An analysis of administrative data found that proximate clinical event ratios provided a systematic approach to identifying possible iatrogenic risk factors or complications

Association between antidepressants with pneumonia and exacerbation in patients with COPD: a self-controlled case series (SCCS)

OBJECTIVE

To assess whether antidepressant prescriptions are associated with an increased risk of pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation.

METHODS

A self-controlled case series was performed to investigate the rates of pneumonia and COPD exacerbation during periods of being exposed to antidepressants compared with non-exposed periods. Patients with COPD with pneumonia or COPD exacerbation and at least one prescription of antidepressant were ascertained from The Health Improvement Network in the UK. Incidence rate ratios (IRR) and 95% CI were calculated for both outcomes.

RESULTS

Of 31 253 patients with COPD with at least one antidepressant prescription, 1969 patients had pneumonia and 18 483 had a COPD exacerbation. The 90-day risk period following antidepressant prescription was associated with a 79% increased risk of pneumonia (age-adjusted IRR 1.79, 95% CI 1.54 to 2.07). These associations then disappeared once antidepressants were discontinued. There was a 16% (age-adjusted IRR 1.16, 95% CI 1.13 to 1.20) increased risk of COPD exacerbation within the 90 days following antidepressant prescription. This risk persisted and slightly increased in the remainder period ((age-adjusted IRR 1.38, 95% CI 1.34 to 1.41), but diminished after patients discounted the treatment.

CONCLUSION

Antidepressants were associated with an increased risk of both pneumonia and exacerbation in patients with COPD, with the risks diminished on stopping the treatment. These findings suggest a close monitoring of antidepressant prescription side effects and consideration of non-pharmacological interventions.

Schizophrenia, but not depression or bipolar affective disorder, adds additional risk of aspiration pneumonia among stroke survivors: A national cohort study in Taiwan

OBJECTIVE

Few studies have assessed the sex-specific and age-specific risk of aspiration pneumonia (AP) in patients with stroke and evaluated whether mental disorders may increase this risk. In this population-based cohort study, we investigated the sex-specific and age-specific risk of AP in association with stroke and the joint effects of stroke and mental disorders on the risk of AP.

METHODS

We included 23,288 patients with incident stroke admitted between 2005 and 2017 and 68,675 matched nonstroke controls. Information on mental disorders was obtained from medical claims data within the 3 years before the stroke incidence. Cox proportional hazards models considering death as a competing risk event were constructed to estimate the hazard ratio of AP incidence by the end of 2018 associated with stroke and selected mental disorders.

RESULTS

After ≤14 years of follow-up, AP incidence was higher in the patients with stroke than in the controls (11.30/1000 vs. 1.51/1000 person-years), representing a covariate-adjusted subdistribution hazard ratio (sHR) of 3.64, with no significant sex difference. The sHR significantly decreased with increasing age in both sexes. Stratified analyses indicated schizophrenia but not depression or bipolar affective disorder increased the risk of AP in the patients with stroke.

CONCLUSION

Compared with their corresponding counterparts, the patients with schizophrenia only, stroke only, and both stroke and schizophrenia had a significantly higher sHR of 4.01, 5.16, and 8.01, respectively. The risk of AP was higher in younger stroke patients than those older than 60 years. Moreover, schizophrenia was found to increase the risk of AP in patients with stroke.

Insights Into Oropharyngeal Dysphagia From Administrative Data and Clinical Registries: A Literature Review

Purpose

The call for data-driven health care has been bolstered by the digitization of medical records, quality initiatives, and payment reform. Administrative databases and clinical registries are increasingly being used to study oropharyngeal dysphagia and to facilitate data-driven decision making. The objective of this work was to summarize key findings, etiologies studied, data sources used, study objectives, and quality of evidence of all original research articles that have investigated oropharyngeal dysphagia or aspiration pneumonia using administrative or clinical registry data to date.

Method

A literature search was completed in MEDLINE, Scopus, and Google Scholar (January 1, 1990, to February 1, 2017). Each study that met inclusion criteria was rated for quality of evidence on a 5-point scale.

Results

Eighty-four research articles were included in the final analysis (n = 221-1,649,871). Over the past 20 years, the number of new publications in this area has quintupled. Most of the administrative database and clinical registry studies of dysphagia have been retrospective cohort studies and cross-sectional studies and limited to quality of evidence levels of 3-4. In these studies, much has been learned about risk factors for dysphagia and pneumonia in defined populations and health care costs and usage. Little has been gleaned from these studies regarding swallowing physiology or dysphagia management.

Conclusions

Investigators are just beginning to develop the methods to study oropharyngeal dysphagia using administrative data and clinical registries. Future research is needed in all areas, from the fundamental issue of how to identify individuals with dysphagia with high sensitivity in these data sets to evaluating treatment effectiveness.

Supplemental Material

https://doi.org/10.23641/asha.6066515.

Risk of pneumonia in new users of cholinesterase inhibitors for dementia

OBJECTIVES

To compare the risk of pneumonia in older adults receiving donepezil, galantamine, or rivastigmine for dementia.

DESIGN

Retrospective cohort study.

SETTING

Nationally representative 5% sample of Medicare databases.

PARTICIPANTS

Medicare beneficiaries aged 65 and older who newly initiated cholinesterase inhibitor therapy between 2006 and 2009.

MEASUREMENTS

Pneumonia, defined as the presence of a diagnosis code for pneumonia as the primary diagnosis on an inpatient claim or on an emergency department claim followed by dispensing of appropriate antibiotics. Cox proportional hazards models were used to estimate the risk of pneumonia. Subgroup analyses and sensitivity analyses were conducted using alternative pneumonia definitions and adjustments using high-dimensional propensity scores to test the robustness of the results.

RESULTS

The mean age of 35,570 new users of cholinesterase inhibitors (30,174 users of donepezil, 1,176 users of galantamine, 4,220 users of rivastigmine) was 82; 75% were women, and 82% were white. The cumulative incidence of pneumonia was 51.9 per 1,000 person-years. The risk of pneumonia for rivastigmine users was 24% lower than that of donepezil users (hazard ratio (HR)=0.75, 95% confidence interval (CI)=0.60-0.93). Risk in galantamine users (HR=0.87, 95% CI=0.62-1.23) was not significantly different from risk in donepezil users. Results of subgroup and sensitivity analyses were similar to the primary results.

CONCLUSION

The risk of pneumonia was lower in individuals receiving rivastigmine than in those receiving donepezil. Additional studies are needed to confirm the findings of pneumonia risk between the oral and transdermal forms of rivastigmine and in users of galantamine.

Clinical management of abdominal trauma

OBJECTIVE

To improve the prognosis of patients with abdominal trauma.

METHODS

Between January 1993 and December 2005, 415 patients were enrolled in this research. The patients consisted of 347 males and 68 females with mean age of 36 years (ranging from 3-82 years). All abdominal traumas consisted of closed traumas (360 cases, 86.7%) and open traumas (55 cases, 13.3%).

RESULTS

A total of 407 cases (98.1%) were fully recovered from trauma and the other 8 cases (1.9%) died of multiple injuries. The mean injury severity score (ISS) of all patients was 22 while the mean ISS of the patients who died in hospital was 42. Postoperative complications were seen in 9 patients such as infection of incisional wounds (6 cases), pancreatic fistula (2 cases) and intestinal fistula (1 case). All these postoperative complications were cured by the conservative treatment.

CONCLUSION

Careful case history inquisition and physical examination are the basic methods to diagnose abdominal trauma. Focused abdominal ultrasonography is always the initial imaging examination because it is non-invasive and can be performed repeatedly with high accuracy. The doctors should consider the severity of local injuries and the general status of patients during the assessment of abdominal trauma. The principle of treatment is to save lives at first, then to cure the injuries. Unnecessary laparotomy should be avoided to reduce additional surgical trauma.

Observed association between antidepressant use and pneumonia risk was confounded by comorbidity measures

OBJECTIVE

A prior study suggested that antidepressants might increase the risk of hospitalization for pneumonia in the elderly. This study sought to confirm or refute this hypothesis.

STUDY DESIGN AND SETTING

Case-control study of persons aged 65 and above nested in the UK General Practice Research Database.

RESULTS

We identified 12,044 cases of the hospitalization for pneumonia (the primary outcome) and 48,176 controls. The odds ratio (OR) for any antidepressant use, adjusting for age, sex, and calendar year was 1.61 (95% confidence interval 1.46-1.78). After further adjustment for comorbidity measures, the OR was 0.89 (0.79-1.00). We also identified 159 cases of hospitalization for aspiration pneumonia (the secondary outcome) and 636 controls. The OR for any antidepressant use, adjusted for age, sex, and calendar year was 1.45 (0.65-3.24). After further adjustment for comorbidity measures, the OR was 0.63 (0.23-1.71).

CONCLUSION

These findings refute the prior hypothesis that use of antidepressants by elderly patients increases the risk of hospitalization for pneumonia or for aspiration pneumonia. Decisions regarding use of antidepressants in elderly persons should not be affected by concern about pneumonia risk. Data-derived hypotheses should be independently confirmed before being acted upon.