Marginal structural model to evaluate the association between cumulative osteoporosis medication and infection using claims data

Due to the suboptimal persistence to osteoporosis (OP) treatment, factors triggering treatment discontinuation/switching may be causing time-varying confounding. BP treatment was associated with the risk of overall infection in opposite directions in the unweighted Cox model versus the weighted MSM. The discrepancy of effect estimates for overall infection in the MSM suggested there may be time-varying confounding.

INTRODUCTION

Due to the suboptimal persistence to osteoporosis (OP) treatment, factors triggering treatment discontinuation/switching may be affected by prior treatment and confound the subsequent treatment effect, causing time-varying confounding.

METHODS

In a US insurance database, the association between joint treatment of bisphosphonates (BP) and other OP medication and the incidence of infections among postmenopausal women was assessed using a marginal structural model (MSM). Stabilized weights were estimated by modeling treatment and censoring processes conditioning on past treatment, and baseline and time-varying covariates.

RESULTS

BP treatment was associated with the risk of overall infection in opposite directions in the unweighted Cox model {incidence rate ratio [IRR] [95% confidence interval (CI)] = 1.15 [1.14-1.17]} versus the weighted MSM [IRR (95% CI) = 0.79 (0.77-0.81)], but was consistently associated with a lower risk of serious infection in both the unweighted Cox model [IRR (95% CI] = 0.79 (0.78-0.81)) and the weighted MSM [IRR (95% CI) = 0.71 (0.68-0.75)]. Similar results were found when current and past treatments were simultaneously assessed.

CONCLUSIONS

The discrepancy of effect estimates for overall but not serious infection comparing unweighted models and MSM suggested analyses of composite outcomes with a wide range of disease severity may be more susceptible to time-varying confounding.

Predictors of response to pain management treatment. The role of family environment and changes in cognitive processes

OBJECTIVE

The purpose of the present study was to examine factors that influence individual differences in treatment response after multidisciplinary pain management.

DESIGN

Pre-post assessment design.

PATIENTS

119 chronic pain inpatients.

MAIN MEASURES

Outcome measures included pain report from the McGill Pain Questionnaire, emotional distress from the Symptom Checklist-90 Revised, and activity discomfort from the Activity Discomfort Scale. Process measures included the Family Environment Scale, the Coping Strategies Questionnaire, and the Inventory of Negative Thoughts in Response to Pain.

RESULTS

Results indicated that pretreatment family environment, cognitive coping strategies, and negative thinking accounted for small yet significant proportions of the variance in outcome. The proportion of variance accounted for by the changes in cognitive coping and negative thinking was somewhat higher. An increase in pain control and rational thinking was related to decreases in depression and anxiety, pain report, and activity discomfort. Decreases in negative social cognitions were related to decreased depression at posttreatment.

CONCLUSIONS

Changes in coping strategies and negative thinking may be important mechanisms related to improvement, or lack of improvement, in a range of outcome measures. Patients from families who are controlling and disorganized, and patients high on negative thinking at pretreatment may represent high-risk groups in need of further individually tailored interventions.

The right atrial free wall: an alternative pacing site

A major advantage of active fixation permanent pacing leads is their ability to be actively attached in areas where conventional passive fixation leads cannot be. In a review of records of 134 consecutive patients requiring dual chamber pacing, all of whom received active fixation atrial leads, 56 had right atrial appendage (AA) pacing and 78 had right atrial free-wall (AFW) pacing. Acute electrical parameters including sensed P wave amplitude (AA = 5.6 +/- 2.3 mV, AFW = 5.5 +/- 2.3 mV), slew rate (AA = 1.21 +/- 0.77 V/sec, AFW = 1.20 +/- 0.74 V/sec), stimulation thresholds (voltage and current) including rheobase voltage (AA = 0.6 +/- 0.2 V, AFW = 0.6 +/- 0.2 V), and pacing impedance (AA = 516 +/- 89 ohms, AFW = 504 +/- 84 ohms) were similar in both groups. There were two dislodgements (atrial appendage group) and no episodes of clinically important perforation or diaphragmatic stimulation. The free wall of the right atrium appears to be an excellent alternative pacing site to the appendage.

Religious coping and depression among elderly, hospitalized medically ill men

OBJECTIVE

The investigators examined the frequency of religious coping among older medical inpatients, the characteristics of those who use it, and the relation between this behavior and depression.

METHOD

The subjects were 850 men aged 65 years and over, without psychiatric diagnoses, who were consecutively admitted to the medical or neurological services of a southern Veterans Administration medical center. Religious coping was assessed with a three-item index. Depressive symptoms were assessed by self-rating (the Geriatric Depression Scale) and observer rating (the Hamilton Rating Scale for Depression).

RESULTS

One out of every five patients reported that religious thought and/or activity was the most important strategy used to cope with illness. Variables that were associated with religious coping included black race, older age, being retired, religious affiliation, high level of social support, infrequent alcohol use, a prior history of psychiatric problems, and higher cognitive functioning. Depressive symptoms were inversely related to religious coping, an association which persisted after other sociodemographic and health correlates were controlled. When 202 men were reevaluated during their subsequent hospital admissions an average of 6 months later, religious coping was the only baseline variable that predicted lower depression scores at follow-up.

CONCLUSIONS

These findings suggest that religious coping is a common behavior that is inversely related to depression in hospitalized elderly men.

Self-rated depressive symptoms in medical inpatients: age and racial differences

One thousand and eleven men under age forty (n = 161) or over age sixty-four (n = 850) admitted to medical and neurological services of an acute care hospital were screened for depressive symptoms as part of the Durham VA Mental Health Survey. Thirty-three percent of younger and 22 percent of older men scored 11 or higher on the Geriatric Depression Scale. Self-rated symptoms were most prevalent among younger whites (40%) and least common in older blacks (19%). Other exogenous factors such as being retired or unemployment and prior psychiatric history were also related to depressive symptoms, as were poor functional status, impaired cognitive status, and respiratory illness. Coping resources associated with fewer symptoms were social support and moderate alcohol use. In a subgroup of 443 patients, self-rated symptoms were compared with observer-rated symptoms. Agreement was highest among young Whites and lowest in older Blacks. Other correlates also varied depending on whether self-rated or observer-rated symptoms were considered. We conclude that self-rated symptoms are common among medical inpatients, are linked with and confounded by certain health and sociodemographic factors, and may be relatively insensitive as a measure of depression in elderly blacks.

Major depressive disorder in hospitalized medically ill patients: an examination of young and elderly male veterans

OBJECTIVE

To study the epidemiology of depressive disorder in younger and older medical inpatients.

DESIGN, PATIENTS, & SETTING

Depressive disorders were examined using the Diagnostic Interview Schedule in 116 young and 332 elderly medically ill men hospitalized in a VA medical center.

RESULTS

Major depressive disorder was diagnosed in 22.4% of men under 40 and 13.3% of those age 70 or over; minor depression was found in 18.1% of young and 29.2% of older men. Besides age, other risk factors for major depression were impaired social support, severe medical illness or functional disability in older men, and history of psychiatric problems primarily in younger men; specific medical diagnosis was not a risk factor. Major depression was associated with more severe symptomatology in younger patients; in both age groups, however, symptoms were of prolonged duration and frequently included suicidal thoughts.

CONCLUSIONS

Depressive disorder in hospitalized male veterans is common, varies with age, severity of medical illness, degree of social support, and history of psychiatric problems and is associated with considerable psychological morbidity.

Obsessive Compulsive Disorder: Improving prognosis through therapy and drug treatment

An estimated three to seven million Americans suffer from obsessive compulsive disorder at some time in their lives. Until recently, obsessive compulsive disorder was considered refractory to most treatments. However, recent studies indicate a better prognosis with behavioral therapy, antidepressant medications, or both. Behavioral treatment is generally more effective for compulsions than for obsessions.

Antidepressant use in elderly medical inpatients: lessons from an attempted clinical trial

The authors conducted a clinical trial to examine the efficacy and safety of nortriptyline in the treatment of major depression in elderly medical inpatients. The diagnosis of major depression was made by a psychiatrist in 41 of 680 patients 65 years of age or older. The study was balted at the midpoint because of inadequate patient recruitment, primarily a consequence of medical illnesses that prevented more than 80% of eligible patients from participating in or completing the clinical trial. Major or minor medical contraindications to the use of antidepressants were present in over 90% of depressed patients. Short-term follow-up was conducted on untreated depressed patients, those receiving antidepressants at the time of assessment, and those in whom antidepressant treatment was initiated after assessment. Non-randomized exposure to antidepressants did not predict remission of depression at follow-up due to spontaneous remission in the untreated group. Given the prevalence of medical contraindications to antidepressant use among depressed elderly patients and the problems with side effects in treated patients, there were few depressed, elderly hospitalized patients who were candidates for antidepressant therapy.

Survival and health care utilization in elderly medical inpatients with major depression

Forty-one elderly medical inpatients with active major depression were matched with nondepressed controls from the same population. Survival and health care utilization were examined during a mean follow-up period of five months. Cases and controls were matched by age, functional status, severity and type of medical illness, and extent of disease. In-hospital mortality was significantly higher among depressed compared with nondepressed controls (6 vs 0 deaths, P = .03). For patients discharged from the hospital alive, however, depression did not have a substantial impact on mortality (31.4% cases, 31.7% controls). Health care utilization--in terms of days of inpatient care--was significantly higher both during the index admission (25 vs 14 days, P less than .005) and during the follow-up period (16 vs 7 days, P less than .05) for depressed patients compared with controls. Hence, older medically ill patients with major depression consume more healthcare resources and experience greater mortality during their initial hospital stay. After discharge, while survival is little affected, excess resource utilization persists among those with depression.

Major depression and the NIMH Diagnostic Interview Schedule: validation in medically ill hospitalized patients

The authors validate the usefulness of the Diagnostic Interview Schedule (DIS) in prevalence studies of major depression (MD) in medically ill male veterans. The affective disorders portion of the DIS was administered by a trained interviewer to a representative sample of 408 medically-ill hospitalized patients (75% over age 70). Using a standardized handscoring method for the DIS, the patients were categorized as having or not having MD. Using a two-stage design, sixty-nine patients scoring above a cutoff score on a self-rated depression scale were referred for blind evaluation by a psychiatrist. The psychiatrist made a clinical diagnosis of MD using a standard checklist of DSM-III criteria. The DIS correctly diagnosed MD in 78 percent (14/18) of older and 69 percent (9/13) of younger patients, and correctly ruled out the disorder in 65 percent (15/23) of older and 67 percent (10/15) of younger patients; the kappa statistic of agreement was .40 in older and .36 in younger patients.