, the intervention was effective at

increasing acceptance without increasing knowledge differentially. Similarly, psychological

treatments target change in adjustment, and not didactic knowledge. Therefore, the PACER

program, though psycho-educational in content, may be more analogous to a therapeutic tool

rather than an educational one. This may also somewhat account for post-hoc findings of

improved mental QOL among PACER patients, but not physical QOL.

Control patients had access to public information resources, such as the Internet, which

could help them increase their ICD-related knowledge. They also likely could acquire through

public resources generalized, simplified concepts of CBT, such as engaging in pleasant activities

and developing a positive outlook to reduce stress. However, what PACER provides, that the

control patients likely would not discover on their own, is a structured, specific application of

empirical techniques to the unique stressors faced by this population. For example, the

intervention does not generically teach cognitive reframing. Rather, it explains how negative

cognitions about the ICD impact one's physical and emotional functioning, and provides









examples regarding device shock and avoidance activities to aid patients in using CBT in such a

way to increase their understanding and acceptance of the device. This reflects the core of what

the FPAS measures, and thus, it is reasonable that such an intervention if effective would

yield improvement in this domain. Despite this, without a control group exposed to similar

content of information minus the CBT modules, it is difficult to attribute effects solely to the

psychological material.

The ecological validity implied by this finding should not be minimized. An increase in a

test score alone would likely hold little practical meaning to a patient. If, however, learning

something new about their device allows ICD patients to ultimately feel more comfortable and

confident, then the quantity of information learned becomes less salient. To say that the PACER

intervention was developed to help ICD patients become more educated about their does not

fully capture the purpose its design. The goal of the program was not merely to serve as a

didactic tool, but to ultimately provide psychological benefit in adjustment and outlook. If this is

occurs, even without significantly increasing patients' knowledge base, than it should be

considered a success. Further, the additional benefits of low cost and high convenience increase

PACER's utility and importance.

Knowledge and Anxiety

In this sample, there was no relationship between gains in knowledge and trait or shock

anxiety. Anxiety tends to be cognitive in nature, and can be deeply engrained and resistant to

change. Self-directed treatments that are entirely computer-based may have difficulty reducing

anxiety for these reasons. Self-directed programs to treat anxiety disorders, including panic

disorder and phobias, may be successfully conducted via computer (Barlow, et al., 2005).

However, effective programs have typically included structured homework assignments and

exposure techniques. Some researchers (Kenwright & Marks, 2004; Schneider, Mataix-Cols,









Marks, & Bachofen, 2005) have supplemented their computerized interventions with brief

clinician contact by telephone. In their pilot study on panic and phobias, Kenwright, Liness, and

Marks (2001) required participants to utilize a computer treatment in the presence of a nurse,

who was available to answer questions and review content from previous sessions. Other

researchers (Carlbring, Ekselius, & Andersson, 2003) used brief contact by both telephone and

email to remind patients about skills (e.g., reminders to engage in relaxation), review homework

assignments, and answer questions. Marks and colleagues (2004) found that a computerized

program for anxiety that utilized minimal clinician contact demonstrated comparable effect sizes

for treatment outcomes versus an in-person CBT group, yet managed to reduce clinician time

per-patient by 73%. Therefore, the brief addition of human interaction to a self-guided, at-home

program such as PACER may effectively treat anxiety, while still reducing provider workload

and treatment burden.

Controllability (or lack thereof) has been identified as an influential factor in the

development and persistence of clinical anxiety (Moulding & Kyrios, 2006), such as OCD. In

these populations, successful therapeutic interventions utilize role playing, behavioral

modification, relaxation, and Socratic questioning (Moulding & Kyrios). While computerized

interventions have been able to significantly improve functional and psychosocial outcomes in

OCD patients (Mataix-Cols & Marks, 2006), these studies still integrated human interaction to

some degree. Although the current study did not examine OCD, these comparisons may be

valuable because controllability is very pertinent to ICD patients. Researchers (Sears & Conti,

2003) have hypothesized that the uncontrollable, unpredictable nature of ICD firings may be

largely responsible for the development of psychiatric distress in shocked patients, via learned

helplessness (Goodman & Hess, 1999) or negative cognitions (Pauli et al., 1991, 2001). It may









be that factors such as negative appraisals and lack of controllability are more difficult to address

in the absence of therapist support, and do not necessarily remit as a result of having increased

one's knowledge about the ICD.

Computerized versus In-Person Treatments

One unique aspect of the current project is that, to date, no published study has compared

in-person and computerized psychoeducation interventions for ICD recipients. The PACER

program demonstrated comparable improvements in mental QOL and device acceptance as an

in-person intervention. However, the in-person group reported better physical QOL and less trait

anxiety than PACER patients, despite the fact that they were drawn from a sample of patients

who had experienced device shock.

The in-person treatment examined in the present study used a multi-visit protocol in which

patients had the opportunity to repeatedly discuss previous topics and were reminded of concepts

taught in prior sessions. Homework assignments allowed participants to individually apply

concepts to their own adjustment difficulties, and they were encouraged to discuss these findings

in subsequent sessions. Conversely, the PACER program is entirely self-directed. Patients can

choose to use the program as little or as frequently as they wish, and may involve themselves in

the topic matter to whatever degree they feel necessary. Attending group treatments may reduce

perceptions of self-burden, as the presence of both the healthcare provider and other attendants

provides opportunities for learning that do not directly require the patient to remain actively

involved throughout. Future research with the PACER Program should consider a more

equivalent approach to the in-person treatment, such that group effects can be accounted for

(e.g., including a moderated chat room).









New versus Established ICD Recipients

Although post-hoc analyses should not be used to draw definitive conclusions, the results

from current analyses comparing new recipients to previous recipients are revealing. Regarding

future research, these data may be valuable in informing clinicians about which patients may

benefit the most from education interventions. Patients typically do receive some education

about their device prior to implant, but they may nevertheless feel uninformed and require

greater information from providers about topics such as sexual concerns, device shock, driving,

and working (Steinke et al., 2005; Shea, 2004). Analyses from the current sample imply that

providing information sooner rather than later could give patients an added advantage in

optimizing their adjustment to the ICD.

New recipients demonstrated worse scores of psychological functioning on nearly every

measure, compared to previous recipients, suggesting that they may be an appropriate target for

psychotherapeutic treatment. Interestingly, they also demonstrated better scores of cardiac-

specific QOL via a measure of symptom assessment. Given that ICDs are being increasingly

implanted prophylacticly, before patients exhibit severe symptoms, this might account for why

newer patients endorsed fewer symptoms, thus improving their score on this measure. Despite

their increase in learning, new patients were also more likely to report less device acceptance and

greater shock-related anxiety at follow-up. This finding supports the utility of psychological

referral for new patients perhaps even prior to implant and not simply disseminating

literature as a means of addressing patient concerns. Understandably, information regarding the

ICD may be overwhelming and anxiety-provoking to some patients. Involving psychological

professionals in the education of ICD recipients may help them better comprehend and apply

information given. In some patients, psychiatric distress (e.g., panic disorder, phobias) may be

less tractable, and education interventions will not be sufficient. Again, by keeping psychological









professionals involved at the onset of implantation, patients will have greater access to care,

which increases their chances of treatment adherence and satisfaction.

Limitations

Results from this pilot study of the PACER program are somewhat encouraging. However,

they should be considered in light of some study limitations. Notably, small sample size is

problematic for numerous reasons, including low statistical power, lack of generalizability, and

poor representation of the ICD population as a whole. Cross-sectional data may be useful for

quickly acquiring a point-in-time view of a sample, but can mask effects of time and limits one's

ability to make causal interpretations. As such, longitudinal collection is necessary to fully

appreciate the short- and long-term effects of the treatment at hand. Given that this study was

designed as a feasibility program, conclusive generalizations cannot be made from these data

alone. Rather, this study may be used as a springboard for broader, more sophisticated protocols

designed to test in-depth the effectiveness of PACER for ICD patients.

The fact that the sample consisted of both new and previous recipients makes drawing

conclusions about knowledge and learning more difficult. Although post-hoc analyses attempted

to parse out effects based on time of implant, a sample composed entirely of new recipients

would help alleviate this problem to some degree. Simply by having had the device longer,

previous recipients are exposed to practice effects of living with and adjusting to the ICD. This is

relevant for both greater opportunities to learn and accept the device, but also greater

opportunities to experience difficulties and struggle with the device. Therefore, the relevance and

usefulness of the intervention may not be consistent across both types of patients.

Other potential barriers include the fact the sample was drawn from a single site and

therefore likely reflects a sampling bias, and heavily relied on self-report measures, which are

influenced by demand-characteristics and may not accurately reflect patient functioning. In









particular, use of the PACER program was not monitored and thus effects cannot be interpreted

in light of factors such as length of time spent using the techniques taught (e.g., relaxed

breathing).









CHAPTER 6
FUTURE WORK

There is more research being conducted on computerized psychological interventions at

this time than at any time before. Data supporting the development of these novel programs is

exciting and helps to enrich the healthcare profession as a whole. The current study contributes

to this body of research in several ways: One, it is among few computerized interventions

intended for cardiac patients to optimize their adjustment to illness; two, there are currently no

published computerized interventions for ICD patients specifically; and three, there are currently

no published interventions comparing computerized psychosocial treatments to in-person

treatments for either cardiac patients or ICD patients specifically.

In this sample, knowledge gained from the PACER program was associated with

improved device acceptance. Further, the program produced comparable improvements in mental

QOL and device acceptance as an in-person psychosocial CBT treatment for shocked patients.

Patients who used the program reported feeling very satisfied with its content and level of ease,

and overwhelming supported its recommendation to other recipients. Taken together, these

outcomes support future testing of PACER and similar programs in this unique population. Lack

of findings in aggregate knowledge and anxiety are informative for future program development.

Subsequent trials of PACER can easily be supplemented with limited therapist assistance, which

may substantially improve some of the null outcomes demonstrated by this sample.

Post-hoc analyses lend further support to the integration of psychological care with

standard clinical care in this population. In this sample, new recipients predominantly accounted

for patients who demonstrated an improvement in learning. Given that participants reported

benefiting from and wanting more information about stress management, this suggests that

involving psychologists at the onset of device implantation may be an effective way of









addressing educational and psychological needs concurrently. The current study, though,

provides an interesting starting point for such research and upholds the importance of increasing

our understanding in this area.

In sum, findings from this study lend support for further use of computerized psychosocial

interventions for ICD patients. The PACER program showed promising results in improving

mental QOL and device acceptance, relative to an in-person group, and minor changes in design

methodology may further strengthen PACER's ability to maximize patient outcomes in future

trials.









APPENDIX
MEASURES

FPAS

We want to understand what it is like for you to live with a medical device. Below are
some statements that describe living with a medical device. Please rate the extent to
which you agree or disagree with each of the following statements by circling the
appropriate response.
Strongly Mostly Neither Mostly Strongly
Disagree Disagree Agree or Agree Agree
Disagree
1. Thinking about the device makes me
depressed. 1 2 3 4 5
2. When I think about the device I avoid doing
things I enjoy. 1 2 3 4 5
3. I avoid my usual activities because I feel
disfigured by my device. 1 2 3 4 5
4. It is hard for me to function without thinking
about my device. 1 2 3 4 5
5. My device was my best treatment option. 1 2 3 4 5
6. I am confident about my ability to return to
work if I want to. 1 2 3 4 5
7. I am safer from harm because of my device. 1 2 3 4 5
8. The positive benefits of this device out-
weigh the negatives. 1 2 3 4 5
9. I have continued my normal sex life. 1 2 3 4 5
10. I would receive this device again. 1 2 3 4 5
11. I know enough about my device. 1 2 3 4 5
12. I am careful when hugging or kissing my
loved ones. 1 2 3 4 5
13. I have returned to a full life. 1 2 3 4 5
14. I feel that others see me as disfigured by my
device. 1 2 3 4 5
15. I feel less attractive because of my device. 1 2 3 4 5
16. I am knowledgeable about how the device
works and what it does for me. 1 2 3 4 5
17. I am not able to do things for my family the
way I used to. 1 2 3 4 5









18. I am concerned about resuming my daily
physical activities. 1 2 3 4

LVD-36

Please answer the following questions as you are feeling these days. Circle either true or false
for each question. If you do these activitiesfor any reason other than your heart condition, then
please mark false.


Because of my heart condition: True False

1. I suffer with tired legs T F

2. I suffer with nausea (feeling sick) T F

3. I suffer with swollen legs T F

4. I am afraid that if I go out I will be short of breath T F

5. I am frightened to do too much in case I become short
of breath T F

6. I get out of breath with the least physical exercise T F

7. I am frightened to push myself to go to far T F

8. I take a long time to get washed or dressed T F

9. I have difficulty running, such as for a bus T F

10. I have difficulty either jogging, exercising or dancing T F

11. I have difficulty playing with children/grandchildren T F

12. I have difficulty either mowing the lawn or
hovering/vacuum cleaning T F

13. I feel exhausted T F

14. I feel low in energy T

15. I feel sleepy or drowsy T F

16. I need to rest more T F

17. I feel that everything is an effort T F










18. My muscles feel weak T F

19. I get cold easily T F

Because of my heart condition: True False

20. I wake up frequently during the night T F

21. I have become frail or an invalid T F

22. I feel frustrated T F

23. I feel nervous T F

24. I feel irritable T F

25. I feel restless T F

26. I feel out of control of my life T F

27. I feel that I can not enjoy a full life T F

28. I've lost confidence in myself T F

29. I have difficulty having a regular social life T F

30. There are places I would like to go to but can't T F

31. I worry that going on holiday could make my heart
condition worse T F

32. I have had to alter my lifestyle T F

33. I am restricted in fulfilling my family duties T F

34. I feel dependent on others T F

35. I feel it is a real nuisance having to take tablets for my
heart condition T F

36. My heart condition stops me doing things that I would
like to do T F









SF-12 HEALTH SURVEY
INSTRUCTIONS: This questionnaire asks for your views about your health. This information
will help keep track of how you feel and how well you are able to do your usual activities.

1. In general, would you say your health is:


Excellent


Very good


Good


Fair


Poor


The following items are about activities you might do during a typical day. Does your health
now limit you in these activities? If so, how much?


Yes,
Limited
A lot


Yes,
Limited
A little


No, Not
Limited
At All


2. Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or playing golf

3. Climbing several flights of stairs


During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health?


YES


4. Accomplished less than you would like


NO

3


5. Were limited in the kind of work or other activities










During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)?


YES


6. Accomplished less than you would like


NO

3


7. Didn't do work or other activities as carefully as usual


8. During the past 4 weeks, how much did pain interfere with your normal work (including both
work outside the home and housework)?


A little bit Moderately


Quite a bit


Extremely


These questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give the one answer that comes closest to the way you have
been feeling. How much of the time during the past 4 weeks -


All
of the
Time


9. Have you felt calm and
peaceful?

10. Did you have a lot of
energy?

11. Have you felt downhearted
and blue?


Most
of the
Time

3



3



3


A Good
Bit of
the Time

3



3



3


Some
of the
Time

3



3



3


A Little
of the
Time

3



3



3


Not at all


None
of the
Time

3



3



3









12. During the past 4 weeks, how much of the time has your physical health or emotional health
problems interfered with your social activities (like visiting with friends, relatives, etc.)?


All of the time


Most of the time


Some of the time A little of the time None


SAS (Shock Anxiety Scale)


I am scared to exercise because it may increase my heart rate and cause my device to
fire.


1 2 3 4
Not at all Rarely Some of the time Most of the time

I am afraid of being alone when the ICD fires and I need help.
1 2 3 4
Not at all Rarely Some of the time Most of the time

I do not get angry or upset because it may cause my ICD to fire.
1 2 3 4
Not at all Rarely Some of the time Most of the time

It bothers me that I do not know when the ICD will fire.
1 2 3 4
Not at all Rarely Some of the time Most of the time

I worry about the ICD not firing sometime when it should.
1 2 3 4
Not at all Rarely Some of the time Most of the time

I am afraid to touch others for fear I'll shock them if the ICD fires.
1 2 3 4
Not at all Rarely Some of the time Most of the time

I worry about the ICD firing and creating a scene.
1 2 3 4


Not at all


Rarely


Some of the time


Most of the time


When I notice my heart beating rapidly, I worry that the ICD will fire.
1 2 3 4
Not at all Rarely Some of the time Most of the time

I have unwanted thoughts of my ICD firing.
1 2 3 4
Not at all Rarely Some of the time Most of the time


5
All the time


5
All the time


5
All the time


5
All the time


5
All the time


5
All the time


5
All the time

5
All the time


5
All the time











I do not engage in sexual activities because it may cause my ICD to fire.
1 2 3 4 5
Not at all Rarely Some of the time Most of the time All the time


Self-Evaluation Questionnaire
STAI Form Y-2

A number of statements which people have used to describe themselves are given below. Read
each statement and then circle the appropriate number to the right of the statement to indicate
how you generally feel.


1. I feel pleasant.
2. I feel nervous and restless.
3. I feel satisfied with myself.
4. I wish I could be as happy as others seem to be.
5. I feel like a failure.
6. I feel rested.
7. I am "calm, cool, and collected."
8. I feel that difficulties are piling up so that I
cannot overcome them.
9. I worry too much over something that really
doesn't matter.
10. I am happy.
11. I have disturbing thoughts.
12. I lack self-confidence.
13. I feel secure.
14. I make decisions easily.
15. I feel inadequate.
16. I am content.
17. Some unimportant thought runs through my
mind and bothers me.
18. I take disappointments so keenly that I can't put
them out of my mind.


Almost
never
1
1
1
1
1
1
1


1


1
1
1
1
1
1
1
1


1


1


Some-
times
2
2
2
2
2
2
2


Often Almost
Always
3 4
3 4
3 4
3 4
3 4
3 4
3 4









19. Iam a steady person. 1 2 3 4
20. I get in a state of tension or turmoil as I think
over my recent concerns and interests. 1 2 3 4




The Florida ICD Knowledge Questionnaire

Education About Your Heart, ICD, and Shocks

1. What does ICD stand for?
1. Internal cardiac device
2. Implanted cardioverter device
3. Implantable cardioverter defibrillator
4. Internal cardiac defibrillator


2. True or False: Approximately one-third of all ICD patients will experience distress, such
as depression or anxiety?
1. True
2. False


3. The ICD's main function is to
1. Remind you of heart disease
2. Prevent cardiac arrest
3. Let you know when to go to the hospital
4. Keep you awake


Managing Stress Before Stress Manages You

4. Which of the following is not a healthy way to reduce stress?
1. Deep breathing
2. Worrying about your health
3. Changing thinking patterns
4. Exercising

5. Good coping skills include
1. Managing your attitude
2. Having a drink
3. Eatingjunk food
4. Watching television

6. How many ICD patients feel stress within the first month after the implantation of their
device?









1. Afew
2. Most
3. None
4. All

7. What percent of ICD patients report having the same or better quality of life after one
year?
1. 15%
2. 42%
3. 60%
4. 85%

8. Most patients report that their emotional well-being is it was before
receiving an ICD.
1. Worse than
2. Different from
3. Better or about the same as
4. No different from

9. The top 10 challenges faced by ICD patients include all except:
1. Socializing with friends
2. Sexual concerns
3. Generalized fear
4. Stress management


Your Outlook Can Make the Difference

10. Which of the following thinking patterns results from exaggerating the negative impact
of an event to the highest extent?
1. Catastrophizing
2. All-or-Nothing
3. Blaming
4. All of these

11. Which thought pattern can be addressed by realizing that life is a balance of both good
and bad elements?
1. Catastrophizing
2. All-or-Nothing
3. Blaming
4. None of these

12. Which of the following thought patterns often develops into anger or resentment
directed at others?
1. Catastrophizing
2. All-or-Nothing









3. Blaming
4. None of these



13. The term "sickness scoreboard" refers to
1. Keeping score of your condition and counting shocks
2. Comparing your shocks to others' shocks
3. Seeing if you have more symptoms than your friends
4. None of these

14. The problem with the "sickness scoreboard" approach is that
1. It makes you sicker
2. It annoys your spouse
3. It is not accurate because shocks do not serve as health
indicators
4. There are no problems with it

15. True or False: Receiving more shocks means you are getting sicker?
1. True
2. False


16. True or False: Research shows that having a positive attitude can affect how you
react to illness and medical procedures?
1. True
2. False


Take Control By Taking Action

17. Which of the following activities should you avoid solely because of your ICD?
1. Being in a crowd
2. Sex
3. Having an argument
4. None of these

18. True or False: Certain everyday activities have been known to trigger shock?
1. True
2. False

19. Good coping skills include
1. Improving your sleep
2. Having a drink
3. Eating junk food
4. Watching television












A Family Affair

20. Family relationships can be improved by:
1. Providing praise to you loved one in front of others
2. Giving your time and attention to loved ones
3. Letting loved ones know their support is helping you
4. All of these

21. True or False: ICD patients should avoid sex because the increased heart rate caused by
sex could trigger a shock?
1. True
2. False

22. True or False: Sex is especially straining on the heart?
1. True
2. False

23. The best predictor of a couple's satisfaction with their sex life is
1. How frequently they have sex
2. How healthy both partners are
3. How comfortable they are discussing their sexual relationship
4. Their age


Planning For and Coping With Shocks

24. Your ICD shock plan should include all of the following parts except:
1. Preparing for shock
2. Actions immediately following shock
3. Along-term plan
4. Fearing shock

25. True or False: If someone is touching you when you receive a shock, they will be
hurt?
1. True
2. False


26. Which of the following can interfere with the functioning of your ICD?
1. Microwaves
2. Irons
3. Televisions
4. None of these









LIST OF REFERENCES


Agre, P., Dougherty, J., & Pirone, J. (2002). Creating a CD-ROM program for cancer-related
patient education. Oncology Nursing Forum, 29, 573-580.

American Heart Association. Heart Disease and Stroke Statistics-2004 Update. Dallas, TX:
American Heart Association, 2004.

Atkinson, N.L., & Gold, R.S. (2002). The promise and challenge of eHealth interventions.
American Journal of Health Behaviors, 26, 494-503.

AVID Investigators. (1997). A comparison of antiarrhythmic-drug therapy with implantable
defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. New
England Journal of Medicine, 337, 1576-1583.

Barlow, J.H., Ellard, D.R., Hainesworth, J.M., Jones, F.R., & Fisher, A. (2005). A review of self-
management interventions for panic disorders, phobias, and obsessive-ocmpulsive
disorders. Acta Psychiatry Scandinavia, 111, 272-285.

Brug, J., Oenema, A., & Campbell, M. (2003). Past, present, and future of computer-tailored
nutrition education. American Journal of Clinical Nutrition, 77, 1028S-1034S.

Burns, J.L., Serber, E.R., Keim, S., & Sears, S.F. (2005). Measuring patient acceptance of
implantable cardiac device therapy: Initial psychometric investigation of the Florida
patient acceptance survey (F-PAS). Journal of Cardiovascular Electrophysiology, In
press.

Buxton, A.E., Lee, K.L., Fisher, J.D., Josephson, M.E., Prystowsky, E.N., Hafley, G., et al., for
the Multicenter Unsustained Tachycardia Trial Investigators. (1999). A randomized study
of the prevention of sudden death in patients with coronary heart disease. New England
Journal of Medicine, 341, 1882-1890.

Carlbring, P., Ekselius, L., & Andersson, G. (2003). Treatment of panic disorder via the Internet:
A randomized trial of CBT vs. applied relaxation. Journal of Behavioral Therapy and
Experimental Psychiatry, 34, 129-140.

Cavanagh, K., & Shapiro, D. (2004). Computer treatment for common mental health problems.
Journal of Clinical Psychology, 60, 239-251.

Christensen, H., Griffiths, K.M., & Korten, A. (2002). Web-based cognitive behavior therapy:
Analysis of site usage and changes in depression and anxiety scores. Journal of Medical
Internet Research, 4, e3.

Cleary P. (1999). The increasing importance of patient surveys. British Medical Journal, 319,
720-721.









Cohen, J. (1988). Statistical Power Analysisfor the Behavioral Sciences, 2nd edition. Lawrence
Erlbaum Associates: Hillsdale, NJ.

Cohen, J. (1992). The Power Primer. Psychology Bulletin, 112, 155-159.

Connolly, S.J., Gent, M., Roberts, R.S., Dorian, P., Roy, D., Sheldon, R.S., et al. (2000).
Circulation Canadian implantable defibrillator study (CIDS): A randomized trial of the
implantable cardioverter defibrillator against amiodarone. Circulation, 101, 1297-302.

Cox, D.J., Borowitz, S.M., Kovatchev, B., & Ling, W. (1998). Contributions of behavior
therapy and biofeedback to laxative therapy in the treatment of pediatric encopresis.
Annals ofBehavioral Medicine, 20, 70-76.

Credner, S.C., Klingenheben, T., Mauss, O., Sticherling, C., & Hohnloser, S.H. (1998).
Electrical storm in patients with transvenous implantable cardioverter defibrillators.
Journal of the American College of Cardiology, 32, 1909-1915.

Delgado D.H., Costigan J., Wu R., & Ross H.J. (2003). An interactive Internet site for the
management of patients with congestive heart failure. Canadian Journal of Cardiology,
19, 1381-5.

Dew, M.A., Goycoolea, J.M., Harris, R.C., Lee, A., Zomak, R., Dunbar-Jacob, J., et al. (2004).
An internet-based intervention to improve psychosocial outcomes in heart transplant
recipients and family caregivers: development and evaluation. Journal ofHeart and Lung
Transplant, 23, 745-758.

Dickerson, S.S., Flaig, D.M., & Kennedy, M.C. (2000). Therapeutic connection: help seeking on
the Internet for persons with implantable cardioverter defibrillators. Heart and Lung, 29,
248-255.

Dunbar, S.B., Kimble, L.P., Jenkins, L.S., Hawthorne, M., Dudley, W., Slemmons, M., et al.
(1999). Association of mood disturbance and arrhythmia events in patients after
cardioverter defibrillator implantation. Depression and Anxiety, 9, 163-168.

Dusseldorp, E., van Elderen, T., Maes, S., Meulman, J., & Kraaij, V. (1999). A meta-analysis of
psychoeducation programs for coronary heart disease patients. Health Psychology, 18,
506-519.

Feil, E.G., Noell, J., Lichtenstein, E., Boles, S.M., & McKay, H.G. (2003). Evaluation of an
Internet-based smoking cessation program: Lessons learned from a pilot study. Nicotine
and Tobacco Research, 5, 189-194.

Frizelle, D.J., Lewin, R.J.P., Kaye, G., Hargreaves, C., Hasney, K., Beaumont, N., et al. (2004).
Cognitive-behavioural rehabilitation programme for patients with an implanted
cardioverter defibrillator: A pilot study. British Journal of Health Psychology, 9, 381-
392.










Gega, L., Marks, I., & Mataix-Cols, D. (2004). Computer-aided CBT self-help for anxiety and
depressive disorders: experience of a London clinic and future directions. Journal of
Clinical Psychology, 60, 147-157.

Glasgow, R.E., Boles, S.M., McKay, H.G., Feil, E.G., & Barrera, M., Jr. (2003). The D-Net
diabetes self-management program: long-term implementation, outcomes, and
generalization results. Preventive Medicine, 36, 410-419.

Godemann, F., Butter, C., Lampe, F., Linden, M., Schlegi. M., Schultheiss, H.P., et al. (2004).
Panic disorders and agoraphobia: Side effects of treatment with an implantable
cardioverter defibrillator. Clinical Cardiology, 27, 321-326.

Goodman, M., & Hess, B. Could implantable cardioverter defibrillators provide a human model
supporting the learned helplessness theory of depression? General Hospital Psychiatry,
21, 382-385.

Gordon, N.F. (2003). New methods of delivering secondary preventive services: The promise of
the Internet. Journal of Cardiopulmonary Rehabilitation, 23, 349-351.

Greenspan, R. (2002). Two-thirds hit the net [Online]. Retrieved October 15, 2003,

Greenspan, R. (2003). Surfing with seniors and boomers [Online]. Retrieved October 15, 2003,
from
http://cyberatlas.internet.com/big_picture/demographics/article/0,,5901_1573621,00.html

Haywood, C. (1995). Psychiatric Illness and cardiovascular disease risk. Epidemiology
Review, 17, 129-138.

Herrman, C., von zur Muhen, F., Schaumann, A., Buss, U., Kemper, S., Wantzen, C., et al.
(1997). Standardized assessment of psychological well-being and quality-of-life in
patients with implanted defibrillators. Pacing and Clinical Electrophysiology, 20, 95-
103.

Irvine, J., Dorian, P., Baker, B., O'Brien, B.J., Roberts, R., Gent, M., et al. (2002). Quality of
life in the Canadian Implantable Defibrillator Study. American Heart Journal, 144, 282-
289.

Januzzi, J.L., Stern, T.A., Pasternak, R.C., & DeSanctis, R.W. (2000). The influence of
anxiety and depression on outcomes of patients with coronary artery disease. Archives of
Internal Medicine, 160, 1913-1921.

Kamphuis, H.C., de Leeuw, J.R., Derksen, R., Hauer, R.N., & Winnubst, J.A. (2003).
Implantable cardioverter defibrillator recipients: quality of life in recipients with and
without ICD shock delivery: a prospective study. Europace, 5, 381-389.









Kenwright, M., Liness, S., & Marks, I. (2001). Reducing demands on clinicians by offering
computer-aided self-help for pobic/panic. A feasibility study. British Journal of
Psychiatry, 179, 456-459.

Kenwright, M., & Marks, I.M. (2004). Coputer-aided self-help for phobia/panic via internet at
home: A pilot study. British Journal ofPsychiatry, 184, 448-449.

Kohn, C.S., Petrucci, R.J., Soto, D.M., Baessler, C., & Movsowitz, C. (2000). The effect
of psychological intervention on patients' long-term adjustment to the ICD: A prospective
study. Pacing and Clinical Electrophysiology, 23, 450-456.

Kubzansky, L.D., Kawachi, I., Weiss, S.T., & Sparrow, D. (1998). Anxiety and coronary heart
disease: a synthesis of epidemiological, psychological, and experimental evidence.
Annals of Behavioral Medicine, 20, 47-58.

Kuck, K.H., Cappato, R., Siebels, J., & Ruppel, R., for the Cardiac Arrest Study Hamberg
Investigators. (2000). Randomized comparison of antiarrhythmic drug therapy with
implantable defibrillators in patients resuscitated from cardiac arrest. Circulation, 102,
748-754.

Lee, A., Chui, P.T., & Gin, T. (2003). Educating patients about anesthesia: A systematic review
of randomized controlled trials of media-based interventions. Ane\the ii & Analgesia,
96, 1424-1431.

Lemon, J., Edelman, S., & Kirkness, A. (2004). Avoidance behaviors in patients with
implantable cardivertoer defibrillators. Heart Lung, 33, 176-82.

Lenhart, A., Horrigan, J., Rainie, L., Allen, K., Boyce, A., Madden, M., et al. (2004). The ever-
shifting Internet population. A new look at Internet access and the digital divide. Pew
Internet Project Report. Available at: http://207.21.232.103/PPF/r/88/reportdisplay.asp
Accessed July 2, 2004.

Linden, W., Stossel, C., & Maurice, J. (1996). Psychosocial interventions for patients with
coronary artery disease. Archives ofInternal Medicine, 156, 745-752.

Luderitz, B., Jung, W., Deister, A., & Manz, M. (1996). Quality of life in multiprogrammable
implantable cardioverter-defibrillator recipients. In InterventionalElectrophysiology: A
Textbook (Eds. Saskena, S. & Luderitz, B.), p. 305-313. Armonk, N.Y.: Futura
Publishing Co., Inc.

Mataix-Cols, D., & Marks, I.M. (2006). Self-help with minimal therapist contact for obsessive-
compulsive disorder: A review. European Psychiatry, 21, 75-80.

Marks, I.M., Kenwright, M., McDonough, M., Whittaker M., & Mataix-Cols, D. (2004). Saving
clinicians' time by delegating routine aspects of therapy to a computer: A randomized
controlled trial in phobia/panic disorder. Psychology and Medicine, 34, 9-17.










McKinley, R., Manku-Scott, T., Hastings, A., French, D., & Baker, R. (1997). Reliability and
validity of a new measure of patient satisfaction with out of hours primary medical care
in the United Kingdom: Development of a patient questionnaire. British Medical
JournaL, 314, 193-198.

Mills, M.E., & Sullivan, K. (1999). The importance of information giving for patients newly
diagnosed with cancer: a review of the literature. Journal of Clinical Nursing, 8, 631-
641.

Moss, A. J., Hall, W. J., Cannom, D. S., Daubert, J. P., Higgins, S. L., Klien, H., et al., for the

Moulding, R., & Kyrios, M. (2006). Anxiety disorders and control related beliefs: The exemplar
of obsessive-compulsive disorder (OCD). Clinical Psychology Review, 26, 573-583.

Mullen, P.D., Mains, D.A., & Velez, R. (1992). A meta-analysis of controlled trials of cardiac
patient education. Patient Education and Counseling, 19, 143-162.

Multicenter Automatic Defibrillator Implantation Trial Investigators. (1996). Improved survival
with an implanted defibrillator in patients with coronary disease at high risk for
ventricular arrhythmia. New England Journal of Medicine, 335, 1933-1940.

Namerow, P.B., Firth, B.R., Heywood, G.M., Windle, J.R., & Parides, M.K. (1999). Quality of
life six months after CABG surgery in patients randomized to ICD versus no ICD
therapy: findings from the CABG Patch trial. Pacing and Clinical Electrophysiology, 22,
1305-1313.

Napolitano, M.A., Fotheringham, M., Tate, D., Sciamanna, C., Leslie, E., Owen, N. et al. (2003).
Evaluation of an Internet-based physical activity intervention: a preliminary
investigation. Annals ofBehavioral Medicine, 25, 92-99

O'Leary, C. J., & Jones, P. W. (2000). The left ventricular dysfunction questionnaire (LVD-36):
Reliability, validity, and responsiveness. Heart, 83, 634-640.

Pauli, P., Wiedemann, G., Dengler, W., Blaumann-Benninghoff, G., & Kuhlkemp, V. (1999).
Anxiety in patients with an automatic implantable cardioverter defibrillator: What
differentiates them from panic patients? Psychosomatic Medicine, 61, 69-76.

Pauli, P., Wiedemann, G., Dengler, W., & Kuhlkamp, V. (2001). A priori expectancy bias and its
relation to shock experience and anxiety: A naturalistic study in patients with an
automatic implantable cardioverter defibrillator. Journal of Behavioral Therapy and
Experimental Psychiatry, 32, 159-171.

Poroch D. (1995). The effect of preparatory patient education on the anxiety and satisfaction of
cancer patients receiving radiation therapy. Cancer Nursing, 18, 206-14.









Powell, P., Bentall., R. P., Nye, F.J., & Edwards, R. (2001). Randomised controlled trial of
patient education to encourage graded exercise in chronic fatigue syndrome. British
Medical Journal, 17, 387-395.

Renzi, C., Abeni, D., Picardi, A., Agostini, E., Melchi, C.F., Pasquini, P., et al. (2001). Factors
associated with patient satisfaction with care among dermatological outpatients. British
Journal ofDermatology, 145, 617-623

Richards, J., Klein, B., & Carlbring, P. (2003). Internet-based treatment for panic disorder.
Cognitive Behaviour Therapy, 32, 125-135.

Ritterband, L.M., Gonder-Frederick, L.A., Cox, D.J., Clifton, A.D., West, R.W., & Borowitz,
S.M. (2003). Internet Interventions: In review, in use, and into the future. Professional
Psychology: Research and Practice, 34, 527-534.

Roberts, K. J. (2002). Physician-patient relationships, patient satisfaction, and antiretroviral
medication adherence among HIV-infected adults attending a public health clinic. AIDS
Patient Care and STDs, 16, 43-50.

Ruggerio, C.M., Barr, E., Davis, J., Lau, R., Minassian, P., Selecky, C.E., et al. (2001). Disease
management and e-Health can be successfully merged. Paper presented at the 2001
Annual HIMSS Conference and Exhibition. New Orleans, LA.

Scherrer-Bannerman, A., Fofonoff, D., Minshall, D., Downie, S., Brown, M., Leslie, F., et al.
(2000). Web-based education and support for patients on the cardiac surgery waiting list.
Journal of Telemedicine and Telecare, 6, S72-4.

Schneider, A.J., Mataix-Cols, D., Marks, I.M., & Bachofen, M. (2005). Internet-guided self-help
with or without exposure therapy for phobic and panic disorders. Psychotherapy and
Psychosomatics, 74, 154-164.

Schron, E.B., Exner, D.V., Yao, Q., Jenkins, L.S., Steinberg, J.S., Cook, J.R., et al. (2002).
Quality of life in the antiarrhythmics versus implantable defibrillators trial: Impact of
therapy and influence of adverse symptoms and defibrillator shocks. Circulation, 105,
589-594.

Schuster, P. M., Phillips, S., Dillon, D. L., & Tomich, P. L. (1998). The psychosocial and
physiological experiences of patients with an implantable cardioverter defibrillator.
Rehabilitation Nursing, 23, 30-7.

Sears, S.F., Burns, J.L., Handberg, E. Sotile, W.M., & Conti, J.B. (2001). Young at
heart: Understanding the unique psychosocial adjustment of young implantable
cardioverter defibrillator recipients. Journal ofPacing and Clinical Electrophysiology,
24, 1113-1117.









Sears, S.F., & Conti, J.B. (2002). Current views on the quality of life and psychological
functioning of implantable cardioverter defibrillator patients. Heart, 87, 488-493.

Sears, S.F., & Conti, J.B. (2003). Understanding implantable cardioverter defibrillator shocks
and storms: Medical and psychosocial considerations for research and clinical care.
Clinical Cardiology, 26, 107-111.

Sears, S.F., Kovacs, A.H., Azzarello, L., Larsen, K., & Conti, J.B. (2004). Innovations in health
psychology: the psychosocial care of adults with implantable cardioverter defibrillators.
Professional Psychology Research Practice, 5, 1-7.

Sears, S.F., Kovacs, A.H., Serber, E.R., Kuhl, E.A, Vazquez, L.D., Handberg, E.M., et al.
Psychosocial treatment to optimize quality of life in implantable cardioverter defibrillator
patients. In preparation.

Sears, S.F., Todaro, J.F., Lewis, T.S., Sotile, W., & Conti, J.B. (1999). Examining the
psychosocial impact of implantable cardioverter defibrillators: A literature review.
Clinical Cardiology, 22, 481-489.

Shedd, O., Sears, S.F., Harvill, J.L., Arshad, A., Conti, J.B., Steinberg, J.S. et al. (2004). The
World Trade Center attack: Increased frequency of defibrillator shocks for ventricular
arrhythmias in patients living remotely from New York City. Journal of the American
College of Cardiology, 44, 1265-1267.

Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies.
American Psychologist, 32, 752-760.

Southard, B.H., Southard, D.R., & Nuckolls, J. (2003). Clinical trial of an Internet-based case
management system for secondary prevention of heart disease. Journal of
Cardiopulmonary Rehabilitation, 23, 341-348.

Spek, V., Cuijpers, P., Nyklick, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based
cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis.
Psychology and Medicine, 37, 319-328.

Steinberg, J.S., Arshad, A., Kowalski, M., Kukar, A., Suma, V., Volka, M.E., et al. (2004).
Incidence of life-threatening ventricular arrhythmias in implantable defibrillator patients
after the World Trade Center attack. Journal of the American College of Cardiology, 44,
1261-1264.

Sturdee, DW. (2000). The importance of patient education in improving compliance.
Climacteric, 3, 9-13.

Tate, D.F., & Zabinski, M.F. (2004). Computer and Internet applications for psychological
treatment: Update for clinicians. Journal of Clinical Psychology, 60, 209-220.









Tate, D.F., Jackvony, E.H., & Wing, R.R. (2003). Effects of Internet behavioral
counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA,
289, 1833-1836.

Ware, J. E., Kosinski, M., & Keller, S. D. (1995). SF-12: How to Score the SF-12 Physical and
Mental Health Scales (2nd ed.). Boston, MA: The Health Institute, New England Medical
Center.

Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey:
Construction of scales and preliminary tests of reliability and validity. Medical Care,
34(3), 220-233.

Winzelberg, A.J., Taylor, C.B., Sharpe, T., Eldredge, K.L., Dev, P., & Constantinou, P.S.
(1998). Evaluation of a computer-mediated eating disorder intervention program.
International Journal ofEating Disorders, 24, 339-49.

Winzelberg, A.J., Eppstein, D., Eldredge, K.L., Wilfley, D., Dasmahapatra, R., Dev, P., et al.
(2000). Effectiveness of an Internet-based program for reducing risk factors for eating
disorders. Journal of Consulting and Clinical Psychology, 68, 346-350.

Zimmerman, R.S. (1988). The dental appointment and patient behavior. Differences in patient
and practitioner preferences, patient satisfaction, and adherence. Medical Care, 26, 403-
414.









BIOGRAPHICAL SKETCH

Emily Ann Kuhl was born on July 19, 1978, at Lakenheath Royal Air Force Base in

Lakenheath, England. The daughter of an Air Force pilot, she spent her childhood living in three

countries, including England, Germany, and the United States, and several states, including

Virginia, California, New York, and Texas. She graduated from Monterey High School in

Lubbock, Texas, at the age of 17. She then enrolled in Texas Tech University, where she

received her bachelor's degree in psychology at the age of 20.

Following undergraduate training, Emily spent two years working as a features writer at

the Manassas Journal Messenger and the Potomac News in suburban Washington, D.C. She later

enrolled in the clinical psychology master's program at East Carolina University in the fall of

2001. At this time, she began studying health psychology and developed what has become her

primary interest within behavioral medicine cardiac psychology. In 2002, Emily was awarded

the Department of Clinical Psychology's Graduate Student of the Year award. Emily was

accepted to the doctoral program with the Department of Clinical and Health Psychology at the

University of Florida in August 2003. There, she honed her expertise in cardiac psychology with

foci in patients with implantable cardioverter defibrillators and adults with congenital heart

disease. She has several publications in peer-reviewed journals and has presented at numerous

conferences. In June 2006, Emily began her year-long pre-doctoral internship at the VA

Maryland Health Care System/University of Maryland Psychology Internship Consortium.

Upon receipt of her Ph.D., Emily will begin a postdoctoral position as a research associate

at the University of Maryland Medical Center in Baltimore, MD. She has one sister, Amy

Lazerson, and two nieces: Rebecca, age 7, and Sarah, age 5. Emily will have a nephew in late

August.





PAGE 1

1 PATIENT ASSISTED COMPUTERIZED EDUCATION FOR RECIPIENTS OF IMPLANTABLE CARDIOVERTER DEFIBRI LLATORS (PACER): A RANDOMIZED CONTROLLED TRIAL OF THE PACER PROGRAM By EMILY ANN KUHL A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

PAGE 2

2 2007 Emily A. Kuhl

PAGE 3

3 To my friends and family who have been by my side throughout it all; my successes are your successes.

PAGE 4

4 ACKNOWLEDGMENTS In order to fully reflect on the time and effo rt that went into this project, I must first acknowledge Dr. Samuel Sears. These pages ar e a manifestation of his unwavering support, enthusiasm, and generosity, and they are undoubted ly the most sincere and gratifying forms of respect a young professional can be lucky enough to receive at any point in her career. Beyond this, though, they speak to an even greater mean ing his integrity as a colleague, a friend, and a fellow human being. He is, in short, an inspiration. I wish to thank Amy Lazerson; even if I did have a choice, I would want her to be my sister. Without family, enduring the most painfu l difficulties and celebrating the most thrilling joys are simply events in time, a thousand tiny im ages that seem randomly thrown about. Family strings the events of your life to gether with purpose so that when you step back, you see that the tiny images make one big picture. Without he r, there simply would be no big picture. I wish to thank Tricia and Larry Beach, who personify the meaning of the word home and remind me that I will always be someones daughter I will spend all the days of my life, all the love in my heart, all the breath in my body thanking them for their endless devotion and guidance. And still, it wont equal half of what they have given. I wish to thank Tracy Montauk, who is the person I most want to be like when I first wake up in the morning, and the person I am most grateful for at the end of my day. To only call her my friend discounts the many thankless roles sh e takes on: my never-ending confidante, my unquestioning defender, my keeper of secrets, and all-around supporter. Finally, I wish to thank my parents, who ha d the unenviable job of having to support and nurture and develop my talents wh en they were at their most ra w, but never got to witness the payoff of their sacrifices. It is one thing to be loved and cherished, but it is something even greater to be honored and missed.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 ABSTRACT....................................................................................................................... ..............8 CHAPTER 1 INTRODUCTION..................................................................................................................10 Utility of Implantable Cardioverter Defibrillators..................................................................10 Psychological Sequelae of ICD Implant.................................................................................11 Computerized Psychosocial Interventions..............................................................................12 2 MATERIALS AND METHODS...........................................................................................14 Participants and Procedure.....................................................................................................14 Instruments.................................................................................................................... .........15 ICD Device Knowledge: Florida ICD Knowledge Questionnaire..................................15 Patient Acceptance: The Florida Pa tient Acceptance Survey (FPAS)............................15 Shock Anxiety: The Florida Shock Anxiety Scale (FSAS).............................................16 General Anxiety: State-Tra it Anxiety Inventory (STAI)................................................16 Health-Related Quality of Life........................................................................................16 Short Form-12 (SF-12).......................................................................................................... .16 Intervention Procedure......................................................................................................... ...17 Theoretical Basis for Change..................................................................................................18 Questions and Hypotheses......................................................................................................19 Question 1: Does the PACER Program Provide Improved Device-Specific Knowledge Acquisition?..............................................................................................19 Question 2: Is Increasing Device Know ledge Related to Increasing Patient Acceptance?.................................................................................................................19 Question 3: Are Increases in Device Knowle dge Related to Decreases in Anxiety? (Shock-related and Generalized)..................................................................................19 Question 4: Does Indepe ndent, Self-directed Use of This Program Produce Comparable Outcomes of Psychosocial a nd Quality of Life Ratings as an Inperson, Group Education Setting?...............................................................................20

PAGE 6

6 3 LITERATURE REVIEW.......................................................................................................21 Psychological Distress and the ICD Patient...........................................................................21 Descriptors and Prevalence.............................................................................................21 Theories of Distress Among ICD Patients......................................................................23 Anxiety and Cardiac Patients..........................................................................................26 Interventions for ICD Patients.........................................................................................27 Patient Acceptance and the ICD.............................................................................................29 Cardiac Patients and the Internet............................................................................................30 Psychology and the Internet....................................................................................................31 Need for Further Research......................................................................................................34 4 RESULTS........................................................................................................................ .......36 Sample......................................................................................................................... ...........36 Descriptive Analyses........................................................................................................... ...38 Hypothesized Analyses.......................................................................................................... .39 Hypothesis 1................................................................................................................... .39 Hypothesis 2................................................................................................................... .39 Hypothesis 3................................................................................................................... .41 Hypothesis 4................................................................................................................... .42 User Survey Data............................................................................................................... .....43 Post-Hoc Analyses.............................................................................................................. ....43 Effects on New Recipients versus Previous Recipients..................................................44 Effects of Knowledge on Quality of Life........................................................................45 5 DISCUSSION..................................................................................................................... ....52 Acquisition of Knowledge Between Groups..........................................................................52 Relationship of Knowledge to Device Acceptance................................................................54 Knowledge and Anxiety.........................................................................................................55 Computerized versus In-Person Treatments...........................................................................57 New versus Established ICD Recipients................................................................................58 Limitations.................................................................................................................... ..........59 6 FUTURE WORK....................................................................................................................61 APPENDIX: MEASURES............................................................................................................63 LIST OF REFERENCES............................................................................................................. ..74 BIOGRAPHICAL SKETCH.........................................................................................................82

PAGE 7

7 LIST OF TABLES Table page 4-1 Social and demographic va riables by treatment condition................................................46 4-2 Psychological variables at ba seline, by treatment condition.............................................47 4-3 Baseline Psychological Variables of New and Previous Recipients.................................48 4-4 Independent predictors of device acceptance at follow-up, among treatment participants................................................................................................................... ......49 4-5 Post-intervention psychological variab les from the PACER Study and the in-person study.......................................................................................................................... .........50 4-6 User Survey of PACER Program.......................................................................................51

PAGE 8

8 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PATIENT ASSISTED COMPUTERIZED EDUCATION FOR RECIPIENTS OF IMPLANTABLE CARDIOVERTER DEFIBRI LLATORS (PACER): A RANDOMIZED CONTROLLED TRIAL OF THE PACER PROGRAM By Emily A. Kuhl August 2007 Chair: Samuel F. Sears Major: Psychology The implantable cardioverter defibrillator (IC D) is the treatment of choice for preventing and correcting potentially-lethal cardiac arrhythm ias. Although its effec tiveness is supported by data from several large-scale, randomized clinical trials, it s psychological impact is less favorable, mostly because of the shock mechan ism by which the device corrects arrhythmias. Patients with ICDs are vulnerable to depres sion and anxiety, includi ng panic disorder and avoidance behaviors, as a resu lt of device placement and expe riencing an ICD shock. There are only a handful of randomized, controlled tria ls focused on enhancing the psychosocial functioning of ICD recipients. Co mputers are becoming an increasi ngly useful tool in providing psychological care due in part to their accessibility, convenience, anonymity, and cost effectiveness. There is ample support for using co mputerized interventions to successfully treat psychiatric dysfunction, includ ing depression, panic disorder, generalized anxiety, and phobias. There are currently no computerized interventions in the literature aime d at the psychosocial fitness of ICD patients. Our study is a pilot study of a ps ychoeducational, computerized intervention for ICD recipients en titled Patient Assisted Computer ized Education for Recipients of Implantable Cardioverter Defibrillators (P ACER). We hypothesized that the PACER program

PAGE 9

9 would increase patient knowledge about thei r ICD, decrease anxiety, and increase device acceptance, as compared to usual care patien ts. PACER patients were also hypothesized to demonstrated equivalent scores of anxiety, devi ce acceptance, and quality of life compared to patients from a similar, in-person interven tion from a related study. Thirty patients were recruited, and half were randomized to the treatment condition. At one-month follow-up, there were no differences in scores between treatmen t and control patients on an ICD knowledge test. Increases in ICD knowledge were associated w ith increases in devi ce acceptance, but only among treatment patients. There was no impact of the program on anxiety. Compared to participants from an in-person treatment, PACER patients demonstr ated similar scores of mental quality of life and device acceptance, but worse scor es of anxiety and physi cal quality of life. A user survey demonstrated overwhelming s upport of the PACER program by participants, suggesting the utility of future testing amongst a larger sample.

PAGE 10

10 CHAPTER 1 INTRODUCTION Utility of Implantable Ca rdioverter Defibrillators Each year, approximately 350,000 Americans e xperience sudden cardiac arrest (SCA) related to the occurrence of cardiac arrhythmias, including vent ricular fibrilla tion (VF) and ventricular tachycardia (VT; American Heart As sociation, 2004). Ventri cular tachycardia is characterized by heartbeats in excess of 160 b eats per minutes. Ventricular fibrillation is characterized by both excessive h eart rate and poorly-d efined contractions wherein the heart manifests a fast-paced, quivering motion. The result is a failure of the ventricles to completely fill and contract, sending insufficient amounts of blood to the lungs and body. In the event of SCA, treatment by defibrillation to shock the hear t back into rhythm is necessary to prevent death, which otherwise occurs w ithin minutes. Indivi duals who experience SCA may be treated pharmacologically (e.g., antiarrhythmic medications) or via implantable cardi overter defibrillator (ICD), an internal device that detects, paces, an d defibrillates arrhythmias including VF and VT. Modern ICDs are equipped with multi-therapeut ic pacing and graduated shock delivery, as well as additional lead placement and algorithmic pr ogramming to differentiate ventricular from supraventricular activity. When an irregular rhythm such as VT or VF occurs, the ICD may send a small shock to slow a fast heart rate (cardiove rsion), or a larger shock to st op the rhythm completely and essentially reboot the heart s electrical system (defibrilla tion). Shock is not a rare phenomenon, with 40-42% of all ICD patients expe riencing one shock within the first year postimplant (Credner, Klingenheben, Mauss, Sticherling, & Hohnloser 1998). Twenty-two percent will experience more than one shock during this initial year, while 17% will experience more than three shocks. Although the s hock mechanism means that a patient with an ICD is not likely

PAGE 11

11 to die from SCA, there are secondary complicati ons that can occur with ICD placement, such as the development of congestive heart failure (C HF) can continue despite reduction in cardiac arrhythmias. The ICD is the treatment of choice for vent ricular cardiac arrhythmias (Anti-arrhythmic versus Implantable Device [AVID] Investigat ors, 1997; Moss et al ., for the Mu lticenter Automatic Defibrillator Implantation Trial I nvestigators, 1996), and nearly 60,000 Americans receive an ICD each year. Previous recipien ts include Vice President Dick Cheney in 2001. Several large-scale, randomized, controlled clinical trials have compared the effectiveness of the ICD versus standard care (e.g., medications). For example, the AVID Trial paired nearly 500 ICD recipients against 500 patients placed on antiarrhythmic medications (e.g., amiodarone, sotalol), and found a 27% reduction in mortality fr om the ICD at 2 years. These results were impressive enough to prematurely terminate the st udy in order to provide implantation for all atrisk patients. Throughout othe r studies (Connolly, et al., 2000; Kuck, Cappato, Siebels, & Ruppel for the Cardiac Arrest Study Hamberg I nvestigators, 2000; Moss et al.), the ICD has repeatedly outperformed medication management with mortality rates ranging from 31-74%. In another such study (Buxton, et al., for the Mu lticenter Unsustained Tachycardia Trial Investigators, 1999), patients randomized to medical management had mortality rates comparable to those of control patients receivi ng no treatment at all. While patients who take medication for SCA can reduce their risk of r ecurrence within 5 years to approximately 50%, those who receive an ICD have a me re 5% risk. Data such as thes e highlight the strength of the ICD in helping patients live with potentially life-threatening ventricular arrhythmias. Psychological Sequelae of ICD Implant Although the ICD has demonstrated impressive mortality rates, th e device nonetheless presents as a potential instigator of psychological maladjustment in recipients. This is primarily

PAGE 12

12 due to the shock mechanism necessary for the de vice to cardiovert and defibrillate potentially lethal arrhythmias. Another factor that ma y make an individual more susceptible to poor adjustment is lack of understanding and knowledge about their device (S ears, Burns, Handberg, Sotile, & Conti, 2001), implying that the need for sound patient education is great. Significant rates of panic symptoms (Godemann et al., 2004 ) and avoidance behaviors (Lemon, Edelman, & Kirkness, 2004) have been documented among this population, as have difficulties with depression, interpersonal functioning, and stress management (Sears & Conti, 2003). It would seem, therefore, that health care providers should consider issues re lated to quality of life, rather than just quantity of life, among these recipients. Unfortunately, there has been little published in the way of psychosocial interventions for ICD pa tients. What studies do exist (Frizelle et al., 2004; Kohn, Petrucci, Soto, Baessler, & Movsow itz 2000) suggest that cognitive-behavioral techniques, such as helping patients break classically-conditioned cycles of avoidance surrounding fear of shock exposure, ma y be of particular benefit. Computerized Psychosocial Interventions In this new era of psychological treatment, the Internet is becoming an increasingly common venue for reaching patients. Indeed, with nearly two-thirds of all Americans having Internet access (Lenhart et al., 2003), this ap pears to be an appropriate arena to which psychologists can extend themselves. Web-base d interventions (WBIs) represent the current interface between modern technology and psycho logy. Already there appears to be much support for the use of WBIs in creating behavioral change, such as in treating panic disorder (Richards, Klein, & Carlbring, 2003) and eating disorders (Winzelbe rg et al., 2000). Similarly, Web programs that address cognitive components, su ch as with individuals with depression, also have been supported (Christense n, Griffiths, & Korten, 2002).

PAGE 13

13 To date, there have been no published studies of WBIs for ICD recipients. In fact, there has been relatively little done for cardiac populat ions in general in the way of Internet interventions. An online intervention that utilizes documented cogni tive and behavioral techniques to improve patient acceptance and ad justment would be desirable. However, the reality of whether such an intervention could ach ieve any success is unknown. Clearly, there is a need for feasibility studies to determine whethe r computerized interventions are usable for the ICD population in the first place. Therefore, the main objective of the current proposal is to examine the effects of a WBI (T he PACER [Patient-Assisted Com puter Education for Recipients of Implantable Cardioverter Defibrillators] Pr ogram) designed for ICD patients in terms of increasing patient knowledge about their device, increasing patient device acceptance, and reducing anxiety among recipients. A secondary objective is to de termine whether participants in this study display different outcomes (e.g., psychosocial ratings, quality of life) compared to participants in a related study w ho utilized the same intervention but in a structured, in-person group format.

PAGE 14

14 CHAPTER 2 MATERIALS AND METHODS Participants and Procedure The current study lasted for two years. Partic ipants were recruited from Shands Teaching Hospital in Gainesville, FL. Initial inclusion crite ria were that all participants will be newly implanted (<3 months), be able to read and wr ite English, and must have access to a computer. Midway through the study, though, a change in the research protocol was implemented due to low enrollment secondary to low implantation rate s at Shands and recruitment difficulties (e.g., lack of patient referrals). The pr otocol was expanded to include all ICD patients and not just new recipients. Permission was obtaine d by Institutional Review Boar d to contact these patients by phone. Patients meeting these criteria were aske d to participate either immediately following implantation during inpatient hospitalization (n ew recipients) or via telephone (previous recipients). All patients were provided with a general desc ription of the study and asked to participate. After giving written consent, participants co mpleted a packet of questionnaires assessing for psychological functioning and device knowle dge. Following completion, participants randomized to the treatment c ondition received a CD-ROM cont aining a computerized psychoeducational program (the PACER program) about how their device works and how to cope with having an ICD. An Internet Service Provi der was not necessary for participation. At one-month follow-up, participants complete d the same measures as at baseline. Follow-up questionnaire packets fo r treatment participan ts included an addendum to the Florida ICD Knowledge Questionnaire that contained a user survey to determine which parts of the program were accessed and deemed effective. C ontrol participants were wait-listed and at the end of the study received the same CD-ROM as those in the treatment group. All participants

PAGE 15

15 were allowed to keep the CD-ROM. Institutional Review Board (IRB) policies at the University of Florida were followed. Medical variables gathered include the left ventricular ejection fraction, history of implantation, and other cardiac risk variables, me dications, other illnesses or surgeries, length of hospitalization, length of time since implant, number of rehospitaliza tions, and number of medical procedures. Demographic information co llected includes age, sex, race, educational status, family income, marital st atus, and employment status. Instruments ICD Device Knowledge: Florida ICD Knowledge Questionnaire This measure was developed specifically for th is study, since no measure of this construct currently exists. The patients know ledge of ICDs was assessed using scores from six sections including basic knowledge about the device and shocks; stress management techniques for ICD recipients; improving cognitions and outlook; utilizing adap tive behaviors to increase adjustment; understanding family relationships; and preparing fo r device shock. Questions are multiple-choice with fourand five-choice answers. A utilization subscale was added to posttests given at one-month follow-up. This subscale is a user satisfaction survey determining how often the participants acc essed the program, how useful they found it, and what areas were most helpful. Patient Acceptance: The Florida Patient Acceptance Survey (FPAS) This measure was developed to examine device acceptance in pacemaker, implantable cardioverter defibrillator (ICD), and implantable at rioverter defibrillator (IAD) patients. It is comprised of 15 items with four valid and consis tent factors: Return to Life, Device-Related Distress, Positive Appraisal, and Body Image Concerns. The FPAS total score and subscale

PAGE 16

16 scores demonstrated both convergent and divergen t validity with the SF36, atrial fibrillation symptoms, the CES-D, STAI, and illne ss intrusiveness (Burns et al., 2004). Shock Anxiety: The Florida Shock Anxiety Scale (FSAS) This scale was developed for a previous study to assess the fear and anxiety that patients may have regarding the ICD and its shocks. Th is 16-item measure examines the cognitive, behavioral, emotional and social impact of shock anxiety. Full psychometric validation is currently being investigated (Kuhl Dixit, Sears, & Conti, 2006). General Anxiety: State-Trai t Anxiety Inventory (STAI) The STAI is a 40-item self-re port questionnaire designed to measure both state and trait anxiety (Speilberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). For the purposes of this study, only the 20-item trait scale of this questionnaire was administered. Trait anxiety is defined as a relatively enduring personality characteristic, or more specifically, as anxiety proneness. The internal reliability of both the state and trait an xiety scales has been shown to be uniformly high across samples of adults ranging from .89 to .96. Test-retest stability coefficients for multiple samples of college students ranged from .73 to .86, w ith test-retest validity specifically for the trait scale being reported at .73 for males and .77 for females. Concurrent validity between the STAI and IPAT Anxiety Scale and the Taylor Ma nifest Anxiety Scale ra nged from .83 to .73 (Spielberger et al., 1983). Health-Related Quality of Life Short Form-12 (SF-12). This measure was developed to gauge mental and physical functioning and can be separated into two comp onents: physical component summary (PCS-12) and mental component summary (MCS-12). All scores of the SF-12 are comparable and highly correlated with scores from the SF-36, from whic h it was derived, (ranging from .63-.97) (Ware et al., 1995; Ware, Kosinski, & Keller, 1996). The SF-12 reproduced 90% of the variance in the

PAGE 17

17 SF-36 PCS and MCS measures in th e United States and on cross-validation in the MOS (Ware et al., 1996). The Left Ventricular Dysfunction Questionnaire (LVD-36). This cardiac-specific measure was designed to assess the impact of le ft ventricular dysfuncti on on daily life and wellbeing. Responses are dichotomous (true or false) True responses are summed, which is then calculated as a percentage; highe r scores indicate worse func tioning (i.e., 0 = best possible score). The measure demonstrated high internal consistency in a sample with chronic left ventricular dysfunction (Kuder-Richardson coeffi cient = 0.95) (OLeary & Jones, 2000). Higher scores indicate greater dysfunction, and poorer QOL. Please see Appendix for printed copies of all measures. Intervention Procedure The intervention in this study is a psychoeducational, cognitive-behavioral program entitled The PACER Program: Patient-Assisted Com puter Education for Recipients of ICDs. Accessing a CD-ROM program only requires the us er to insert the CD and double-click on the appropriate icon, and therefore invo lves considerably less experien ce on the part of the user. The intervention program provides information about coping, mood, relationships, device functioning, and other areas relevant to ICD patients adjustment. As described earlier, it has been theorized that cognitive appraisals and cl assical conditioning contribute to ICD patient anxiety. Cognitive-behavioral techniques help di spel the cognitive distortions behind patients attempts to predict shocks and avoid activities. The current intervention teaches participants about the unpredictability of s hock; helps patients devise a plan to cope with shock, thereby assisting them in feeling more prepared; and pr ovides coping techniques th at allow patients to return to everyday activities and enjoy life ag ain. The program is in teractive and allows participants to apply concepts and strategies to their own situations and concerns.

PAGE 18

18 Psychological and QOL scores from participan ts receiving the PACER intervention were compared to those of participants from a relate d study that utilized a similar intervention (Sears, Vazquez Sowell, Kuhl, et al., und er review). In this original study, ICD recipients who had received a device shock were randomized to either a 6-week cognitive-behavioral stress management program or a one-day workshop control group. Both groups received the same information although the control groups info rmation was abbreviated. The information presented is the same as the information c ontained in the PACER program. Post-treatment analyses indicate that the weekly interventi on resulted in improved scores of mental QOL, anxiety, and decreased diurnal salivary cortis ol production, which is a validated biological marker of stress. All participants demonstrated improved scores of depr ession and physical QOL. However, it is unclear whether the information it self provided the basis for change, or whether the didactic format of the groups was more influen tial. By comparing scores from participants in the original study to those using the PACER progr am, we will be able to better understand where to attribute outcomes. In order to control for th e fact that the original study participants were shocked, baseline scores of anxi ety between both groups were compared to determine whether or not anxiety should be used as a covariate. Theoretical Basis for Change Classic learning theory can be used to con ceptualize how the PACER program will affect participants. Learning theory is built on concepts of reinforcem ent, shaping, and self-monitoring all of which are addressed by th is intervention. For example, participants are provided with psychoeducation to reduce avoidanc e behaviors and increase pleasant activities. As they engage in these behaviors, it will provide reinforcement for the notion that virtually all activities are safe for ICD patients, that they do not need to act ively avoid objects/activit ies, and that such avoidance does not reduce their risk of shock. By encouraging participan ts to create a shock

PAGE 19

19 plan in the event that their device fires, the pr ogram is shaping behaviors, such as preparedness and active coping. Lastly, partic ipants are taught various form s of self-monitoring, such as relaxation techniques (which are directly built on the premise of self-monitoring for the stress response), and identifying and reframing cognitive dist ortions. It is believed that these are the primary pathways by which the PACER program is likely to produce changes in participants thinking patterns and behaviors. Questions and Hypotheses The following questions and hypotheses are proposed and comprise the a priori analyses to be conducted after data collection is complete. Question 1: Does the PACER Program Pr ovide Improved Device-Specific Knowledge Acquisition? Hypothesis 1: Treatment participants will yield greater change in test scores from baseline to follow-up. Analysis 1: Descriptive and repeated measures analyses of covariance (R-MANCOVA) will determine changes in scor es between the groups while c ontrolling for the effects of age, education level, and disease severity (e.g., ejection fraction). Question 2: Is Increasing Device Knowledge Related to Increasing Patient Acceptance? Hypothesis 2: Gains in knowledge will be associ ated with greater device acceptance scores at follow-up among both groups. Analysis 2: Separate hierarchical regression analyses will de termine whether change in knowledge scores predict scores of device a cceptance within both groups. In the first block, demographic variables related to knowle dge acquisition including age and education level, will be entered. In the second block, medical variables will be entered. In the third block, change in knowledge score will be entered. Question 3: Are Increases in Device Knowle dge Related to Decreases in Anxiety? (Shockrelated and Generalized) Hypothesis 3: Knowledge acquisition is related to shock anxiety and trait anxiety, with increases in knowledge being associated w ith a decrease in bot h types of anxiety. Analysis 3: Separate hierarchical regression analyses will de termine whether change in knowledge scores predict scores of shock anxiet y and trait anxiety within both groups. In

PAGE 20

20 the first block, demographic variables relate d to knowledge acquisi tion including age and education level, will be entered. In the sec ond block, medical variables will be entered. In the third block, change in knowle dge score will be entered. Question 4: Does Independent, Self-directe d Use of This Program Produce Comparable Outcomes of Psychosocial and Quality of Li fe Ratings as an In-person, Group Education Setting? Hypothesis 4: Participants in this current study will produce scores of psychosocial adjustment and quality of lif e that are not significantly different from ratings of participants in a related study that utilized the same program but in an in-person, group format (Sears et a., in preparation). Analysis 4: Multivariate Analysis of Variance will be employed to explore differences by treatment group in trait anxiet y (STAI), patient ac ceptance (FPAS), and quality of life (SF12).

PAGE 21

21 CHAPTER 3 LITERATURE REVIEW The following literature review wi ll describe how ICD patients adjust to their device, and what psychological treatments are recommended for this population. Further, it will review how the Internet has been utilized as a clinical tool by psychologists, and how Internet interventions apply to cardiac patients. Psychological Distress and the ICD Patient Descriptors and Prevalence With mortality benefits of the ICD well established, the focus of its impact has shifted beyond the physiological outcomes of the patient a nd toward the psychosocial and quality of life issues that coincide with implantation. The shock mechanism by which the ICD attempts to correct arrhythmias is a unique e xperience to which few individua ls can relate. Although most recipients say this phenomenon is more surprising th an it is painful, and rate it as a 6/10 on a 1to-10 scale of pain (Sears, Kovacs, Azzare llo, Larsen, & Conti, 2004), it nonetheless is sometimes an anxiety-provoking and fearful expe rience (Herrman, et al., 1997; Luderitz, Jung, Deister, & Manz, 1996; Schuster, Phillips, Dill on, & Tomich, 1998; Sears, Todaro, Saia-Lewis, Sotile, & Conti, 1999). Other common concerns among ICD patients include fear of shock, device malfunction, battery failure and sexual/intimacy concerns (Sears et al., 1999). Approximately 15% of ICD patients struggle with psychological di stress secondary to device placement (Sears et al., 1999). A large-sc ale national survey from Sears and colleagues (1999) found that ICD patients e xperience relatively hi gh rates of anxiety compared to the general population. Specificall y, about 24-48% of ICD patients have anxiety symptoms, with 13-38% meeting criteria for an a nxiety disorder. Rates of depre ssion are more similar to those seen in the general population. Approximately 12-24% of ICD patients describe symptoms of

PAGE 22

22 depression, while about 9-15% actua lly meet criteria for clinical depression. Despite this, about 91% of ICD patients return to pre-implant levels of QOL within the first year of device implant (Sears et al. 1999, 2000). Quality of life for ICD pa tients appears to be as good as, if not better than, that of patients receiv ing pharmacological care (Sears & Conti, 2002). Irvine and colleagues (2001) found that ICD patients QOL wa s better than those pa tients receiving only drug therapy, except in the areas of pain and social functioning. Although ICD patients have device-specific anxieties and con cerns that are worthy of attenti on, a majority of these patients appear to experience good QOL. Among the ICD patients who do experience di stress, shock seems to be the primary culprit. Schron and colleagues (2002) found that experiencing more than one shock within the first year was associated with lower mental and physical QOL scores on the Short Form-36 questionnaire. Luderitz, Jung, Deister, and Manz (1996) suggest that fi ve shocks may be the magic number in determining whether an ICD patient experiences significant anxiety. Other researchers (Kamphuis, de Leeuw, Derksen, Ha uer, & Winnubst, 2003) emphasize time of shock rather than number, finding that sh ocks within the first 6 months ar e significantly associated with an increased risk of distress. Regardless of whether it is re lated to when they occur or simply how many occur, the incidence and impact of shock ca nnot be overlooked. A recent larg e-scale study assigned half of post-bypass patients to receiving an ICD, while th e other half was maintained via drug therapy (Namerow, Firth, Heywood, Windle, & Parides, 2002). It was repor ted that the ICD recipients experienced worse QOL than thos e taking medication. However, fu rther analyses revealed that the non-shocked ICD patients did not differ signifi cantly on QOL ratings from those assigned to the medical condition. The experience of shock solely accounted for the difference in groups.

PAGE 23

23 Further, Godemann and colleagues (2004) studied diagnostic rates of panic disorder with agoraphobia among ICD patients and found that, when shocked, ICD patients were more likely to meet criteria for diagnosis (7% no-shocked versus 21% shocked). While these studies clearly implicate shock in the advent of psychol ogical distress, other studies suggest different risk factors are at hand. Pauli, Wiedemann, Dengler, BlaumannBenninghoff, and Kuhlkemp (1999) opi ne that anxiety in ICD patient s is not related to shock, but rather to catastrophic thinking. Specifically, anxious patients in their study were prone to somaticizing and interpreting changes in their bodie s as negative signs of failing health, which in turn can spiral into negative cognitions about ones health, life and future. Sears and Conti (2003) further elaborate by suggesting that there ar e multiple risk factors for distress, such as young age (<50 years), female gender, poor device understanding, the presence of 3 or more shocks within a 24-hour period (aka., ICD storm ), and a history of si gnificant psychiatric distress. Theories of Distress Among ICD Patients How is it that some ICD patients adapt norma lly while others con tinually struggle with anxiety and health-related concer ns? Several theories attempt to explain the development of psychopathology among some ICD recipients. Four su ch theories focus speci fically on patients perceptions of their device and shock. The first theory is that of classical conditioning, introduced to psychology by Ivan Pavlovs research with his dogs. This theory holds that pairing a neutral stimulus with a negative or positive event can create a resulting associa tion between the two items. In the case of ICD patients, the negative event is de vice shock. Pairing the existence of shock with an object, event, or place can result in avoidance (Lemon et al., 2004) due to the newly created negative association. This avoidance can subsequently lead to maladjustm ent (Sears & Conti, 2002). For

PAGE 24

24 example, a patient who is shocked while gardenin g may associate being in the garden with the negative experience of being shoc ked, and therefore avoids worki ng in the garden despite the fact that is a safe activity and possibly one that gives the patient enjoyment. Consider the same consequences when an individual is shocked wh ile being intimate with a loved one. Suddenly, the conditioning of the patient to avoid contact with their loved one now not only affects the patient himself, but also the spous e. This can also lead to soci al isolation, depression, low selfimage, and feelings of helplessness. Similar to this theory is th at of operant conditioning. Op erant conditioning holds that individuals are motivated to do or avoid doing th ings for which they are reinforced. An ICD patient who believes they are avoiding shock by avoiding an activity is receiving negative reinforcement. A recent example of a female patient who was shocked while eating illustrates the serious consequences that th is faulty reasoning can have. Third is the theory of learned helplessness, de veloped by Seligman. This theory states that when we are presented with an aversive situati on from which we cannot escape, we tend to give up and cease trying to find a way to avoid the ne gative consequences. In the case of an ICD patient, there is no way to avoid being shocked. S hock is not predictable or directly controlled by what a patient does, says, eats, behaves, etc. This clearly can lead to feelings of helplessness and despondency. Patients who come to believe that they will be shocked no matter what they do may give up trying to cope and adjust, feeling that they have no control over their lives or health. This in turn can lead to feelings of depres sion, withdrawal, social isolation, and fear. The fourth theory, proposed by Sears and Conti (2003), is the theory of cognitive appraisal, also known as the sickness scoreboard theory Patients who are shocked, and often times those who are not, may come to view device firing as a sign of failing health. Over time, patients may

PAGE 25

25 keep score of whether their health is improving or declining by tracking device firings. In an attempt to gain control over their health, and ther efore alter their score, they may avoid activities that they erroneously believe will lead to shock. This score-keep ing also gives patients a false sense of control over their health, causing them to become hypervigilant of their bodys changes and physical sensations. The occurrence of shock does not indicate failing health. In fact, as mentioned previously, shocks can occur for reasons unrelated to arrhythmias (e.g., lead dysfunction). More recently, some researchers have suggested that patient personality characteristics may make them more vulnerable to distress following implanta tion, especially among patients who experience shock. Dunbar and colleagues (1999) studied mood dist urbance in 207 ICD patients. Participants were aske d to rate their levels of anxi ety, anger, confusion, fatigue, and vigor at pre-implant, post-implant, 1-month, 3-months, 6-months, and 9-months follow-up. These scores yielded a total mood disturbance (TMD ) rating. Statistical anal yses determined that the only significant predictor of shock was TMD at time points 1 and 3, which also predicted shock at subsequent time points. Anxiety, confusion, and fatigue were all significant predictors of shock. Further, they found that there was no significant difference between pre-implant and post-implant TMD scores, signifyin g that the psychological variable s acted as precursors to and not consequences of being shocked. Results from Dunbar et al. (1999) are consistent with another recent study from Shedd and colleagues (2004) concerning device firing durin g the period immediately following the World Trade Center bombings on September 11, 2001. The authors examined rates of device shock among ICD patients at Shands Teaching Hospital a nd the Veterans Affairs Medical Center in Gainesville, FL, in the 30 days prior to and fo llowing the terrorist attacks. During this time,

PAGE 26

26 electrophysiologists in Florida w itnessed a 2.8-fold increase in nu mber of tachyarrhythmias. Similarly, electrophysiologists studying ICD patients at six hospitals in New York City and upstate New York also witnessed an incr ease in cardiac events post-September 11th (Steinberg et al., 2004). As with the Florida patients, the New York sample experienced a 2.3 fold increase in ventricular tachyarrhythmias from preto post-September 11th. Furthermore, there were no reports of cardiac events in the 3 days immediately following the bombings, and patients returned to baseline levels of events within a month. The authors note that this finding in particular differs from previous studies of tr aumas and cardiac events, which have reported immediate increases in activity. These fascinatin g data imply that not only can anxiety and fear from directly experiencing trauma impact ones heart rhythms, but that experiencing an event indirectly can affect cardiac functioning as well. Anxiety and Cardiac Patients As noted above, anxiety and depression have been identified as common comorbidities to ICD placement, and there are several theories as to why anxiety in particular may transpire so frequently in this population. This is particular ly worrisome because of the devastating effects that anxiety can have to both one s emotional and physical self. Anxiety has been identified as a significant contributor to the pathogenesis of cardiac disease (Kubzansky, Kawachi, Weiss, & Sparrow, 1998). Through activation of the sympathetic nervous system and subsequent release of catech olamines, anxiety is implicated in platelet aggregation, injury of arterial lining, and release of fatty acids into the blood all of which promote the atherosclerotic process. Anxiety also may cause injury by decreasing heart rate variability and increasing the incidence of vent ricular premature beats, thereby contributing to electrical instability. Finally, anxiety may tri gger myocardial infarction due to the association between hyperventilation and coronary vasospasms Behavioral mechanisms have also been

PAGE 27

27 established associating anxiety with health-compromising activiti es, such as smoking, decreased physical activity, or poor diet (Haywood, 1995; Januzzi, Stern, Pasternak, & DeSanctis, 2000). Myocardial infarction and sudden cardiac death ar e subsequently common outcomes (Januzzi et al., 2000). Clearly, anxiety is an important psycho logical and physical cont ributor that should be monitored in cardiac patients, such as ICD recipients. Interventions for ICD Patients Current research with ICD pa tients suggests that there is a great need for psychosocial interventions to help ICD patients cope with comorbid distress. Unfortunately, much of the research in this area is methodologically flawed due to problems such as small sample size and the use of interventions, such as support groups, that are unstruc tured and predominantly provide emotional support. While emotional support is undoubtedly an important component to patient adjustment, the use of patient education and c ognitive-behavioral therapy techniques should not be ignored, and have been shown to be more effective in decreasing distress and improving QOL than emotional support alone. Structured interventions for ICD patients ba sed on cognitive-behavioral techniques have only recently been studied. In one landm ark study (Kohn et al., 2000) ICD patients were randomized to a six-week i ndividual psychotherapy interv ention, or standard care. Measurements of depression, anxiety, and illness adjustment were taken pre-implant, and at 1, 3, 5, and 9 months following implant. The aut hors reported that providing individual cognitivebehavioral therapy to ICD patie nts resulted in significant decr eases in depression and anxiety, and improved adjustment compared to a no-tr eatment control group. Even more notable, the experimental group contained more women and reported a greater number of shocks, both of which are recognized predicto rs of poorer adjustment.

PAGE 28

28 An additional study (Frizelle et al., 2004) exam ined the impact of a cardiac rehabilitation program fitted with cognitive-behavioral techniques for ICD patients. Participants were randomized to a six-week treatment program or a wait-list control gr oup. The intervention consisted of psychoeducation about the ICD a nd its functioning, relaxa tion techniques (e.g., breathing exercises), and goal-setting to help patients increase avoi ded activities. Post-treatment results revealed a significant improvement in anxiety and depressi on scores; improved QOL measurements; and a decrease in ICD-related co ncerns. Intervention pa tients also improved significantly on physical measures of exertional capacity (e.g., S huttle test). Taken together, these few studies highlight the early success of these strategies in aiding ICD patients. Patient education is a reasonabl e intervention for medical patien ts, and may be particularly helpful with reducing anxiety (L ee, Chui, & Gin, 2003; Poroch, 1995) Research has highlighted the benefits of patient education beyond merely reducing anxiety, such as increasing quality of life, compliance and patient satisfaction with car e (Mills & Sullivan, 1996; Powell, Bentall, Nye, & Edwards, 2001; Sturdee, 2000). However, thr ee meta-analyses of studies on psychoeducation programs for cardiac patients (Dusseldorp, van Elderen, Maes, Meulman, & Kraaij, 1999; Linden, Stossel, & Maurice, 1996; Mullen, Mains, & Velez, 1992) reported positive results for cardiac outcomes, but mixed results for psychosoc ial outcomes. Unlike the review from Linden and colleagues, Dusseldorp et al. found no signifi cant effects of psychoe ducation on anxiety or depression. The authors suggest that this could be due to various f actors such as floor effects of their population, sexor age-spec ific needs that were not addr essed, or use of psychoeducation programs that were too general or vague in th eir content (e.g., group di scussions of MI risk factors as a stress management intervention). Similarly, Mullen, Mains, and Velez suggest that individually tailored conten t focused on promoting behavioral change may help maximize

PAGE 29

29 psychosocial outcomes. Given this, a psychoeduc ation program driven by patient-specific needs (e.g., shock anxiety among ICD pati ents) that aims to change be haviors and cognitions, rather than simply disseminate information, may be appropriate for cardiac patients and could potentially improve psychosocial outcomes. Patient Acceptance and the ICD In addition to psychological disturbances, he alth care providers shoul d also be aware of patient acceptance among ICD recipients. Pati ent acceptance of medical treatment is a complicated variable (Cleary, 1999) that is wort hy of attention due to its association with improved patient understanding and satisfaction with outcome, as well as adherence (McKinley, Manku-Scott, Hastings, French, & Baker ,1997; Renzi et al., 2001; Roberts, 2002; Zimmerman, 1988). Patient satisfaction may be contingent on several variables including disease severity, health-related quality of life, and, often times, patient-provider relationship. Implantable cardioverter defibrillator recipien ts are confronted with significant burdens, particularly during the first 6 months after implant (Kamphuis et al., 2003), which can impact their level of device acce ptance. Burns, Serber, Keim, and Sears (2005) state that ICD patient acceptance encompasses an understanding of device benefits and detriments, the likelihood of future recommendation of the ICD to other indivi duals, and an awareness of what benefits the patient perceives are being provided by their devi ce. As a global term, patient acceptance is thought to be a construct of QOL, incorporating disease-specific aspects that may be lost on other general or even cardiac-specifi c measures of quality of life (Burns et al., 2005). Therefore, measuring patient acceptance in ICD recipients is crucial to unde rstanding their unique experiences and forming an awareness of how the device impacts their functioning.

PAGE 30

30 Cardiac Patients and the Internet Cardiac patients are a prime population for Web-based care. According to CyberAtlas (Greenspan, 2002), there were 137 million American s online in 2002, nearly one-third of which were age 50 or older. The U.S. Bureau of the Census and the National Center for Health Statistics reports there are 35 million Ameri cans age 65 and older (Greenspan, 2003). An estimated 20 percent (7.6 million) of those are currently on the Internet, but that number is projected to more than double by 2007. Further, Harris Poll data (2002) suggest that men and women were nearly even among Internet use, with women slightly edging out men. By racial ethnicity, Caucasian users make up approximately three-fourths of all adults on the Web, with African-American users totaling 12 % and Hispanic users 9%. A t ypical cardiac patient is a male Caucasian, age 65 or older, and therefore is well suited for a Web intervention. Moreover, a 2000 study (Dickerson, Flaig, & Kennedy) on Intern et use among ICD recipients found that patients readily utilized the In ternet for supportive communica tion and information exchanging, suggesting that the ICD population is an appr opriate group for an online intervention, although no specific intervention was provided in their study. Web-based interventions have been scarcely appl ied to cardiac patients. A majority of the studies conducted thus far conc ern enhancing professional devel opment, medical monitoring, or improving technology. There are considerably fewer studies aimed at directly impacting patients via improved psychosocial and physical outcomes, though WBIs for cardiac-related risk factors such as obesity (Tate, Jackvony, & Wing, 2003), sm oking (Feil, Noell, Lichtenstein, Boles, & McKay, 2003), and sedentary lifestyle (Napolitano et al., 2003) have ga ined attention. Studies of tertiary care populations s how hopeful results for populations such as transplant patients (Dew et al., 2004), individuals with CHF (Delgado, Costigan, Wu, & Russ, 2003; Scherrer-Bannerman et al., 2000), and secondary prevention populations (Gordon, 2004). Other research suggests that

PAGE 31

31 cardiac patients may benefit from computer ized treatment by incr easing education and communication (Delgado et al., 2003), as well as improving treatment adherence (Ruggerio et al., 2000). Further, Southard, Southard, and Nuckel s (2004) demonstrated cost efficiency with a computerized nursing case management system developed as an alternative to cardiac rehabilitation. Participants in the tr eatment condition exhibited improved, though nonsignificant, outcomes in time spent exercising, fat intake, and cholesterol, along with significant improvements in weight loss and body mass inde x. In addition, among the treatment condition, there was a significant cost-savi ngs per patient (net cost savi ngs = $965) on hospitalizations and emergency department visits. These studies indicate that, though s till nascent in their development, Web-based interventions for cardiac patients show potential. Psychology and the Internet Todays technology sees traditional psychosocia l interventions merging with the world of high-speed computer programming to form psychosocial WBIs. Web-based interventions have been successfully utilized in various arenas in cluding eating disorders (Winzelberg et al., 2000; Winzelberg et al., 1998), diabetes (Glasgow, Bo les, McKay, Feil, & Barrera, 2003), weight loss (Tate, Jackvony, & Wing 2003), and toilet tr aining (Cox, Borowitz, Kovatchev, & Ling, 1998). Internet interventions are noteworthy because of their potential to redu ce some of the barriers encountered in traditional treat ment (Ritterband et al., 2003). There are four primary benefits to using WBIs for treatment. First, WBIs are convenient. The Internet is always on and is always open. Internet interventions do not require patients to make appointments, wait in line, or contend with scheduling. In fact, as long as the technology is available, patients dont even need to leave their home to access services, making WBIs exceedingly convenient.

PAGE 32

32 A second benefit concerns accessibility. The In ternet is easily reached at any time from nearly any place. Although use of the Internet does require some equipment, much of this technology now comes standard in computers today, and is available outside the home for people not wanting to personally invest in equipment. Further, with the advent of updated technology, such as wireless Internet cards, reliance on accessory equipment is becoming less necessary. A third benefit is that WBIs can offer anonym ity, which may be particularly helpful in addressing highly personal and sens itive topics that patients might not otherwise be inclined to address in face-to-face arenas (T ate & Zabzinsky, 2004). The abil ity to exchange dialogue or view text anonymously is likel y appealing to many patients an d could encourage a sense of honesty and openness that is not always easy to ac hieve in traditional settings. Individuals who are sensitive about in-person setti ngs (e.g., those with physical disabi lities) may be more likely to seek treatment from WBIs, which may gradually help them feel more comfortable to seek treatment in person in the future. Last, because of their reliance on computers, WBIs allow for individual tailoring of treatments. Brug, Oenema, and Taylor (2002) write extensively about the benefits of individually-tailored interventions particularly in the realm of providing psycho-education, and how computers adapt to those this method more easily than standard formats (e.g., pamphlets, print material). The authors found that when patien ts received information more relevant to their particular problem or situation, they were more likely stay enga ged with the intervention, thereby increasing the chance of treatment effects. Computers are more adaptable to tailored interventions because of their capacity to create large databases of information combined with programming technique (e.g., use of if then stat ements to direct text) to selectively produce individualized information. In addition, a study of a computerized education program for cancer

PAGE 33

33 patients (Agre, Dougherty, & Pirone, 2002) suggests that the CD-ROM format in particular is highly beneficial over other modes (such as the Internet) and is readil y accepted by patients. Web-based interventions are stil l relatively new, and thus earl y studies have limitations for future studies to attempt to correct and strengthen (Ritterband et al., 2003). For example, researchers have continually c ited compliance as a major problem in making WBIs effective. Another important drawback concerns the dispar ity in access between different populations, also termed the digital divide (Lenhart et al., 2003). Indi viduals most likely to fall into this gap of non-users are ethnic minorities, reside nts of rural areas or residents in the Southern portion of the United States, individuals with annual inco mes below $30,000, and individuals with a highschool education or less (Lenhart et al.). Other groups of people who are less likely to be online are individuals older than 65 years of age, children from low-income homes, and disabled individuals (Lenhart et al.). Other well-known concerns includ e lack of comfort with the Internet, lack of security and validity of info rmation accessed, and initial cost in developing a WBI. Although cost has been suggested as a po ssible long-term benefit, in the short-term, developing the technology to in itially provide WBIs (e.g., Web site design; programming fees; hardware costs) is expensiv e (Atkinson & Gold, 2002). Despite the above-noted con cerns, the Internet remains a promising option for which psychology to transition its traditional treatments and techniques. For example, one type of intervention that seems readily a pplicable to the Internet is th at focusing on behavioral change techniques (Cavanagh & Shapiro, 2002). One stu dy from Gega, Marks, and Mataix-Cols (2004) details three individual cases of psychotherapeutic change using three different WBIs to treat depression, panic with agoraphobi a, and obsessive-compulsive di sorder. Although this is only one study, and no definitive conclusions should be made regarding the efficacy of WBIs based

PAGE 34

34 solely on these results, it does provide some pr omising and intriguing evidence on which future research can build. Therefore, it is reasonable to continue conducti ng effectiveness tr ials, such as the proposed study, to further investigate th e viability of this treatment option. Need for Further Research The structural, plumbing, and pumping ca pacities of the heart directly impact its electrical performance. Th e near-epidemic proportion of co ronary artery disease and cardiovascular diagnoses in this country ensures that, unfortunately, SCA will continue to occur and ICDs will continue to be necessary. The psychological distress that can accompany ICD placement is an important consideration. Anxiety in particular appears to be a common concern among this population, and given the deleterious effects it can have on ones physical and emotional well-being, it should also be of concer n to health care providers looking after ICD patients. Education is one reasonable method for a ddressing distress am ong medical patients, especially those with anxiety. A review of litera ture suggests that the application of WBIs to cardiac populations has been poorly achieved. Further, to date, there are no published intervention studies aimed at re aching ICD recipients via the computer. Although the typical ICD patient is older and therefor e less likely to have experience with the Internet, Pew data indicates that this is a wil ling and burgeoning online population. Furthermore, CD-ROMs are considered a reasonable and accessible method fo r educating patients (Agre et al., 2002), and provide a good alternative for indivi duals without Internet access. The proposed studys focus on ICD patients and co mputerized care is a unique feature, but there are other benefits of note. The results from this study wi ll help contribute to the growing body of literature examining the usability of Webbased interventions in general, as well as adding to the meager research on cardiac populations. Further, the ICD may be viewed by some

PAGE 35

35 patients as more of a life destr oyer rather than a life saver due to the shock mechanism and perceived limitations it carries. This study cont ributes to understand ing patient acceptance among ICD recipients and may provi de information that could help this population feel more satisfied and comfortable with their device. This in turn should impact their treatment compliance and future adjustment.

PAGE 36

36 CHAPTER 4 RESULTS Sample All participants were recruited from the Univer sity of Florida Health Science Center, were older than 18 years of age, and spoke and read English. Forty-six participants consented to participate in this project: 39 completed all ba seline measures and 30 completed 1-month followup measures. Therefore, the tota l number of participants who completed all phases of the study was 30. Compared to the number of participants recruited, intent-t o-treat attrition rate was 35%; attrition rate for study initiati on was 24%. Known reasons for at trition included no longer being interested in participating in the study and having significant ne gative feelings about the device. Twenty-one participants were randomized to the treatment cond ition, and 18 were randomized to the control condition. Of the 30 co mpleters, 15 were treatment par ticipants and 15 were control participants. Midway through the study, a cha nge in the research protocol was implemented due to low enrollment secondary to low implantation rates at Shands and recruitment difficulties (e.g., lack of patient referrals). The prot ocol was expanded to include al l ICD patients and not just new recipients. Permission was obtaine d by Institutional Review Boar d to contact these patients by phone. Therefore, not all participants were re cruited post-implant during hospitalization, as originally outlined. Of the 46 participants who consented, 23 were new ICD patients recruited during the peri-implant period; the remaining ha lf were recruited outp atient via telephone. Regarding demographic data, 59 percent of the sample was male ( n = 23) and 41 percent were female ( n = 16). Mean age of the sample was 57.44 years ( S.D. = 14.28). Three of participants (8%) identified themselves as African American, wh ile 35 (90%) identified themselves as non-Hispanic White. Regarding ma rital status, 69% reported being married or

PAGE 37

37 cohabitating, while 13% were divorced or widowed. Thirty-eight percent ( n = 15) of the sample reported having earned a high school education or less; however, of those 15 participants, only one reportedly did not complete a high school degree. Fifty-five pe rcent had at leas t two years of college education, including th ree participants who reported having completed post-graduate work. Seven participants (18%) re portedly were engaged in partor full-time employment, while 31% were receiving disability a nd 41% were retired. Three partic ipants were unemployed. Five (13%) of the participants reported living in household with an annual income of less than $15,000. Most (31%) participants reporte d earning between $15,000 and $29,000 annually. Twenty-three percent ( n = 9) reported earning at least $60,000 annually. Information was also collected regarding cu rrent and past psychiatric treatment, and current and past psychotropic medication use. Th ree participants reported currently receiving psychological treatment for either depression, anxiety, or both. Te n participants (26%) reported currently taking a psychotropic me dication, including antidepressant s (sertraline, fluoxetine, and venlafaxine) and anxiolytics (buproprion, escitalopram, alprazo lam, and paroxetine). Four participants (10%) reported having received psychol ogical treatment previously, most recently in 2003. Two of these participants reported being tr eated for depression, one reported being treated for anxiety, and one patient repo rted being treated for a non-m ood disorder. Six participants (15%) endorsed having previously taken psyc hotropic medications (citalopram, paroxetine, buproprion, and diazepam). Medical data on cardiac diagnoses, current me dication, and ICD-related information was gathered. Mean time since implantation was 11.77 months ( S.D. = 21.53). Mean ejection fraction was 29.87 ( S.D. = 11.36). Respondents medical history was significant for ventricular tachycardia (28%), ventricular fi brillation (13%), coronary artery disease (56%), and myocardial

PAGE 38

38 infarction (26%). Sixty-nine percent of the sa mple had been diagnosed with congestive heart failure, with 31% in NYHA Class II, 26% in Cl ass III, and 3% in Class IV. Five (13%) participants had a history of sudden cardiac arrest, with one patient having multiple episodes. Medication use was as follows: 56% endorsed taking aspirin, 28% Coumadin, 82% betablockers, 13% calcium channel blockers, 46% ACE inhibitors, 23% angiotensin receptor blockers, 44% diuretics, 8% amiodarone, and 5% sotalol. Thirty-eight percent ( n = 15) of the participants were implanted with a bi-ventricular device. Descriptive Analyses Descriptive analyses were run to examine ba seline ratings of psychological, ICD-related medical, and demographic variables. Except for the FSAS total scores and the follow-up physical QOL score, no variables violated the Kolmogorov-Smirnov test of normality or Levenes test of homogeneity of variance. The FSAS total scores variable underwent logarithmic transformation and subsequently displayed normal distribution; the physical QOL score underwent square root transformations. There were no differences on any measures of demographic or medical variables by treatment group (see Table 4-1), no r were there group differences on any of the psychological measures (see Table 4-2). Given that the original intent of the study was to investigat e new ICD recipients, baseline analyses also included examining demographic, medical, and psychologi cal variables of new ICD recipients (< 3 months) versus previous re cipients. In these analyses, all demographic and medical variables were comparable. As shown in Table 4-3, significant differences were found on all baseline psychological measures except on device knowledge and the Return to Life subscale of the device acceptance measure. Direction of effects were such that newer patients reported greater trait anxiety, worse physical an d mental QOL, lower devi ce acceptance, greater device-related distress, less use of positive device-related appraisa ls, greater body image

PAGE 39

39 concerns, and greater shock anxiet y. However, they also reported better scores on a measure of cardiac-specific QOL that assesses symptoms of vent ricular dysfunction. There was no difference in number of mont hs since implantation by treatment group ( t [37] = 0.35, p = 0.72). There were no differences in any va riables by whether or not participants were taking psychotropic medications, nor were there differences by whether not participants were currently receiving or had previously rece ived psychological treatment. Examination of baseline ratings of drop-outs revealed no differences compared to completers. Hypothesized Analyses The following statistical analyses were perf ormed to evaluate the proposed hypotheses for this research project. The Statistical Package for the Social Sciences (SPSS) was utilized to perform all the analyses. Hypothesis 1 This first analysis was conducted to examin e effects of the inte rvention on ICD-related knowledge, operationalized by changes in scores on baseline and follow-up administrations of the Florida ICD Knowledge Survey. A Repeat ed Measures Analysis of Covariance was conducted to examine changes in scores while cont rolling for age, educat ion level, and disease severity. Examination of Boxs M and Levenes st atistic revealed no significant violations of assumptions. The overall model was not significant ( Pillais Trace = 0.02, p > 0.50). This analysis suggests there was no difference in test scores between intervention and control participants over a one-month time period. Hypothesis 2 Separate hierarchical regression analyses ex amined whether change in knowledge scores predict scores of device acceptan ce within both groups. In the fi rst block, demographic variables related to knowledge acquisition (e.g., age and education level) were entered. In the second

PAGE 40

40 block, medical variables (e.g., ejection fraction a nd length of time since implant) were entered. In the third block, change in knowledge score was entered. Among treatment participants, the full model was significant ( F = 3.96, p = 0.04) and accounted for 69% of the variance in device acceptance at follow-up ( Adj R2 = 0.51). The first block accounted for 26% of the variance, while adding medical variables accounted for an a dditional 12% of varian ce, which was a nonsignificant change in R2. However, adding the knowledge chan ge score significantly accounted for an additional 30% of va riance in device acceptance ( F-Change = 8.71, p = 0.02). As shown in Table 4, age and knowledge change score were both significant independent predictors of device acceptance at follow-up. Overestimated R2 values can result from having a sma ll sample size relative to the number of predictors entered into a model. Most r ecommendations suggest a minimum of 5, and as many as 20, subjects per predictor in order to su fficiently power the analysis. Although planned analyses included examining all five predicto rs, the above regression was re-examined using only three predictors in orde r to investigate the possibility of falsely-inflated R2 values. Eliminated predictors were determined by exam ining zero-order correlations between education, age, EF, and length of time since implant with device acceptance. Based on lack of significance with the criterion, there was not a need to contro l for the variables age and EF, and they were therefore eliminated from the model. The analys is was run with education entered in the first block, length of time since implant in the sec ond, and knowledge change in the third. The full model remained significant ( F = 3.69, p = 0.04) and accounted for 50% of the variance in device acceptance at follow-up ( Adj R2 = 0.37). Although this represen ts a decrease from the fivepredictor model, it is nonetheless a signifi cant finding. The first block accounted for 23% of variance, while the second block contributed less than 1% of additional variance. However, as

PAGE 41

41 with the five-predictor model, knowledge added a significant proportion of variance explained in device acceptance ( R2-change = 0.26; p = 0.03). In this new model, the only significant independent predictor was knowledge ( = 0.56, p = 0.03). Among control participants, the full model fell short of significance ( R2 = 0.54, Adj R2 = 0.21, F = 1.66, p = 0.26). None of the blocks accounted for a significant proportion of variance in device acceptance; in partic ular, the knowledge variable acc ounted for only an additional 6% of variance beyond the demographic and medical variables. Therefore, the hypothesis that increases in knowledge would be associated with increased devi ce acceptance at follow-up was only observed among treatment participants. Ther e was no relationship between knowledge and device acceptance among the control participants. Hypothesis 3 Separate hierarchical regression analyses ex amined whether change in knowledge scores predict scores of trait anxi ety and shock-related anxiety within both groups. The same demographic and medical variables were entered in to blocks one and two, respectively, as in the previous analyses. In the th ird block, anxiety was entered. Among treatment participants, the full model was not significant in predicting either trait anxiety ( R2 = 0.59, Adj R2 = 0.36, F = 2.56, p = 0.10) or shock anxiety ( R2 = 0.12 F = 0.26, p = 0.92). None of the blocks accounted for a significant proportion of variance in shock a nxiety. In the trait anxiety model, however, the demographic block explained 54% of the variance in anxiety ( Adj R2 = 0.46, F = 7.05, p = 0.01) with age ( = -0.57, p = 0.04) being the only significant indepe ndent predictor. In both models, knowledge accounted for an addition al 1% of variance in anxiety. Among control participants, the full model was not significant in predicting either trait anxiety ( R2 = 0.14, F = 0.23, p = 0.94) or shock anxiety ( R2 = 0.47 Adj R2 = 0.09, F = 1 .24, p= 0.38). None of the blocks accounted for a significa nt proportion of variance in shock anxiety or

PAGE 42

42 trait anxiety, and there were no significant independent predictors in either model. Change in knowledge explained an additional 8% of the variance in trait a nxiety and 7% in shock-related anxiety. Hypothesis 4 There were no differences of baseline anxiety between the PACER participants and the inperson treatment participants, t = -0.73, p = 0.47, and thus no need to use anxiety as a covariate. A Multivariate Analysis of Variance was employ ed to explore differences by treatment study in trait anxiety, device acceptan ce, and mental and physical QOL at follow-up. There were no violations of Boxs M test of homogeneity; however, Levenes te st statistic was significant for trait anxiety ( p = 0.00). Therefore, the more conservative Pillais Trace was used in interpreting the multivariate model. The omnibus F was significant ( Pillais Trace = 2.94, p = 0.04, partial 2 = 0.28). Separate tests of between-subjects eff ects demonstrated a significant effect on the dependent variable physical QOL ( F = 8.71, p = 0.006), while the ANOVA for trait anxiety approached significance (F = 3.23, p = 0.08). The direction of effect was such that participants in the in-person study had greater scores of phys ical QOL post-interventio n, and a trend toward lower scores of trait anxiety (see Table 4-5). Given the violation of the Levenes statistic, a separate ANOVA using the Kruskal-Wallis rank test for non-parametric data was employed to examine scores of trait anxiety. In this analysis, no differences in trait anxiety between study participants was demonstrated ( 2 = 1.13, p = 0.29). Scores of anxiety for PACER patients increased slightly from baseline to post-tre atment (33.81 vs. 36.25), t hough not significantly ( t = -1.12, p = 0.28). In order to examine whether there were chan ges in physical QOL a nd trait anxiety over time, a repeated measures design was employe d. There was no violation of Boxs M test; however, there was a violation of Mauchlys tests of sphericity ( Mauchlys W = 0.38, p = 0.00).

PAGE 43

43 Violation of the sphericity assumption can re sult in inflated F-ra tios. Therefore, the Huynh-Feldt correction was applied on tests of within-s ubjects effects. The multivariate model was significant, Pillais Trace = 3.87, p = 0.02, partial2 = 0.28, and within-subjects time by group effects were also significant, F = 4.69, p = 0.01. Parameter estimates demonstrated significant group differences for physical QOL ove r time, but not for trait anxiety. User Survey Data Following completion of the follow-up knowledge survey, treatment patients were asked brief questions about their opinions of the PACER program (see Table 4-6). Thirteen participants completed this portion of the questionnaire. When asked when would be the most effective time to receive the PACER Program, 10 said followi ng implant and two said immediately following their clinic visit. Regarding ease of use, six rated the program as easy, four as moderately easy, and three as excellent. All responde nts stated that they would recommend the program to another device recipient. When asked to rate which sections were most helpful, four selected information about managing stress, five selected information about the device itself, tw o selected information about device shock, and one se lected information on managing family relationships. Seven participants rated the program as somewhat he lpful and six rated it as extremely helpful. When asked about which topics they would want additional information, four selected stress management, three selected device informati on, and two selected family relationships. Post-Hoc Analyses The following section addresses additional interesting findings and post-hoc analyses that were conducted after the initial pl anned statistical analyses. Due to the addendum nature of these analyses, caution should be uti lized in interpreting this data.

PAGE 44

44 Effects on New Recipients v ersus Previous Recipients The original intent of the study was to incl ude only new recipients of ICDs. As noted earlier, recruitment difficulties resulted in new and previous recipients being enrolled in the study simultaneously. A post-hoc analysis was co nducted to search for possible differences in scores between new and previous ICD patients, with length of time since implant being dichotomized according to whether or not so meone was a very recent recipient (e.g., < 3 months). Zero-order correlations revealed an association between dichotomized length of time and improvement in knowledge score, device ac ceptance at follow-up, and shock anxiety at follow-up. New ICD recipients had a mean change in knowledge score from baseline to followup of 4.14 points ( S.D. = 3.98), while previous recipients had a mean change score of less than 1 point ( M = 0.71, S.D. = 2.79); this difference was statistically significant ( t = 2.64, p = 0.01). Improvement in knowledge was dichotomized by wh ether or not an indivi duals score increased from baseline to follow-up. Being a new recipi ent was associated with improved knowledge scores (r = 0.50, p = 0.01), but lower device acceptance ( r = 0.38, p = 0.04) and greater shock anxiety at follow-up ( r = 0.42, p = 0.02). A chi-square analysis indicated that new recipients were significantly more likely to have improved knowledge at one month ( 2 = 7.04, p = 0.01), accounting for 73% of the cases of improved know ledge scores. There were no differences by treatment condition among the new recipients ( p > 0.50). Although at baseline new r ecipients differed from pr evious ones on nearly all psychological measures, a MANOVA examining QOL, shock anxiety, and device acceptance was employed because these were the only follo w-up variables correlated with being a new recipient. Further, at follow-up, the only va riables that differed between new and previous recipients were device acceptance and shock an xiety, with new patients having worse scores on both measures. The overall model failed to reach significance ( Pillais Trace = 1.56, p = 0.22,

PAGE 45

45 partial 2 = 0.21). Although the omnibus F was not signi ficant, tests of between-subjects effects were examined in order to inform possible di rections for future research. These separate ANOVAs revealed significant results for th e dependent variables device acceptance ( F = 4.35, p = 0.04) and shock anxiety ( F = 5.65, p = 0.02), with new recipients de monstrating lower scores of device acceptance and greater scores of s hock anxiety at followup than previous ICD recipients. Effects of Knowledge on Quality of Life Two of the a priori analyses in this study examined know ledge as a potential predictor in device acceptance and anxiety. Post-hoc, the relationship between knowledge and QOL was examined. In this analysis, a hierarchical regression was employed to examine whether knowledge at follow-up predicted me ntal QOL at follow-up among all participants. In the first block, demographic variables related to knowledg e acquisition (e.g., age and education level) were entered. In the second block, medical va riables (e.g., ejection fraction and length of time since implant) were entered. In the third block, knowledge score at one month was entered. The full model was not significant ( F = 2.10, p = 0.11) and accounted for 26% of the variance in mental QOL at follow-up ( Adj R2 = 0.14). However, the knowledge change score significantly accounted for an additional 13% of variance in de vice acceptance ( F-Change = 4.03, p = 0.05) beyond demographic and medi cal variables. Age ( = 0.39, p = 0.04) and knowledge at followup ( = 0.37, p = 0.05) were both significant independent predictors of mental QOL at followup. When examined separately by treatment condition, both regression analyses failed to meet significance. Further, when the same model was examined using physical QOL as the criterion, all analyses failed to meet significance.

PAGE 46

46 Table 4-1. Social and demographi c variables by treatment condition Characteristics Treatment Condition Control Condition Test statistic p -value Gender Male = 62% Female = 38% Male = 56% Female = 44% 2 = 1.61 p = 0.69 Mean age 56.05 (SD = 15.11) 58.72 (SD = 12.10) t (1, 37) = -0.60 p = 0.55 Ethnicity 2 = 3.82 p = 0.15 White 81% 100% Black 14% 0% Marital status 2 = 3.78 p = 0.44 Single, never married 10% 0% Separated, divorced 10% 0% Widowed 5% 11% Married/remarried 62% 56% Living with partner 10% 11% Education 2 = 5.88 p = 0.55 High school degree or less 43% 33% College degree or some college 48% 50% Graduate 10% 6% Employment 2 = 0.84 p = 0.93 Retired 43% 39% Disability/ government 33% 28% Part time 10% 11% Full time 10% 6% Unemployed 5% 11% Income (annual) 2 = 4.52 p = 0.61 Less than $30,000 10% 17% $30,000-$60,000 33% 33% More than $60,000 33% 11%

PAGE 47

47 Table 4-2. Psychological variables at baseline, by treatment condition Measure Treatment Condition Control Condition Test statistic p -value ICD Knowledge M = 18.30 (S.D. = 3.60) M = 17.76 (S.D. = 3.09) F = 0.23 p > 0.50 STAI M = 34.93 (S.D. = 9.80) M = 33.76 (S.D. = 7.22) F = 0.00 p > 0.50 FSAS M = 14.80 (S.D. = 5.98) M = 16.17 (S.D. = 7.76) F = 0.31 p > 0.50 FPAS Return to Life Scale M = 53.75 (S.D. = 20.16) M = 62.87 (S.D. = 25.62) F = 1.23 p = 0.28 Body Image Scale M = 11.67 (S.D. = 20.30) M = 14.70 (S.D. = 18.87) F = 0.19 p > 0.50 Device Related Distress Scale M = 20.31 (S.D. = 19.36) M = 16.56 (S.D. = 18.59) F = .31 p > 0.50 Positive Appraisal Scale M = 87.50 (S.D. = 16.08) M = 86.02 (S.D. = 18.69) F = 0.05 p > 0.50 Total Score M = 76.19 (S.D. = 15.25) M = 79.22 (S.D. = 18.34) F = 0.24 p > 0.50 SF-12 Mental QOL M = 52.31 (S.D. = 8.71) M = 51.39 (S.D. = 11.67) F = 0.06 p > 0.50 Physical QOL M = 32.34 (S.D. = 10.60) M = 35.00 (S.D. = 10.15) F = 0.53 p = 0.47 LVD-36 M = 59.07 (S.D. = 30.14) M = 58.16 (S.D. = 27.86) F = 0.03 p > 0.50

PAGE 48

48 Table 4-3. Baseline Psychological Variables of New and Previous Recipients Mean SD F Sig. ICD Knowledge 0.72 0.40 New 17.29 2.93 Previous 10.93 30.62 Trait Anxiety 4.09 0.05 New 36.52 8.74 Previous 30.80 7.04 Mental QOL 14.4 0.00 New 46.42 10.19 Previous 57.93 6.15 Physical QOL 6.41 0.01 New 29.76 9.52 Previous 38.27 9.44 Device Acceptance Total Score 6.89 0.01 New 70.88 18.23 Previous 84.66 9.536 Device Acceptance: Return To Life Scale 2.53 0.12 New 52.57 24.71 Previous 65.41 20.30 Device Acceptance: Device-Related Distress Scale 6.76 0.01 New 25.88 21.45 Previous 10.00 10.52 Device Acceptance: Positive Appraisal Scale 4.22 0.04 New 80.51 18.99 Previous 92.50 12.98 Device Acceptance: Body Image Concern Scale 4.71 0.03 New 19.85 22.56 Previous 5.83 11.44 FSAS Total Score 4.33 0.04 New 17.82 8.33 Previous 12.93 5.58 LVD Total Score 19.50 0.00 New 41.99 26.25 Previous 76.48 15.91

PAGE 49

49 Table 4-4. Independent predictors of device acceptance at followup, among treatment participants Unstandardized Coefficients Standardized Coefficients t Sig. Correlations B Std. Error Beta Zeroorder Partial Part (Constant) 2.936 1.799 1.632 .137 Age .032 .014 .498 2.285 .048 .253 .606 .426 Highest grade completed .203 .098 .461 2.067 .069 .484 .567 .385 Ejection Fraction .023 .019 .266 1.207 .258 .146 .373 .225 How long had ICD? (months) .002 .008 .065 .263 .798 .182 .087 .049 Change in score from pre to post .171 .058 .642 2.952 .016 .448 .701 .550

PAGE 50

50 Table 4-5. Post-intervention psychol ogical variables from the PACER Study and the in-person study. Study M SD Sig. Physical QOL PACER 36.35 7.96 In-person 44.85 8.74 p < 0.01 Mental QOL PACER 55.14 7.38 In-person 55.25 5.49 ns Trait Anxiety PACER 36.25 11.60 In-person 30.67 5.90 ns FPAS Total PACER 78.23 15.93 In-person 83.43 11.12 ns

PAGE 51

51 Table 4-6. User Survey of PACER Program Number of times program accessed 1.77 times What areas of the program were most beneficial? Number of minutes spent viewing program 28.69 minutes Stress Management31% Shock Management15% When should PACER be given? Device Information39% Following implant 83% Family Relationships8% Following clinic visit 17% Other8% How easy would you rate the program? Would you recommend this program to other ICD recipients? Moderately Easy 46% Yes100% Easy 31% Excellent 23% What areas of the program would you like more information? Stress Management40% How beneficial was the program? Device Information30% Somewhat beneficial 54% Family Relationships20% Very beneficial 46% Other10%

PAGE 52

52 CHAPTER 5 DISCUSSION The primary findings from this pilot study of a computerized psychoeducation program for ICD recipients were as follows: 1) Increases in device-related knowledge were predictive of better device acceptance, but only among treatment pa tients; and 2) treatment participants using the PACER program demonstrated comparable improvements in mental QOL and device acceptance, significantly lower scores of physical QOL, and a trend toward higher trait anxiety post-treatment, as compared to indivi duals in an in-person intervention. Acquisition of Knowledge Between Groups There was no identifiable difference between treatment groups in learning, as measured by the ICD Knowledge Questionnaire. It may be th at patients in the control condition sought information on their own, or that much of th e information in the program overlapped with information all patients received from their heal thcare providers or other resources encountered during routine care. The PACER program is c onsidered a psychoeducation tool because it provides not only descriptive facts about the device and its functioning, it also relays psychological techniques for returning to full activities. Because these are more complex concepts, it may be that treatment participants failed to learn more due to lack of human interaction to explain, teach, dem onstrate, and answer questions. A recent meta-analysis of online CBT program s for depression and anxiety (Spek, et al., 2007) suggested that treatment effects may be strongly influenced by whether or not an intervention is supplemented with minimal therap ist involvement. The authors defined minimal involvement as being brief, supportive, and facili tative, such as answeri ng questions about using the intervention or providing brief reinforcemen t for using the material. They did not include studies that utilized clinician involvement th at would be considered more traditional and

PAGE 53

53 analogous to in-person therapy. Among 12 rando mized-controlled studies, the authors found a mean effect size of 0.24 for all studies examined. When analyzed by design characteristics, they found a significantly smaller effect size fo r studies without cl inician involvement (d = 0.24) than for studies that provided therapist assistance ( d = 1.00). It is hypothesized th at treatment patients in the current study may have failed to demonstr ate a quantifiable difference in learning score due to lack of therapist support. Previous pa rticipants (Carlbring, Ek selius, & Andersson, 2003) have reported that while at-home, self-guided treatments are conve nient, they require more selfdiscipline in adhering to assignments and attendi ng to information. They also note that a group setting in which patients could discuss conten t and concerns with one another may enhance motivation (Carlbring et al., 2003) Supplementing the PACER program with brief support, such as random phone calls to inquire about participan t questions and to provide positive feedback may be an easy and effective way to optimize the effects of the intervention. Qualitatively, there was overwhelming suppor t of the PACER program from treatment participants. All recipients not ed that they thought the progr am was worth recommending to others, and described it as being beneficial. Research from Shea ( 2004) and others (S teinke et al., 2005) reveal that patients often require additi onal education about sexua l activity, driving, and managing device shock. In this sample, treatment patients reported benef iting from and desiring more information about stress management a nd about the device in general (e.g., non-shock related information, post-implant adjustment). Becau se of its aversive nature, it is somewhat surprising that more participants did not endorse needing and benefiting from information related to device shock. While education about firings such as making a shock plan, is arguably important and necessary for patient adjustme nt and good QOL (Sears & Conti, 2003), healthcare providers should not overlook the importance of other domains. In particular participant

PAGE 54

54 feedback about the importance of stress manage ment speaks to the necessity of psychological assistance as an integral part of comprehensive care in this population. User ratings from this sample suggest that there is an audience for furt her testing of computeri zed programs in the ICD population, which may help clarify how and in what ways these patients understand and process information about their device. Relationship of Knowledge to Device Acceptance As stated previously, treatment participants in this study did not de monstrate a quantifiable change in aggregate knowledge compared to usua l care patients. However, the fact that they demonstrated improvements in device accepta nce relative to gains in knowledge, whereas control participants did not exhibit this pattern, is important. It may be that while the intervention did not substantially incr ease the amount of information learne d, the intervention was effective at increasing acceptance without increasing knowledge differentia lly. Similarly, psychological treatments target change in adjustment, and not didactic knowledge. Therefore, the PACER program, though psycho-educational in content, may be more an alogous to a therapeutic tool rather than an educational one. This may al so somewhat account for post-hoc findings of improved mental QOL among PACER patients, but not physical QOL. Control patients had access to public informa tion resources, such as the Internet, which could help them increase their ICD-related knowledge. They also likely could acquire through public resources generalized, simplified concepts of CBT, such as engaging in pleasant activities and developing a positive outlook to reduce stress However, what PACE R provides, that the control patients likely would not discover on thei r own, is a structured, specific application of empirical techniques to the unique stressors faced by this population. For example, the intervention does not generically teach cognitive reframing. Ra ther, it explains how negative cognitions about the ICD impact ones physi cal and emotional functioning, and provides

PAGE 55

55 examples regarding device shock and avoidance activ ities to aid patients in using CBT in such a way to increase their understanding and acceptance of the device. This reflects the core of what the FPAS measures, and thus, it is reasonable that such an intervention if effective would yield improvement in this domain. Despite this without a control group exposed to similar content of information minus the CBT modules, it is difficult to attribute effects solely to the psychological material. The ecological validity implied by this finding should not be minimized. An increase in a test score alone would likely hold little practical meaning to a patient. If, however, learning something new about their device allows ICD patie nts to ultimately feel more comfortable and confident, then the quantity of information lear ned becomes less salient. To say that the PACER intervention was developed to help ICD patients become more educated about their does not fully capture the purpose its design. The goal of the program was not merely to serve as a didactic tool, but to ultimately provide psychologi cal benefit in adjustment and outlook. If this is occurs, even without signifi cantly increasing patients knowle dge base, than it should be considered a success. Further, the additional benef its of low cost and high convenience increase PACERs utility and importance. Knowledge and Anxiety In this sample, there was no relationship betw een gains in knowledge and trait or shock anxiety. Anxiety tends to be cogni tive in nature, and can be deep ly engrained and resistant to change. Self-directed treatments that are entir ely computer-based may have difficulty reducing anxiety for these reasons. Self-directed programs to treat anxiety disord ers, including panic disorder and phobias, may be successfully conduc ted via computer (Barlow, et al., 2005). However, effective programs have typically included structured homework assignments and exposure techniques. Some researchers (Kenwr ight & Marks, 2004; Schneider, Mataix-Cols,

PAGE 56

56 Marks, & Bachofen, 2005) have supplemented th eir computerized interventions with brief clinician contact by telephone. In their pilot study on panic and phobias, Kenwright, Liness, and Marks (2001) required part icipants to utilize a computer treatment in the presence of a nurse, who was available to answer questions and review content from previous sessions. Other researchers (Carlbring, Ekselius, & Andersson, 20 03) used brief contact by both telephone and email to remind patients about skills (e.g., reminde rs to engage in relaxation), review homework assignments, and answer questions. Marks and colleagues (2004) found that a computerized program for anxiety that utilized minimal clinicia n contact demonstrated comparable effect sizes for treatment outcomes versus an in-person CBT group, yet managed to reduce clinician time per-patient by 73%. Therefore, the brief addition of human interaction to a self-guided, at-home program such as PACER may effectively treat anxiety, while still reducing provider workload and treatment burden. Controllability (or lack thereof) has been identified as an influential factor in the development and persistence of clinical anxiety (Moulding & Kyri os, 2006), such as OCD. In these populations, successf ul therapeutic interv entions utilize role playing, behavioral modification, relaxation, and Socratic questioni ng (Moulding & Kyrios). While computerized interventions have been able to significantly improve functional and ps ychosocial outcomes in OCD patients (Mataix-Cols & Marks, 2006), these st udies still integrated human interaction to some degree. Although the current study did not examine OCD, these comparisons may be valuable because controllability is very pertinen t to ICD patients. Researchers (Sears & Conti, 2003) have hypothesized that the uncontrollable, unpredictable na ture of ICD firings may be largely responsible for the development of psychi atric distress in shocked patients, via learned helplessness (Goodman & Hess, 1999) or nega tive cognitions (Pauli et al., 1991, 2001). It may

PAGE 57

57 be that factors such as negative appraisals and lack of controllab ility are more difficult to address in the absence of therapist suppor t, and do not necessarily remit as a result of having increased ones knowledge about the ICD. Computerized versus In-Person Treatments One unique aspect of the current project is that, to date, no published study has compared in-person and computerized psychoeducation in terventions for ICD recipients. The PACER program demonstrated comparable improvements in mental QOL and device acceptance as an in-person intervention. However, the in-person group reported better physical QOL and less trait anxiety than PACER patients, desp ite the fact that they were dr awn from a sample of patients who had experienced device shock. The in-person treatment examined in the pres ent study used a multi-visit protocol in which patients had the opportunity to repeatedly discuss previous topics and were reminded of concepts taught in prior sessions. Homewo rk assignments allowed partic ipants to individually apply concepts to their own adjustment difficulties, a nd they were encouraged to discuss these findings in subsequent sessions. Convers ely, the PACER program is entirel y self-directed. Patients can choose to use the program as little or as frequen tly as they wish, and may involve themselves in the topic matter to whatever degree they feel necessary. Attending group treatments may reduce perceptions of self-burden, as the presence of both the health care provider and other attendants provides opportunities for learning that do not directly require th e patient to remain actively involved throughout. Future res earch with the PACER Program should consider a more equivalent approach to the in-person treatment, such that group effects can be accounted for (e.g., including a moderated chat room).

PAGE 58

58 New versus Established ICD Recipients Although post-hoc analyses should not be used to draw definitive c onclusions, the results from current analyses comparing new recipients to previous recipients are revealing. Regarding future research, these data may be valuable in informing clinicians about which patients may benefit the most from education interventions Patients typically do receive some education about their device prior to implant, but they may nevertheless feel uninformed and require greater information from providers about topics such as sexual concerns, device shock, driving, and working (Steinke et al., 2005; Shea, 2004). An alyses from the current sample imply that providing information sooner rather than later could give pati ents an added advantage in optimizing their adjustment to the ICD. New recipients demonstrated worse scores of psychological functi oning on nearly every measure, compared to previous recipients, sugges ting that they may be an appropriate target for psychotherapeutic treatment. Interestingly, they also demonstrated better scores of cardiacspecific QOL via a measure of symptom assessmen t. Given that ICDs are being increasingly implanted prophylacticly, before patients exhibit severe symptoms, this might account for why newer patients endorsed fewer symptoms, thus im proving their score on this measure. Despite their increase in learning, new patients were also more likely to report less device acceptance and greater shock-related anxiety at follow-up. This finding supports the utility of psychological referral for new patients perhaps even prio r to implant and not simply disseminating literature as a means of addre ssing patient concerns. Understanda bly, information regarding the ICD may be overwhelming and anxiety-provoking to some patients. Involving psychological professionals in the education of ICD recipien ts may help them better comprehend and apply information given. In some patients, psychiatri c distress (e.g., panic disorder, phobias) may be less tractable, and education inte rventions will not be sufficient. Again, by keeping psychological

PAGE 59

59 professionals involved at the onset of implanta tion, patients will have greater access to care, which increases their chances of tr eatment adherence and satisfaction. Limitations Results from this pilot study of the PACER program are some what encouraging. However, they should be considered in light of some study limitations. Notably, small sample size is problematic for numerous reasons including low statisti cal power, lack of generalizability, and poor representation of the ICD population as a whol e. Cross-sectional data may be useful for quickly acquiring a point-in-time view of a sample, but can mask effects of time and limits ones ability to make causal interpretations. As suc h, longitudinal collection is necessary to fully appreciate the shortand long-te rm effects of the treatment at hand. Given that this study was designed as a feasibility program, conclusive ge neralizations cannot be made from these data alone. Rather, this study may be us ed as a springboard for broader, more sophisticated protocols designed to test in-depth the effec tiveness of PACER for ICD patients. The fact that the sample consisted of both new and previous recipients makes drawing conclusions about knowledge and learning more difficult. Although post-hoc analyses attempted to parse out effects based on time of implant, a sample composed entirely of new recipients would help alleviate this problem to some degree. Simply by having had the device longer, previous recipients are exposed to practice effects of living with a nd adjusting to the ICD. This is relevant for both greater oppor tunities to learn and accept th e device, but also greater opportunities to experience difficultie s and struggle with the device. Therefore, the relevance and usefulness of the intervention may not be c onsistent across both types of patients. Other potential barriers incl ude the fact the sample was drawn from a single site and therefore likely reflects a sampling bias, and h eavily relied on self-repo rt measures, which are influenced by demand-characteristics and may not accurately reflect patient functioning. In

PAGE 60

60 particular, use of the PACER program was not m onitored and thus effects cannot be interpreted in light of factors such as length of time spent using th e techniques taught (e.g., relaxed breathing).

PAGE 61

61 CHAPTER 6 FUTURE WORK There is more research being conducted on co mputerized psychological interventions at this time than at any time before. Data suppor ting the development of these novel programs is exciting and helps to enrich the healthcare prof ession as a whole. The current study contributes to this body of research in several ways: One, it is among fe w computerized interventions intended for cardiac patients to optimize their ad justment to illness; two, there are currently no published computerized interventi ons for ICD patients specifically; and three, there are currently no published interventions comparing computeri zed psychosocial treatments to in-person treatments for either cardiac patients or ICD patients specifically. In this sample, knowledge gained from the PACER program was associated with improved device acceptance. Furthe r, the program produced comparable improvements in mental QOL and device acceptance as an in-person psyc hosocial CBT treatment for shocked patients. Patients who used the program reported feeling very satisfied with its cont ent and level of ease, and overwhelming supported its recommendation to other recipients. Ta ken together, these outcomes support future testing of PACER and si milar programs in this unique population. Lack of findings in aggregate knowledge and anxiety are informative for future program development. Subsequent trials of PACER can easily be supple mented with limited therapist assistance, which may substantially improve some of the nu ll outcomes demonstrated by this sample. Post-hoc analyses lend further support to the integration of psychological care with standard clinical care in this population. In this sample, new recipients predominantly accounted for patients who demonstrated an improvement in learning. Given that participants reported benefiting from and wanting more information about stress management, this suggests that involving psychologists at the on set of device implantation ma y be an effective way of

PAGE 62

62 addressing educational and psychological n eeds concurrently. The current study, though, provides an interesting starting point for such re search and upholds the importance of increasing our understanding in this area. In sum, findings from this study lend support for further use of computerized psychosocial interventions for ICD patients. The PACER pr ogram showed promising results in improving mental QOL and device acceptance, relative to an in-person group, and minor changes in design methodology may further strengthen PACERs ability to maximize patient outcomes in future trials.

PAGE 63

63 APPENDIX MEASURES FPAS We want to understand what it is like for y ou to live with a medical device. Below are some statements that describe living with a medical device. Please rate the extent to which you agree or disagree with each of the following statements by circling the appropriate response. Strongly Disagree Mostly Disagree Neither Agree or Disagree Mostly Agree Strongly Agree 1. Thinking about the device makes me depressed. 1 2 3 4 5 2. When I think about the device I avoid doing things I enjoy. 1 2 3 4 5 3. I avoid my usual activities because I feel disfigured by my device. 1 2 3 4 5 4. It is hard for me to function without thinking about my device. 1 2 3 4 5 5. My device was my best treatment option. 1 2 3 4 5 6. I am confident about my ability to return to work if I want to. 1 2 3 4 5 7. I am safer from harm because of my device. 1 2 3 4 5 8. The positive benefits of this device outweigh the negatives. 1 2 3 4 5 9. I have continued my normal sex life. 1 2 3 4 5 10. I would receive this device again. 1 2 3 4 5 11. I know enough about my device. 1 2 3 4 5 12. I am careful when hugging or kissing my loved ones. 1 2 3 4 5 13. I have returned to a full life. 1 2 3 4 5 14. I feel that others see me as disfigured by my device. 1 2 3 4 5 15. I feel less attractive because of my device. 1 2 3 4 5 16. I am knowledgeable about how the device works and what it does for me. 1 2 3 4 5 17. I am not able to do things for my family the way I used to. 1 2 3 4 5

PAGE 64

64 18. I am concerned about resuming my daily physical activities. 1 2 3 4 5 LVD-36 Please answer the following questions as you are feeling these days Circle either true or false for each question. If you do these activities for any reason other than y our heart condition, then please mark false Because of my heart condition: True False 1. I suffer with tired legs T F 2. I suffer with nausea (feeling sick) T F 3. I suffer with swollen legs T F 4. I am afraid that if I go out I will be short of breath T F 5. I am frightened to do too mu ch in case I become short of breath T F 6. I get out of breath with the least physical exercise T F 7. I am frightened to push myself to go to far T F 8. I take a long time to get washed or dressed T F 9. I have difficulty running, such as for a bus T F 10. I have difficulty either joggi ng, exercising or dancing T F 11. I have difficulty playing with children/grandchildren T F 12. I have difficulty either mowing the lawn or hovering/vacuum cleaning T F 13. I feel exhausted T F 14. I feel low in energy T 15. I feel sleepy or drowsy T F 16. I need to rest more T F 17. I feel that everything is an effort T F

PAGE 65

65 18. My muscles feel weak T F 19. I get cold easily T F Because of my heart condition: True False 20. I wake up frequently during the night T F 21. I have become frail or an invalid T F 22. I feel frustrated T F 23. I feel nervous T F 24. I feel irritable T F 25. I feel restless T F 26. I feel out of cont rol of my life T F 27. I feel that I can not enjoy a full life T F 28. Ive lost confidence in myself T F 29. I have difficulty having a regular social life T F 30. There are places I would like to go to but cant T F 31. I worry that going on holiday could make my heart condition worse T F 32. I have had to alter my lifestyle T F 33. I am restricted in fulfilling my family duties T F 34. I feel dependent on others T F 35. I feel it is a real nuisance having to take tablets for my heart condition T F 36. My heart condition stops me doing things that I would like to do T F

PAGE 66

66 SF-12 HEALTH SURVEY INSTRUCTIONS: This questionnaire asks for your view s about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. 1. In general, would you say your health is: Excellent Very good Good Fair Poor The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Yes, Yes, No, Not Limited Limited Limited A lot A little At All 2. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 3. Climbing several flights of stairs During the past 4 weeks have you had any of the following problems with your work or other regular daily activities as a result of your physical health ? YES NO 4. Accomplished less than you would like 5. Were limited in the kind of work or other activities

PAGE 67

67 During the past 4 weeks have you had any of the following problems with your work or other regular daily activities as a re sult of any emotional problems (such as feeling depressed or anxious)? YES NO 6. Accomplished less than you would like 7. Didnt do work or other activities as carefully as usual 8. During the past 4 weeks how much did pain interfere with your nor mal work (including both work outside the home and housework)? Not at all A little bit Modera tely Quite a bit Extremely These questions are about how you feel and how th ings have been with you during the past 4 weeks For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks All Most A Good Some A Little None of the of the Bit of of the of the of the Time Time th e Time Time Time Time 9. Have you felt calm and peaceful? 10. Did you have a lot of energy? 11. Have you felt downhearted and blue?

PAGE 68

68 12. During the past 4 weeks how much of the time has your physi cal health or emotional health problems interfered with your social activities (like vi siting with friends, relatives, etc.)? All of the time Most of the time Some of the time A little of the time None SAS (Shock Anxiety Scale) I am scared to exercise because it may increase my heart rate and cause my device to fire. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time I am afraid of being alone when the ICD fires and I need help. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time I do not get angry or upset because it may cause my ICD to fire. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time It bothers me that I do not know when the ICD will fire. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time I worry about the ICD not firing sometime when it should. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time I am afraid to touch others for fear Ill shock them if the ICD fires. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time I worry about the ICD firing and creating a scene. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time When I notice my heart beating rapidly, I worry that the ICD will fire. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time I have unwanted thoughts of my ICD firing. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time

PAGE 69

69 I do not engage in sexual activities because it may cause my ICD to fire. 1 2 3 4 5 Not at all Rarely Some of the time Most of the time All the time Self-Evaluation Questionnaire STAI Form Y-2 A number of statements which people have used to describe themselves are given below. Read each statement and then circle the appropriate numb er to the right of the statement to indicate how you generally feel. Almost never Sometimes Often Almost Always 1. I feel pleasant. 1 2 3 4 2. I feel nervous and restless. 1 2 3 4 3. I feel satisfied with myself. 1 2 3 4 4. I wish I could be as happy as others seem to be. 1 2 3 4 5. I feel like a failure. 1 2 3 4 6. I feel rested. 1 2 3 4 7. I am calm, cool, and collected. 1 2 3 4 8. I feel that difficulties are piling up so that I cannot overcome them. 1 2 3 4 9. I worry too much over something that really doesnt matter. 1 2 3 4 10. I am happy. 1 2 3 4 11. I have disturbing thoughts. 1 2 3 4 12. I lack self-confidence. 1 2 3 4 13. I feel secure. 1 2 3 4 14. I make decisions easily. 1 2 3 4 15. I feel inadequate. 1 2 3 4 16. I am content. 1 2 3 4 17. Some unimportant thoug ht runs through my mind and bothers me. 1 2 3 4 18. I take disappointments so keenly that I cant put them out of my mind. 1 2 3 4

PAGE 70

70 19. I am a steady person. 1 2 3 4 20. I get in a state of tension or turmoil as I think over my recent concerns and interests. 1 2 3 4 The Florida ICD Knowledge Questionnaire Education About Your Heart, ICD, and Shocks 1. What does ICD stand for? 1. Internal cardiac device 2. Implanted cardioverter device 3. Implantable cardioverter defibrillator 4. Internal cardiac defibrillator 2. True or False: Approximately one-third of all ICD patients will experience distress, such as depression or anxiety? 1. True 2. False 3. The ICDs main function is to ___________. 1. Remind you of heart disease 2. Prevent cardiac arrest 3. Let you know when to go to the hospital 4. Keep you awake Managing Stress Before Stress Manages You 4. Which of the following is not a healthy way to reduce stress? 1. Deep breathing 2. Worrying about your health 3. Changing thinking patterns 4. Exercising 5. Good coping skills include __________. 1. Managing your attitude 2. Having a drink 3. Eating junk food 4. Watching television 6. How many ICD patients feel stress within the first month after the implantation of their device?

PAGE 71

71 1. A few 2. Most 3. None 4. All 7. What percent of ICD patients report having the same or better quali ty of life after one year? 1. 15% 2. 42% 3. 60% 4. 85% 8. Most patients report that their emo tional well-being is _________ it was before receiving an ICD. 1. Worse than 2. Different from 3. Better or about the same as 4. No different from 9. The top 10 challenges faced by ICD patients include all except: 1. Socializing with friends 2. Sexual concerns 3. Generalized fear 4. Stress management Your Outlook Can Make the Difference 10. Which of the following thinking patterns re sults from exaggerating the negative impact of an event to the highest extent? 1. Catastrophizing 2. All-or-Nothing 3. Blaming 4. All of these 11. Which thought pattern can be addressed by re alizing that life is a balance of both good and bad elements? 1. Catastrophizing 2. All-or-Nothing 3. Blaming 4. None of these 12. Which of the following thought patterns of ten develops into anger or resentment directed at others? 1. Catastrophizing 2. All-or-Nothing

PAGE 72

72 3. Blaming 4. None of these 13. The term sickness scoreboard refers to ____________. 1. Keeping score of your condition and counting shocks 2. Comparing your shocks to others shocks 3. Seeing if you have more symptoms than your friends 4. None of these 14. The problem with the sickness scoreboard approach is that___________. 1. It makes you sicker 2. It annoys your spouse 3. It is not accurate because shocks do not serve as health indicators 4. There are no problems with it 15. True or False: Receiving more shocks means you are getting sicker? 1. True 2. False 16. True or False: Research shows that having a positive attit ude can affect how you react to illness a nd medical procedures? 1. True 2. False Take Control By Taking Action 17. Which of the following ac tivities should you avoid sole ly because of your ICD? 1. Being in a crowd 2. Sex 3. Having an argument 4. None of these 18. True or False: Certain everyday activ ities have been known to trigger shock? 1. True 2. False 19. Good coping skills include __________. 1. Improving your sleep 2. Having a drink 3. Eating junk food 4. Watching television

PAGE 73

73 A Family Affair 20. Family relationships can be improved by: 1. Providing praise to you loved one in front of others 2. Giving your time and attention to loved ones 3. Letting loved ones know thei r support is helping you 4. All of these 21. True or False: ICD patients should avoid sex because the increased heart rate caused by sex could trigger a shock? 1. True 2. False 22. True or False: Sex is esp ecially straining on the heart? 1. True 2. False 23. The best predictor of a couples sa tisfaction with their sex life is ___________. 1. How frequently they have sex 2. How healthy both partners are 3. How comfortable they are disc ussing their sexual relationship 4. Their age Planning For and Coping With Shocks 24. Your ICD shock plan should include all of the following parts except: 1. Preparing for shock 2. Actions immediately following shock 3. A long-term plan 4. Fearing shock 25. True or False: If someone is touchi ng you when you receive a shock, they will be hurt? 1. True 2. False 26. Which of the following can interfere with the functioning of your ICD? 1. Microwaves 2. Irons 3. Televisions 4. None of these

PAGE 74

74 LIST OF REFERENCES Agre, P., Dougherty, J., & Pirone, J. (2002). Creating a CD-ROM program for cancer-related patient education. Oncology Nursing Forum, 29 573-580. American Heart Association. H eart Disease and Stroke Sta tistics Update. Dallas, TX: American Heart Association, 2004. Atkinson, N.L., & Gold, R.S. (2002). The prom ise and challenge of eH ealth interventions. American Journal of Health Behaviors, 26 494-503. AVID Investigators. (1997). A comparison of antiarrhythmic-d rug therapy with implantable defibrillators in patients resuscitated fr om near-fatal ventricular arrhythmias. New England Journal of Medicine, 337, 1576-1583. Barlow, J.H., Ellard, D.R., Hainesworth, J.M., Jone s, F.R., & Fisher, A. (2005). A review of selfmanagement interventions for panic diso rders, phobias, and obsessive-ocmpulsive disorders. Acta Psychiatry Scandinavia, 111 272-285. Brug, J., Oenema, A., & Campbell, M. (2003). Past present, and future of computer-tailored nutrition education. American Journal of C linical Nutrition, 77 1028S-1034S. Burns, J.L., Serber, E.R., Keim, S., & Sears, S.F. (2005). Measuring patient acceptance of implantable cardiac device therapy: Initial psychometric investig ation of the Florida patient acceptance survey (F-PAS). Journal of Cardiovascular Electrophysiology In press. Buxton, A.E., Lee, K.L., Fisher, J.D., Josephson, M.E., Prystowsky, E.N., Hafley, G., et al., for the Multicenter Unsustained Tachycardia Tr ial Investigators. ( 1999). A randomized study of the prevention of sudden death in pa tients with coronary heart disease. New England Journal of Medicine, 341 1882-1890. Carlbring, P., Ekselius, L., & Andersson, G. (2003). Treatment of panic diso rder via the Internet: A randomized trial of CBT vs. applied relaxation. Journal of Behavioral Therapy and Experimental Psychiatry, 34, 129-140. Cavanagh, K., & Shapiro, D. (2004). Computer tr eatment for common mental health problems. Journal of Clinical Psychology, 60, 239. Christensen, H., Griffiths, K.M., & Korten, A. (2002). Web-based cognitive behavior therapy: Analysis of site usage and change s in depression and anxiety scores. Journal of Medical Internet Research, 4 e3. Cleary P. (1999). The increasing im portance of patient surveys. British Medical Journal, 319, 720-721.

PAGE 75

75 Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences, 2nd edition. Lawrence Erlbaum Associates: Hillsdale, NJ. Cohen, J. (1992). The Power Primer. Psychology Bulletin, 112 155-159. Connolly, S.J., Gent, M., Roberts, R.S., Dori an, P., Roy, D., Sheldon, R.S., et al. (2000). Circulation Canadian implantable defibrilla tor study (CIDS): A random ized trial of the implantable cardioverter defibr illator against amiodarone. Circulation, 101 1297-302. Cox, D.J., Borowitz, S.M., Kovatchev, B., & Li ng, W. (1998). Contributions of behavior therapy and biofeedback to la xative therapy in the treatmen t of pediatric encopresis. Annals of Behavioral Medicine, 20 70-76. Credner, S.C., Klingenheben, T., Mauss, O ., Sticherling, C., & Hohnloser, S.H. (1998). Electrical storm in patients w ith transvenous implantable ca rdioverter defibrillators. Journal of the American College of Cardiology, 32, 1909-1915. Delgado D.H., Costigan J., Wu R., & Ross H.J. (2003). An interactive Internet site for the management of patients with congestive heart failure. Canadian Journal of Cardiology, 19 1381-5. Dew, M.A., Goycoolea J.M., Harris, R.C., Lee, A., Zomak, R., Dunbar-Jacob, J., et al. (2004). An internet-based intervention to improve psychosocial outcomes in heart transplant recipients and family caregivers: development and evaluation. Journal of Heart and Lung Transplant, 23 745-758. Dickerson, S.S., Flaig, D.M., & Kennedy, M.C. (2000) Therapeutic connection: help seeking on the Internet for persons with implan table cardioverter defibrillators. Heart and Lung, 29 248-255. Dunbar, S.B., Kimble, L.P., Jenkins, L.S., Hawt horne, M., Dudley, W., Slemmons, M., et al. (1999). Association of mood disturbance and arrhythmia events in patients after cardioverter defibrillator implantation. Depression and Anxiety, 9 163-168. Dusseldorp, E., van Elderen, T., Maes, S., Meulman, J., & Kraaij, V. (1999). A meta-analysis of psychoeducation programs for cor onary heart disease patients. Health Psychology, 18 506-519. Feil, E.G., Noell, J., Lichtenstein, E., Boles, S.M., & McKay, H.G. (2003). Evaluation of an Internet-based smoking cessa tion program: Lessons learned from a pilot study. Nicotine and Tobacco Research, 5 189-194. Frizelle, D.J., Lewin, R.J.P., Kaye, G., Hargreav es, C., Hasney, K., Beaumont, N., et al. (2004). Cognitive-behavioural rehabilitation progr amme for patients with an implanted cardioverter defibrilla tor: A pilot study. British Journal of Health Psychology, 9 381392.

PAGE 76

76 Gega, L., Marks, I., & Mataix-Cols, D. (2004). Computer-aided CBT self-help for anxiety and depressive disorders: experience of a London clinic and future directions. Journal of Clinical Psychology, 60 147-157. Glasgow, R.E., Boles, S.M., McKay, H.G., Feil, E.G., & Barrera, M., Jr. (2003). The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results. Preventive Medicine, 36 410-419. Godemann, F., Butter, C., Lampe, F., Linden, M., Schlegi. M., Schultheiss, H.P., et al. (2004). Panic disorders and agoraphobia: Side eff ects of treatment with an implantable cardioverter defibrillator. Clinical Cardiology, 27, 321-326. Goodman, M., & Hess, B. Could implantable cardi overter defibrillators provide a human model supporting the learned helplessn ess theory of depression? General Hospital Psychiatry, 21, 382-385. Gordon, N.F. (2003). New methods of delivering s econdary preventive services: The promise of the Internet. Journal of Cardi opulmonary Rehabilitation, 23, 349-351. Greenspan, R. (2002). Two-thirds hit the net [Online]. Retrieved October 15, 2003, Greenspan, R. (2003). Surfing with seniors a nd boomers [Online]. Retrieved October 15, 2003, from http://cyberatlas. internet.com/big_picture/dem ographics/article/0,,5901_1573621,00.html Haywood, C. (1995). Psychiatric Illne ss and cardiovascular disease risk. Epidemiology Review, 17 129-138. Herrman, C., von zur Muhen, F., Schaumann, A., Bu ss, U., Kemper, S., Wantzen, C., et al. (1997). Standardized assessm ent of psychological well-being and quality-of-life in patients with implanted defibrillators. Pacing and Clinical Electrophysiology, 20 95103. Irvine, J., Dorian, P., Baker, B., OBrien, B.J., R oberts, R., Gent, M., et al. (2002). Quality of life in the Canadian Implan table Defibrillator Study. American Heart Journal, 144 282289. Januzzi, J.L., Stern, T.A., Pasternak, R.C., & De Sanctis, R.W. (2000). The influence of anxiety and depression on outcomes of patie nts with coronary artery disease. Archives of Internal Medicine, 160 1913-1921. Kamphuis, H.C., de Leeuw, J.R., Derksen, R., Hauer, R.N., & Winnubst, J.A. (2003). Implantable cardioverter defibrillator recipien ts: quality of life in recipients with and without ICD shock delivery: a prospective study. Europace, 5 381-389.

PAGE 77

77 Kenwright, M., Liness, S., & Marks, I. (2001) Reducing demands on clinicians by offering computer-aided self-help for pobi c/panic. A feasibility study. British Journal of Psychiatry, 179 456-459. Kenwright, M., & Marks, I.M. ( 2004). Coputer-aided self-help fo r phobia/panic via internet at home: A pilot study. British Journal of Psychiatry, 184 448-449. Kohn, C.S., Petrucci, R.J., Soto, D.M., Baessl er, C., & Movsowitz, C. (2000). The effect of psychological intervention on patients' long-te rm adjustment to the ICD: A prospective study. Pacing and Clinical Electrophysiology, 23 450-456. Kubzansky, L.D., Kawachi, I., Weiss, S.T., & Sparrow, D. (1998). Anxiety and coronary heart disease: a synthesis of epidemiological, psychological, and expe rimental evidence. Annals of Behavioral Medicine, 20 47-58. Kuck, K.H., Cappato, R., Siebels, J., & Ruppe l, R., for the Cardiac Arrest Study Hamberg Investigators. (2000). Randomized comparis on of antiarrhythmic drug therapy with implantable defibrillators in patien ts resuscitated from cardiac arrest. Circulation, 102 748. Lee, A., Chui, P.T., & Gin, T. (2003). Educating patients about anesthesia: A systematic review of randomized controlled trials of media-based interventions. Anesthesia & Analgesia, 96 1424-1431. Lemon, J., Edelman, S., & Kirkness, A. (2004) Avoidance behavior s in patients with implantable cardivertoer defibrillators. Heart Lung, 33 176-82. Lenhart, A., Horrigan, J., Rainie, L., Allen, K., B oyce, A., Madden, M., et al. (2004). The evershifting Internet population. A ne w look at Internet access an d the digital divide. Pew Internet Project Report. Available at: http://207.21.232.103/PPF/r/88/ report_display.asp Accessed July 2, 2004. Linden, W., Stossel, C., & Maur ice, J. (1996). Psychosocial in terventions for patients with coronary artery disease. Archives of Internal Medicine, 156 745-752. Luderitz, B., Jung, W., Deister, A., & Manz, M. (1996). Quality of lif e in multiprogrammable implantable cardioverter-defi brillator recipients. In Interventional Elec trophysiology: A Textbook (Eds. Saskena, S. & Luderitz, B.), p. 305-313. Armonk, N.Y.: Futura Publishing Co., Inc. Mataix-Cols, D., & Marks, I.M. (2006). Self-hel p with minimal therapist contact for obsessivecompulsive disorder: A review. European Psychiatry, 21 75-80. Marks, I.M., Kenwright, M., McDonough, M., Whittak er M., & Mataix-Cols, D. (2004). Saving clinicians time by delegating routine aspect s of therapy to a computer: A randomized controlled trial in phobia/panic disorder. Psychology and Medicine, 34 9-17.

PAGE 78

78 McKinley, R., Manku-Scott, T., Hastings, A., Fr ench, D., & Baker, R. (1997). Reliability and validity of a new measure of patient satisfaction with out of hours primary medical care in the United Kingdom: Developm ent of a patient questionnaire. British Medical JournaL, 314 193-198. Mills, M.E., & Sullivan, K. (1999). The importa nce of information giving for patients newly diagnosed with cancer: a revi ew of the literature. Journal of Clinical Nursing, 8 631641. Moss, A. J., Hall, W. J., Cannom, D. S., Daubert, J. P., Higgins, S. L., Klien, H., et al., for the Moulding, R., & Kyrios, M. (2006). Anxiety disorders and control related beliefs: The exemplar of obsessive-compulsive disorder (OCD). Clinical Psychology Review, 26 573-583. Mullen, P.D., Mains, D.A., & Velez, R. (1992). A meta-analysis of controlled trials of cardiac patient education. Patient Education and Counseling, 19 143-162. Multicenter Automatic Defibrillator Implantation Tr ial Investigators. (1996). Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. New England Journal of Medicine, 335 1933-1940. Namerow, P.B., Firth, B.R., Heywood, G.M., Windl e, J.R., & Parides, M.K. (1999). Quality of life six months after CABG surgery in pa tients randomized to ICD versus no ICD therapy: findings from the CABG Patch trial. Pacing and Clinical Electrophysiology, 22, 1305. Napolitano, M.A., Fotheringham, M., Tate, D., Scia manna, C., Leslie, E., Owen, N. et al. (2003). Evaluation of an Internet-based physical activity interventio n: a preliminary investigation. Annals of Behavioral Medicine, 25 92-99 OLeary, C. J., & Jones, P. W. (2000). The le ft ventricular dysfuncti on questionnaire (LVD-36): Reliability, validity, and responsiveness. Heart, 83 634-640. Pauli, P., Wiedemann, G., Dengl er, W., Blaumann-Benninghoff, G., & Kuhlkemp, V. (1999). Anxiety in patients with an automatic im plantable cardioverter defibrillator: What differentiates them from panic patients? Psychosomatic Medicine, 61 69-76. Pauli, P., Wiedemann, G., Dengler, W., & Kuhlkam p, V. (2001). A priori expectancy bias and its relation to shock experience a nd anxiety: A naturalistic study in patients with an automatic implantable cardioverter defibrillator. Journal of Behavioral Therapy and Experimental Psychiatry, 32, 159-171. Poroch D. (1995). The effect of preparatory pati ent education on the anxiety and satisfaction of cancer patients receiv ing radiation therapy. Cancer Nursing, 18 206-14.

PAGE 79

79 Powell, P., Bentall., R. P., Nye, F.J., & Edwa rds, R. (2001). Randomi sed controlled trial of patient education to encour age graded exercise in chronic fatigue syndrome. British Medical Journal, 17 387-395. Renzi, C., Abeni, D., Picardi A., Agostini, E., Melchi, C.F., Pasquini, P. et al. (2001). Factors associated with patient satisfaction with care among dermatological outpatients. British Journal of Dermatology, 145, 617 Richards, J., Klein, B., & Carlbr ing, P. (2003). Internet-based treatment for panic disorder. Cognitive Behaviour Therapy, 32 125-135. Ritterband, L.M., Gonder-Frederick, L.A., Cox, D. J., Clifton, A.D., West, R.W., & Borowitz, S.M. (2003). Internet Inte rventions: In review in use, and into the future. Professional Psychology: Research and Practice, 34 527-534. Roberts, K. J. (2002). Physician-patient relati onships, patient satisfac tion, and antiretroviral medication adherence among HIV-infected a dults attending a public health clinic. AIDS Patient Care and STDs, 16 43-50. Ruggerio, C.M., Barr, E., Davis, J., Lau, R., Mina ssian, P., Selecky, C.E., et al. (2001). Disease management and e-Health can be successf ully merged. Paper presented at the 2001 Annual HIMSS Conference and Ex hibition. New Orleans, LA. Scherrer-Bannerman, A., Fofonoff, D., Minshall, D., Downie, S., Brown, M., Leslie, F., et al. (2000). Web-based education and support for pa tients on the cardiac surgery waiting list. Journal of Telemedi cine and Telecare, 6 S72-4. Schneider, A.J., Mataix-Cols, D., Marks, I.M., & Bachofen, M. (2005). In ternet-guided self-help with or without exposure thera py for phobic and panic disorders. Psychotherapy and Psychosomatics, 74, 154-164. Schron, E.B., Exner, D.V., Yao, Q., Jenkins, L.S ., Steinberg, J.S., Cook, J.R., et al. (2002). Quality of life in the antiarrhythmics versus implantable defibrillators trial: Impact of therapy and influence of adverse sy mptoms and defibrillator shocks. Circulation, 105 589-594. Schuster, P. M., Phillips, S., Dillon, D. L., & Tomich, P. L. (1998). The psychosocial and physiological experiences of pa tients with an implantable car dioverter defibrillator. Rehabilitation Nursing, 23, 30-7. Sears, S.F., Burns, J.L., Handberg, E. Sotile, W.M., & Conti, J.B. (2001). Young at heart: Understanding the unique psychosoc ial adjustment of young implantable cardioverter defibrillator recipients. Journal of Pacing and Clin ical Electrophysiology, 24 1113-1117.

PAGE 80

80 Sears, S.F., & Conti, J.B. (2002). Current views on the quality of life and psychological functioning of implantable cardi overter defibrillator patients. Heart, 87 488-493. Sears, S.F., & Conti, J.B. (2003). Understandi ng implantable cardioverter defibrillator shocks and storms: Medical and psychosocial consider ations for research and clinical care. Clinical Cardiology, 26 107-111. Sears, S.F., Kovacs, A.H., Azzarello, L., Larsen, K ., & Conti, J.B. (2004). Innovations in health psychology: the psychosocial care of adults with implantable cardioverter defibrillators. Professional Psychology Research Practice, 5 1-7. Sears, S.F., Kovacs, A.H., Serber, E.R., Kuhl, E.A, Vazquez, L.D., Handberg, E.M., et al. Psychosocial treatment to optimize quality of lif e in implantable cardioverter defibrillator patients. In preparation. Sears, S.F., Todaro, J.F., Lewis, T.S., Sotile, W., & Conti, J.B. (1999). Examining the psychosocial impact of implan table cardioverter defibrillato rs: A literature review. Clinical Cardiology, 22, 481-489. Shedd, O., Sears, S.F., Harvill, J.L., Arshad, A., Conti, J.B., Steinberg, J. S. et al. (2004). The World Trade Center attack: Increased frequency of defibrillator shocks for ventricular arrhythmias in patients living remotely from New York City. Journal of the American College of Cardiology, 44 1265-1267. Smith, M. L., & Glass, G. V. (1977). Meta -analysis of psychotherapy outcome studies. American Psychologist, 32 752-760. Southard, B.H., Southard, D.R., & Nuckolls, J. (2 003). Clinical trial of an Internet-based case management system for secondary prevention of heart disease. Journal of Cardiopulmonary Rehabilitation, 23 341-348. Spek, V., Cuijpers, P., Nyklick, I., Riper, H ., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychology and Medicine, 37 319-328. Steinberg, J.S., Arshad, A., Kowalski, M., Kuka r, A., Suma, V., Volka, M.E., et al. (2004). Incidence of life-threatening ve ntricular arrhythmias in implantable defibrillator patients after the World Trade Center attack. Journal of the American College of Cardiology, 44, 1261-1264. Sturdee, DW. (2000). The importance of patient education in improving compliance. Climacteric, 3 9-13. Tate, D.F., & Zabinski, M.F. ( 2004). Computer and Internet a pplications for psychological treatment: Update for clinicians. Journal of Clinical Psychology, 60 209-220.

PAGE 81

81 Tate, D.F., Jackvony, E.H., & Wing, R.R. ( 2003). Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA, 289 1833-1836. Ware, J. E., Kosinski, M., & Keller, S. D. (1995). SF-12: How to Score the SF-12 Physical and Mental Health Scales (2nd ed.). Boston, MA: The Health Institute, New England Medical Center. Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form health survey: Construction of scales and prelimin ary tests of reliability and validity. Medical Care, 34 (3), 220-233. Winzelberg, A.J., Taylor, C.B., Sharpe, T., Eldredge, K.L., Dev, P., & Constantinou, P.S. (1998). Evaluation of a computer-mediate d eating disorder intervention program. International Journal of Eating Disorders, 24 339-49. Winzelberg, A.J., Eppstein, D., Eldredge, K.L., Wilfley, D., Dasmahapatra, R., Dev, P., et al. (2000). Effectiveness of an Internet-based program for reducing risk factors for eating disorders. Journal of Consulting and Clinical Psychology, 68 346-350. Zimmerman, R.S. (1988). The dental appointment and patient beha vior. Differences in patient and practitioner prefer ences, patient satisfac tion, and adherence. Medical Care, 26 403414.

PAGE 82

82 BIOGRAPHICAL SKETCH Emily Ann Kuhl was born on July 19, 1978, at Lakenheath Royal Air Force Base in Lakenheath, England. The daughter of an Air For ce pilot, she spent her childhood living in three countries, including England, Germany, and the United States, and several states, including Virginia, California, New York, and Texas. She graduated from Monterey High School in Lubbock, Texas, at the age of 17. She then enro lled in Texas Tech University, where she received her bachelors degree in psychology at the age of 20. Following undergraduate training, Emily spent tw o years working as a features writer at the Manassas Journal Messenger and the Potomac News in suburban Washington, D.C. She later enrolled in the clinical psychol ogy masters program at East Carolina University in the fall of 2001. At this time, she began studying health psychology and developed what has become her primary interest within behavioral medicine cardiac psychology. In 2002, Emily was awarded the Department of Clinical Psychologys Gra duate Student of the Year award. Emily was accepted to the doctoral program with the Departme nt of Clinical and Health Psychology at the University of Florida in August 2003. There, sh e honed her expertise in cardiac psychology with foci in patients with implantable cardioverter defibrillators and adults with congenital heart disease. She has several publications in peer-revi ewed journals and has presented at numerous conferences. In June 2006, Emily began her ye ar-long pre-doctoral in ternship at the VA Maryland Health Care System/University of Maryland Psychology Internship Consortium. Upon receipt of her Ph.D., Emily will begin a postdoctoral position as a research associate at the University of Maryland Medical Center in Baltimore, MD. She has one sister, Amy Lazerson, and two nieces: Rebecca, age 7, and Sarah, age 5. Emily will have a nephew in late August.