0182 The Sleep Regularity Questionnaire: Development and Preliminary Psychometric Properties

Abstract Introduction Sleep is a critically important behavior which influences diverse aspects of health, functioning, and longevity. An increasing literature suggests the importance of sleep regularity, also referred to as sleep inconsistency, sleep variability, or intraindividual variability in sleep. Given there is no brief, subjective measure of sleep regularity, the purpose of this study was to examine the psychometric properties of an in-development, ten-item Sleep Regularity Questionnaire (SRQ). Methods In an online study of sleep and health, participants (n = 3284; Mage (SD)= 42.74(16.72); 47.8% female; 77.1% white) completed the in-development SRQ, as well as other sleep-related measures including the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI). Results An exploratory factor analysis on a random half of the sample revealed a two factor structure, with four items representing “circadian regularity” and two items representing “sleep disturbance regularity.” A confirmatory factor analysis on the other random half of the sample fit the two factor model with good model fit indices (X2 = 50.9, df = 7, p < .001; RMSEA = .06; CFI= .99; NFI = .99; IFI = .99; TLI = .98). The SRQ was negatively associated with poor sleep quality measured via the PSQI (r = -.37, p < .001) and negatively associated with insomnia severity measured via the ISI (r = -.40, p < .001). Conclusion The SRQ appears to be a valid instrument for the assessment of sleep regularity in adults that is related to, but distinct from, other established sleep constructs. Future research will benefit from examining test-retest reliability of the measure as well as assessing the validity of the SRQ as a measure of objective sleep regularity by comparing it to conventional diary, actigraphy, and/or polysomnography methods of sleep assessment. Support This work was supported by the National Institute on Aging of the National Institutes of Health under Award Number K23AG049955 (PI: Dzierzewski). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Relationships Among Types of Activity Engagement and Sleep Quality Among Older Adults

Innovation in Aging ◽

10.1093/geroni/igaa057.1385 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 429-429

Author(s):

Da Eun Kim ◽

Tonya Roberts

Keyword(s):

Older Adults ◽

Sleep Quality ◽

Factor Model ◽

Secondary Data ◽

Single Type ◽

Future Research ◽

Poor Sleep ◽

Validity And Reliability ◽

Primary Analysis ◽

Activity Engagement

Abstract There is increasing awareness that lack of activity engagement is associated with poor sleep quality. However, the majority of studies have focused on the effect of a single type of activity engagement on sleep quality. Little is known about the combined effect of multiple types of activity engagement on sleep quality. The aim of this study is to identify relationships among different types of activity engagement and sleep quality among older adults. This study is a secondary data analysis using the Health and Retirement Study data. The participants included 3,357 persons who were age 65 or older and who responded to survey modules on activity engagement and sleep quality in 2016. Before we conducted primary analysis, factor analyses and calculating coefficient omega were conducted to identify factor structure, construct validity and reliability of the activity engagement questionnaire. Then, regression was conducted to examine the relationships among multiple types of activity engagement and sleep quality after adjusting for covariates based on the senescent sleep model. Exploratory and confirmatory factor analysis showed the 14-item questionnaire was comprised of three factors; social, cognitive, and physical activity and the three-factor model showed adequate validity and reliability. In the regression model social (β=0.25, p=0.033) and cognitive (β=0.36, p=0.001) activity engagement were positively related to better sleep quality. Based on these results, future research is needed to identify the mechanisms in which social and cognitive activities influence sleep quality positively and to develop targeted activity interventions for older adults.

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Factor structure and psychometric properties of the Insomnia Severity Index in Mainland China

Social Behavior and Personality An International Journal ◽

10.2224/sbp.6639 ◽

2018 ◽

Vol 46 (2) ◽

pp. 209-218 ◽

Cited By ~ 1

Author(s):

Rong-Mao Lin ◽

Shan-Shan Xie ◽

Wen-Jing Yan ◽

You-Wei Yan

Keyword(s):

Factor Analysis ◽

Psychometric Properties ◽

Factor Structure ◽

Severity Index ◽

Internal Reliability ◽

Mainland Chinese ◽

Insomnia Severity Index ◽

Multiple Group ◽

Chinese Undergraduates ◽

Insomnia Severity

We explored the factor structure and psychometric properties of the Insomnia Severity Index (ISI) using 3 samples totaling 2,066 Mainland Chinese undergraduates. All participants completed the ISI and Sample 2 completed 3 other related measures. Their responses were processed using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and multiple group analyses. The EFA results revealed a 2-factor structure, whereas the CFA results supported a 3-factor solution, the latter of which was further confirmed by the results of multiple group analyses. The Chinese version of the ISI had a satisfactory Cronbach's alpha coefficient of internal reliability, 2-week test–retest reliability, and criterion validity. Overall, we found that the ISI is a reliable, valid, and psychometrically sound measure of insomnia for use with Mainland Chinese undergraduates.

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Psychometric Properties of the Persian Pittsburgh Sleep Quality Index for Adolescents

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17197095 ◽

2020 ◽

Vol 17 (19) ◽

pp. 7095

Author(s):

Azita Chehri ◽

Serge Brand ◽

Nastaran Goldaste ◽

Sodabeh Eskandari ◽

Annette Brühl ◽

...

Keyword(s):

Factor Analysis ◽

Sleep Quality ◽

Psychometric Properties ◽

Quality Index ◽

Pittsburgh Sleep Quality Index ◽

Health Concern ◽

Poor Sleep ◽

Sleep Patterns ◽

Factor Solution ◽

Persian Version

Background: Both cross-sectional and longitudinal studies show that poor sleep is a health concern related to further psychological and physiological issues during adolescence. To assess subjective sleep quality and sleep patterns among adults, the Pittsburgh Sleep Quality Index (PSQI) is a well and internationally established tool. Here, we established the psychometric properties of the Persian version of the PSQI for adolescents. Method: A total of 1477 adolescents (mean age: 15.47 years; 53.2% females) took part in the study. They completed a booklet on sociodemographic information, the Persian version of the PSQI for adolescents, and the Adolescent Sleep Hygiene Scale (ASHS). We relied on classical test reliability approaches of exploratory and confirmatory factor analyses. Results: Classical exploratory factor analysis yielded the seven-factor solution, with concurrent confirmation and overlap with the dimensions of the ASHS, although correlation coefficients were small to medium. A further factor analysis yielded a four-factor solution, explaining 72% of the variance of the PSQI. Further, three out of these four factors predicted the ASHS overall score. Conclusions: The Persian version of the PSQI for adolescents showed satisfactory psychometric properties. It follows that the Persian PSQI is a suitable tool to assess sleep quality and sleep patterns among adolescents.

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722 Sleep Loss in Healthcare Workers During the COVID-19 Pandemic

SLEEP ◽

10.1093/sleep/zsab072.862 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A-A

Author(s):

Nancy Stewart ◽

Anya Koza ◽

Serena Dhaon ◽

Christiana Shoushtari ◽

Maylyn Martinez ◽

...

Keyword(s):

Social Media ◽

Sleep Quality ◽

Healthcare Workers ◽

Sleep Disturbances ◽

Severity Index ◽

Poor Sleep ◽

Career Information ◽

Multivariable Regression ◽

Home Stress ◽

Insomnia Severity

Abstract Introduction During the pandemic, healthcare workers have shared their stresses on social media, including regarding sleep disturbances. However, an assessment of sleep using validated measures among healthcare workers on social media is lacking. Methods A restricted, self-selection survey was distributed on Facebook, Twitter, and Instagram for 16 days targeting healthcare workers who were clinically active during COVID-19. In addition to demographics and career information, participants completed the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index. Poor sleep quality was defined as PSQI > 5. Moderate-to-severe insomnia was defined as an ISI > 14. Multivariate logistic regression tested the association between demographics and career characteristics and sleep outcomes. Results Of the 983 who clicked our link, 906 completed the survey. Participants were mostly white (70%), female (75%), physicians (64%). Mean sleep duration was 6.1 (SD1.2) hours. Nearly 90% experienced poor sleep (PSQI). One third reported moderate or severe insomnia. Many (60%) reported sleep disruptions due to device usage or due to bad dreams at least once per week (45%). In multivariable regression, non-physicians (OR 3.5, CI: 2.5, 5.0), Hispanic ethnicity (OR 2.2; CI: 1.44, 3.45), being single (1.5, CI: 1.03, 2.21), and youngest age group (18–24) (OR 9.9; CI: 1.44, 68.09) had increased odds of insomnia. In open-ended comments, sleep disruptions mapped to 5 categories: (1) Work demands (“The volume of calls and messages from my patient and caregiver population is through the roof”); (2) Pandemic related (“I never had sleep issues prior to the COVID-19 pandemic. Suddenly I had issues with sleep initiation.”; (3) Children and family (“COVID plus home stress plus stress over my kids, my job, my marriage.”); (4) Personal health (“Insomnia predating COVID, but worsened with COVID.”); (5) Responses to the pandemic (“I worry about how COVID is being managed by the President...This does keep me awake at night.”). Conclusion During the COVID-19 pandemic, 90% of healthcare workers surveyed on social media reported poor sleep, with over one-third of participants reporting moderate-severe insomnia. Online sleep interventions for healthcare workers are urgently needed. Support (if any):

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Mindfulness-based therapy for insomnia for older adults with sleep difficulties: a randomized clinical trial

Psychological Medicine ◽

10.1017/s0033291721002476 ◽

2021 ◽

pp. 1-11

Author(s):

Francesca Perini ◽

Kian Foong Wong ◽

Jia Lin ◽

Zuriel Hassirim ◽

Ju Lynn Ong ◽

...

Keyword(s):

Older Adults ◽

Sleep Quality ◽

Behavioral Therapy ◽

Sleep Onset ◽

Exercise Program ◽

Severity Index ◽

Poor Sleep ◽

Sleep Onset Latency ◽

Post Intervention ◽

Insomnia Severity

Abstract Objective Poor sleep is a modifiable risk factor for multiple disorders. Frontline treatments (e.g. cognitive-behavioral therapy for insomnia) have limitations, prompting a search for alternative approaches. Here, we compare manualized Mindfulness-Based Therapy for Insomnia (MBTI) with a Sleep Hygiene, Education, and Exercise Program (SHEEP) in improving subjective and objective sleep outcomes in older adults. Methods We conducted a single-site, parallel-arm trial, with blinded assessments collected at baseline, post-intervention and 6-months follow-up. We randomized 127 participants aged 50–80, with a Pittsburgh Sleep Quality Index (PSQI) score ⩾5, to either MBTI (n = 65) or SHEEP (n = 62), both 2 hr weekly group sessions lasting 8 weeks. Primary outcomes included PSQI and Insomnia Severity Index, and actigraphy- and polysomnography-measured sleep onset latency (SOL) and wake after sleep onset (WASO). Results Intention-to-treat analysis showed reductions in insomnia severity in both groups [MBTI: Cohen's effect size d = −1.27, 95% confidence interval (CI) −1.61 to −0.89; SHEEP: d = −0.69, 95% CI −0.96 to −0.43], with significantly greater improvement in MBTI. Sleep quality improved equivalently in both groups (MBTI: d = −1.19; SHEEP: d = −1.02). No significant interaction effects were observed in objective sleep measures. However, only MBTI had reduced WASOactigraphy (MBTI: d = −0.30; SHEEP: d = 0.02), SOLactigraphy (MBTI: d = −0.25; SHEEP: d = −0.09), and WASOPSG (MBTI: d = −0.26; SHEEP (d = −0.18). There was no change in SOLPSG. No participants withdrew because of adverse effects. Conclusions MBTI is effective at improving subjective and objective sleep quality in older adults, and could be a valid alternative for persons who have failed or do not have access to standard frontline therapies.

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Measuring Subjective Sleep Quality: A Review

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18031082 ◽

2021 ◽

Vol 18 (3) ◽

pp. 1082

Author(s):

Marco Fabbri ◽

Alessia Beracci ◽

Monica Martoni ◽

Debora Meneo ◽

Lorenzo Tonetti ◽

...

Keyword(s):

Construct Validity ◽

Sleep Quality ◽

Psychometric Properties ◽

Internal Consistency ◽

Self Report ◽

Measurement Properties ◽

Poor Sleep ◽

Daily Routine ◽

Factorial Structure ◽

Poor Sleep Quality

Sleep quality is an important clinical construct since it is increasingly common for people to complain about poor sleep quality and its impact on daytime functioning. Moreover, poor sleep quality can be an important symptom of many sleep and medical disorders. However, objective measures of sleep quality, such as polysomnography, are not readily available to most clinicians in their daily routine, and are expensive, time-consuming, and impractical for epidemiological and research studies., Several self-report questionnaires have, however, been developed. The present review aims to address their psychometric properties, construct validity, and factorial structure while presenting, comparing, and discussing the measurement properties of these sleep quality questionnaires. A systematic literature search, from 2008 to 2020, was performed using the electronic databases PubMed and Scopus, with predefined search terms. In total, 49 articles were analyzed from the 5734 articles found. The psychometric properties and factor structure of the following are reported: Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale (AIS), Insomnia Severity Index (ISI), Mini-Sleep Questionnaire (MSQ), Jenkins Sleep Scale (JSS), Leeds Sleep Evaluation Questionnaire (LSEQ), SLEEP-50 Questionnaire, and Epworth Sleepiness Scale (ESS). As the most frequently used subjective measurement of sleep quality, the PSQI reported good internal reliability and validity; however, different factorial structures were found in a variety of samples, casting doubt on the usefulness of total score in detecting poor and good sleepers. The sleep disorder scales (AIS, ISI, MSQ, JSS, LSEQ and SLEEP-50) reported good psychometric properties; nevertheless, AIS and ISI reported a variety of factorial models whereas LSEQ and SLEEP-50 appeared to be less useful for epidemiological and research settings due to the length of the questionnaires and their scoring. The MSQ and JSS seemed to be inexpensive and easy to administer, complete, and score, but further validation studies are needed. Finally, the ESS had good internal consistency and construct validity, while the main challenges were in its factorial structure, known-group difference and estimation of reliable cut-offs. Overall, the self-report questionnaires assessing sleep quality from different perspectives have good psychometric properties, with high internal consistency and test-retest reliability, as well as convergent/divergent validity with sleep, psychological, and socio-demographic variables. However, a clear definition of the factor model underlying the tools is recommended and reliable cut-off values should be indicated in order for clinicians to discriminate poor and good sleepers.

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Sleep symptomatology is associated with greater subjective cognitive concerns: Findings from the community-based Healthy Brain Project

SLEEP ◽

10.1093/sleep/zsab097 ◽

2021 ◽

Author(s):

Jessica Nicolazzo ◽

Katharine Xu ◽

Alexandra Lavale ◽

Rachel Buckley ◽

Nawaf Yassi ◽

...

Keyword(s):

Cognitive Function ◽

Sleep Quality ◽

Cognitive Performance ◽

Sex Education ◽

Severity Index ◽

Analysis Of Covariance ◽

Psychomotor Function ◽

Community Based ◽

The Relationship ◽

Insomnia Severity

Abstract Study objectives To examine if sleep symptomatology was associated with subjective cognitive concerns or objective cognitive performance in a dementia-free community-based sample. Methods A total of 1421 middle-aged participants (mean±standard deviation = 57±7; 77% female) from the Healthy Brain Project completed the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and Epworth Sleepiness Scale (ESS) to measure sleep quality, insomnia symptom severity, and daytime sleepiness, respectively. Participants were classified as having no sleep symptomatology (normal scores on each sleep measure), moderate sleep symptomatology (abnormal scores on one sleep measure), or high sleep symptomatology (abnormal scores on at least two sleep measures), using established cut-off values. Analysis of covariance was used to compare objective cognitive function (Cogstate Brief Battery) and subjective cognitive concerns (Modified Cognitive Function Instrument) across groups. Results Following adjustments for age, sex, education, mood, and vascular risk factors, persons classified as having high sleep symptomatology, versus none, displayed more subjective cognitive concerns (d=0.24) but no differences in objective cognitive performance (d=0.00-0.18). Subjective cognitive concerns modified the association between sleep symptomatology and psychomotor function. The strength of the relationship between high sleep symptomatology (versus none) and psychomotor function was significantly greater in persons with high as compared with low cognitive concerns (β±SE =-0.37±0.16; p=0.02). Conclusions More severe sleep symptomatology was associated with greater subjective cognitive concerns. Persons reporting high levels of sleep symptomatology may be more likely to display poorer objective cognitive function in the presence of subjective cognitive concerns.

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Validation of the psychometric properties of the Malay advance care planning questionnaire

BMC Palliative Care ◽

10.1186/s12904-021-00790-7 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Mun Kit Lim ◽

Pauline Siew Mei Lai ◽

Pei Se Wong ◽

Sajaratulnisah Othman ◽

Fadzilah Hanum Mohd Mydin

Keyword(s):

Factor Analysis ◽

Psychometric Properties ◽

Advance Care Planning ◽

Response Rate ◽

Factor Model ◽

Tertiary Education ◽

Primary Care Clinic ◽

Care Planning ◽

Care Clinic ◽

Advance Care

Abstract Background There is a growing interest among the developing countries on advance care planning (ACP) due to the reported benefits of planning ahead in the developed countries. Validated instruments in various languages have been developed to facilitate study on the views of public prior to its implementation. However, instrument to explore the views on ACP in Malay has not been developed and validated yet, even though Malay is spoken extensively by approximately 220 million people in the Malay Archipelago. There is also a need for instrument in Malay language to facilitate the assessment of knowledge, attitude and practice (KAP) of Malaysians regarding ACP. Therefore, the aim of this study was to validate the psychometric properties of the Malay Advance Care Planning Questionnaire (ACPQ-M). Methods The ACPQ was translated according to international guidelines. This validation study was conducted from January to June 2018. Participants who were ≥ 21 years old, and able to understand Malay were recruited from an urban primary care clinic and a tertiary education institution in Malaysia. A researcher administered the ACPQ-M to participants via a face-to-face interview at baseline and 2 weeks later. Each interview took approximately 10–20 min. Results A total of 222/232 participants agreed to participate (response rate = 96.0%). Exploratory factor analysis and confirmatory factor analysis found that the ACPQ-M was a 4-factor model. The Cronbach’s α values for the four domains ranged from 0.674–0.947. Only 157/222 participants completed the test-retest (response rate = 71%). At test-retest, quadratic weighted kappa values for all domains ranged from 0.340–0.674, except for two domains which ranged from − 0.200-0.467. Conclusions The ACPQ-M was found to be a 4-factor model, and a valid and reliable instrument to assess the KAP regarding ACP. This instrument can contribute to profound understanding of the KAP of Malaysians regarding ACP, and assist policy makers in determining the readiness for legislation of ACP in Malaysia.

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Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

Otolaryngology ◽

10.1177/0194599817737977 ◽

2017 ◽

Vol 158 (2) ◽

pp. 249-256 ◽

Cited By ~ 12

Author(s):

Daniel C. Sukato ◽

Jason M. Abramowitz ◽

Marina Boruk ◽

Nira A. Goldstein ◽

Richard M. Rosenfeld

Keyword(s):

Systematic Review ◽

Sleep Quality ◽

Chronic Rhinosinusitis ◽

Endoscopic Sinus Surgery ◽

Meta Analysis ◽

Research Direction ◽

Sinus Surgery ◽

Future Research ◽

Apnea Hypopnea Index ◽

Poor Sleep

Objective Up to 75% of patients with chronic rhinosinusitis (CRS) suffer with poor sleep quality and reduced quality of life. Endoscopic sinus surgery has demonstrated encouraging results in improving sleep function. The aim of this systematic review is to assess the change in sleep quality after surgery for CRS. Data Sources PubMed, Web of Science, EMBASE. Review Methods An electronic search was conducted with the keywords “sinusitis” or “rhinosinusitis” and “sleep.” Studies were included only when adults underwent endoscopic sinus surgery and were evaluated pre- and postoperatively by the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Apnea-Hypopnea Index (AHI), the sleep domain of Sino-Nasal Outcome Test–22, or the sleep domain of Rhinosinusitis Disability Index. Results The database search yielded 1939 studies, of which 7 remained after dual-investigator screening. The standardized mean differences (95% CI) for the ESS, PSQI, and AHI were −0.94 (−1.63 to −0.26), −0.80 (−1.46 to −0.14), and −0.20 (−0.32 to −0.07), indicating large, moderate to large, and small improvements, respectively. All analyses displayed high heterogeneity ( I2 = 95%-99%). Conclusion Sleep quality, as measured by the ESS and PSQI surveys, shows substantial improvement after surgery for CRS, with smaller improvement seen for AHI. Generalizability of our results is limited by high heterogeneity among studies and by broad confidence intervals that cannot exclude small to trivial changes. The findings of this meta-analysis provide insight into the effect of CRS-related endoscopic sinus surgery on sleep quality, which should guide future research direction and counseling of patients in the clinical setting.

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351 Informal Caregivers with Insomnia May Benefit From an Insomnia Treatment Using an Acceptance and Commitment Therapy Approach

SLEEP ◽

10.1093/sleep/zsab072.350 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A140-A140

Author(s):

Yeonsu Song ◽

Sarah Kate McGowan ◽

Monica Kelly ◽

Gwendolyn Carlson ◽

Constance Fung ◽

...

Keyword(s):

Sleep Quality ◽

Experiential Avoidance ◽

Behavioral Therapy ◽

Informal Caregivers ◽

Women Veterans ◽

Severity Index ◽

Poor Sleep ◽

Acceptance And Commitment ◽

Insomnia Treatment ◽

Daytime Impairment

Abstract Introduction Insomnia among informal caregivers (providing care to family/friends) is common and associated with worse mental and physical health outcomes. Traditional cognitive behavioral therapy for insomnia may be challenging for caregivers whose beliefs about sleep may relate to beliefs and behaviors that are intertwined with their unique situation of caregiving. We examined whether an insomnia treatment using an acceptance and commitment (ACT) approach (i.e. committing to values-based actions toward goals vs. experiential avoidance of distressing emotions/thoughts) plus sleep restriction, stimulus control and sleep hygiene improves sleep, mental health, and daytime symptoms among caregivers. Methods We analyzed data from women veterans with insomnia who were informal caregivers (mean age=44 years [range 25–57]; N=6) and were participating in a clinical trial of an ACT-focused treatment (termed ABC-I). We measured: Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Patient Health Questionnaire (PHQ-9), General Anxiety Disorder (GAD-7), 11 items assessing symptoms of daytime impairment due to poor sleep derived from the International Classification of Sleep Disorders-Third Edition, and the Acceptance and Action Questionnaire (AAQ). Student t-tests were used to compare outcomes between pre- and post-ABC-I. Results Caregivers showed significant improvements between pre- and post-ABC-I (all p-values<0.05) in the following outcomes: ISI (14.3±5.4 vs. 3.8±3.2), PHQ-9 (9.8±7.2 vs. 2.8±3.8), GAD-9 (9.0±6.6 vs. 2.0±1.8), and number of symptoms of sleep-related daytime impairment (6.8±4.0 vs. 3.8±3.5). Caregivers also showed improvement trends in PSQI (10.0±4.1 vs. 5.2±1.2, p=0.06) and AAQ score (24.0±12.7 vs. 16.2±8.0, p=0.05). Conclusion We found that caregivers with insomnia may benefit from ACT-based treatment in improving perceived sleep quality and insomnia, depression, anxiety, sleep-related daytime impairment and reduced experiential avoidance. This approach may increase motivation by linking the sleep program to core values, and acceptance and tolerance of emotions or thoughts may benefit caregivers with insomnia. Further studies using an ACT-based insomnia program are needed to test its effect in a larger sample of caregivers and evaluate benefits in terms of reduced stress and improved health. Support (if any) VA HSR&D (Martin IIR 13-058-2 and RCS-20–191), NIA (K23AG055668, Song), NHLBI (K23HL143055, Martin) of the NIH, VAGLAHS GRECC, and VA Office of Academic Affiliations (Kelly; Carlson).

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