Search

Background: Central nervous system (CNS)‐active medication use is an important modifiable risk factor for falls in older adults. A fall‐related injury should prompt providers to evaluate and reduce CNS‐active medications to prevent recurrent falls. We evaluated change in CNS‐active medications up to 12 months following a fall‐related injury in community‐dwelling older adults compared with a matched cohort without fall‐related injury. Methods: Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall‐related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall‐related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS‐active medication use at 3, 6, and 12 months post‐index according to the presence or absence of CNS‐active medication use before index. Results: One thousand five hundred sixteen participants with fall‐related injury index encounters (449 CNS‐active users, 1067 nonusers) were matched to 7014 index encounters from people without fall‐related injuries (1751 users, 5236 nonusers). Among CNS‐active users at the index encounter, those with fall‐related injury had an average decrease in standard daily doses (SDDs) at 12 months (−0.43; 95% CI: −0.63 to −0.23), and those without injury had a greater (p = 0.047) average decrease (−0.66; 95% CI: −0.78 to −0.55). Among nonusers at index, those with fall‐related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005). Conclusions: The differences in CNS‐active medication use change over 12 months between those with and without fall‐related injury were small and unlikely to be clinically significant. These results suggest that fall risk‐increasing drug use is not reduced following a fall‐related injury, thus opportunities exist to reduce CNS‐active medications, a potentially modifiable risk factor for falls. [ABSTRACT FROM AUTHOR]

Clinical visit data are clustered within people, which complicates prediction modeling. Cluster size is often informative because people receiving more care are less healthy and at higher risk of poor outcomes. We used data from seven health systems on 1,518,968 outpatient mental health visits from January 1, 2012 to June 30, 2015 to predict suicide attempt within 90 days. We evaluated true performance of prediction models using a prospective validation set of 4,286,495 visits from October 1, 2015 to September 30, 2017. We examined dividing clustered data on the person or visit level for model training and cross‐validation and considered a within cluster resampling approach for model estimation. We evaluated optimism by comparing estimated performance from a left‐out testing dataset to performance in the prospective dataset. We used two prediction methods, logistic regression with least absolute shrinkage and selection operator (LASSO) and random forest. The random forest model using a visit‐level split for model training and testing was optimistic; it overestimated discrimination (area under the curve, AUC = 0.95 in testing versus 0.84 in prospective validation) and classification accuracy (sensitivity = 0.48 in testing versus 0.19 in prospective validation, 95th percentile cut‐off). Logistic regression and random forest models using a person‐level split performed well, accurately estimating prospective discrimination and classification: estimated AUCs ranged from 0.85 to 0.87 in testing versus 0.85 in prospective validation, and sensitivity ranged from 0.15 to 0.20 in testing versus 0.17 to 0.19 in prospective validation. Within cluster resampling did not improve performance. We recommend dividing clustered data on the person level, rather than visit level, to ensure strong performance in prospective use and accurate estimation of future performance at the time of model development. [ABSTRACT FROM AUTHOR]

Background: Despite extensive interest in risk for dementia following traumatic brain injury (TBI), there is scant research on neuropathological outcomes among community‐dwelling elders with TBI exposure. We previously reported an association of TBI resulting in loss of consciousness (LOC) with microinfarcts and Lewy body pathology, but TBI exposure data were limited to a single self‐report question. With expanded ascertainment data from medical records and structured interview on lifetime TBI exposure, we conducted a comprehensive investigation of neuropathological associations of TBI in a large autopsy cohort. Method: 780 older adults from the Adult Changes in Thought (ACT) study underwent brain autopsy (Table 1). Participants were members of Kaiser Permanente Washington who completed biennial clinic visits including self‐reported head trauma with LOC exposure. These data were supplemented with medical record abstraction, and, for 244 people, with structured interviews, increasing the sensitivity for TBI‐LOC in that sample from 16% to 20% (see Figure 1). Neuropathology outcomes included neurofibrillary tangle distribution (Braak), neuritic plaque density, Lewy body distribution, vascular pathology, hippocampal sclerosis, and cerebral cortical atrophy. Exposures of interest included TBI with or without LOC. We used Poisson regressions with robust standard errors adjusted for age, sex, education, and APOε4 genotype, weighted back to the full cohort (n=5546; Table 2) in a bootstrapping procedure accounting for errors in estimating weights. Result: TBI with LOC was associated with increased cortical atrophy (Table 3). In those with the structured interview (including TBI without LOC), the neuropathological associations of TBI were attenuated; no outcomes were statistically significant (Table 4). These findings apply to the full ACT cohort, not just people with TBI data in the autopsy sample. Conclusion: Cerebral cortical atrophy results from chronic brain parenchymal injury, potentially including vascular brain injury and tauopathy. Understanding mechanisms underlying associations of TBI with microvascular brain injury and pathological tau are poorly understood; future studies deploying new techniques to better quantify these lesions and differentiate between TBI‐related, age‐related, and ADRD‐related pathways are needed. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Early recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)‐based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]). DESIGN: Retrospective cohort study. SETTING: Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system. PARTICIPANTS: A total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples. MEASUREMENTS: EHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills). RESULTS: Overall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31‐predictor model included markers of dementia‐related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic =.78; 95% confidence interval [CI] =.76‐.81) and validation (C statistic =.81; 95% CI =.78‐.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia. CONCLUSION: The eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103–111, 2019 [ABSTRACT FROM AUTHOR]

Objectives: To examine the association between central nervous system (CNS)‐active medication use and the risk of fall‐related injury in community‐dwelling older adults following dementia onset. Further, to evaluate increased risk at higher doses or with a greater number of CNS‐active medication classes. Methods: Participants included community‐dwelling older adults aged 65 years and older with a dementia diagnosis participating in the Adult Changes in Thought Study. From automated pharmacy data, a time‐varying composite measure of CNS‐active medication use was created. Central nervous system‐active medication use was classified as current (use within prior 30 days), recent (prior 31–90 days), past (prior 91–365 days), and nonuse (no exposure in prior year). For current users, standardized daily doses (SDDs) were calculated for each CNS‐active medication and summed across medications, and the number of CNS‐active medication classes used was also measured. The outcome was fall‐related injury based on emergency department, inpatient, and outpatient International Classification of Diseases, Ninth Revision (ICD‐9) and external cause of injury (E) codes. Results: Among 793 subjects, 303 fall‐related injuries occurred over a mean follow‐up of 3.7 years (2907 total person‐years). Relative to nonuse, fall risk was significantly higher for current use (adjusted hazard ratio [HR] 1.59, 95% confidence internal [CI] 1.19–2.12) but not for past or recent use. Among current users, increased risk was seen across SDD levels: HRs (95% CI): 1.77 (1.19–2.62), 1.79 (1.25–2.56), and 1.35 (0.96–1.92) for less than 1 SDD, 1 to less than 2 SDDs, and 2 or more SDDs, respectively (trend test, p=0.14). A trend was seen for increasing risk with a greater number of CNS‐active medication classes; however, this was not statistically significant (trend test, p=0.084). Conclusions: Current use of CNS‐active medications was associated with fall‐related injury in community‐dwelling older adults followed from time of dementia onset, with increased risk even with use of low doses. [ABSTRACT FROM AUTHOR]

Purpose The purpose of the study is to determine whether initiatives to improve the safety of opioid prescribing decreased injuries in people using chronic opioid therapy (COT). Methods: We conducted an interrupted time series analysis using data from Group Health (GH), an integrated health care delivery system in the United States. In 2007, GH implemented initiatives which substantially reduced daily opioid dose and increased patient monitoring. Among GH members age 18 or older receiving COT between 2006 and 2014, we compared injury rates for patients in GH's integrated group practice (IGP; exposed to the initiatives) vs patients cared for by contracted providers (not exposed). Injuries were identified using a validated algorithm. We calculated injury incidence during the baseline (preintervention) period from 2006 to 2007; the dose reduction period, 2008 to 2010; and the risk stratification and monitoring period, 2010 to 2014. Using modified Poisson regression, we estimated adjusted relative risks (RRs) representing the relative change per year in injury rates. Results: Among 21 853 people receiving COT in the IGP and 8260 in contracted care, there were 2679 injuries during follow‐up. The baseline injury rate was 1.0% per calendar quarter in the IGP and 0.9% in contracted care. Risk reduction initiatives did not decrease injury rates: Within the IGP, the RR in the dose reduction period was 1.01 (95% CI, 0.95‐1.07) and in the risk stratification and monitoring period, 0.99 (95% CI, 0.95‐1.04). Injury trends did not differ between the two care settings. Conclusions: Risk reduction initiatives did not decrease injuries in people using COT. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate associations between high‐density lipoprotein cholesterol (HDL) and non‐HDL‐C levels at specific ages and subsequent Alzheimer's disease (AD) risk. Design Prospective population‐based cohort study. Setting: Adult Changes in Thought (ACT) Study. Participants: Individuals aged 65 and older with no dementia at ACT Study entry. We identified separate, partially overlapping subcohorts of ACT participants who were eligible for each age band–specific analysis (50–59, n = 1,088; 60–69, n = 2,852; 70–79, n = 2,344; 80–89, n = 537). Measurements Exposure consisted of clinical measures of total cholesterol (TC) and HDL‐C from laboratory data during a given age band. Outcomes of incident AD were assessed post‐age band using standard research diagnostic criteria. Statistical analyses used adjusted Cox proportional hazards regression models for each exposure and outcome pair within an age band. Cholesterol exposures were modeled using cubic splines. Results: For non‐HDL‐C, we found a statistically significant association with AD risk in the 60 to 69 (omnibus p =.005) and 70 to 79 (omnibus p =.04) age bands, suggesting a potential U‐shaped relationship (greater risk at low and high levels). For example, in people aged 60 to 69, those with an average non‐HDL‐C level of 120 mg/DL had a 29% greater AD hazard (hazard ratio (HR)=1.29, 95% confidence interval (CI)=1.04–1.61) than those with an average non‐HDL‐C level of 160 mg/dL, whereas those with an average non‐HDL‐C level of 210 mg/dL had a 16% greater hazard (HR=1.16, 95% CI=1.01–1.33). We did not find a statistically significant association between HDL‐C and AD risk. Conclusion: People with low (120 mg/dL) and high (210 mg/dL) non‐HDL‐C levels during their 60s and 70s had modestly higher risk of AD than those with intermediate (160 mg/dL) levels. The extreme age bands (50s and 80s) had small sample sizes. J Am Geriatr Soc 66:2344–2352, 2018. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The purpose of the study is to determine if the use of a proton pump inhibitor (PPI) is associated with an increased fracture risk, as some prior studies have suggested. Methods: This retrospective cohort study included data on 4438 participants aged 65 and older who had no fracture in the year prior to baseline and had ≥5 years of enrollment history in Kaiser Permanente Washington, an integrated healthcare delivery system in Seattle, WA, during 1994 to 2014. Time‐varying cumulative exposure to PPIs was determined from automated pharmacy data by summing standard daily doses (SDDs) across fills, and patients were categorized as no use (reference group, ≤30 SDD), light use (31‐540 SDD), moderate use (541‐1080 SDD), and heavy use (≥1081 SDD). Incident fractures were assessed using International Classification of Diseases, Ninth Revision codes from electronic medical records. Potential confounders, chosen a priori, were assessed at baseline and at each 2‐year follow‐up visit. Fracture risk was analyzed using a Cox proportional hazards model. Results: Over a mean follow‐up of 6.1 years, 802 (18.1%) participants experienced a fracture. No overall association was found between PPI use and fracture risk. Adjusted hazard ratios comparing users to the referent category were 1.08 (95% CI 0.83‐1.40) for light users, 1.31 (95% CI 0.86‐1.95) for moderate users, and 0.95 (95% CI 0.68‐1.34) for heavy users. Among patients with SSD > 30, no appreciable increase in fracture risk was present in persons with recent versus distant use (adjusted hazard ratio of 1.14 [95% CI 0.91‐1.42]). Conclusions: No association was observed between PPI use and fracture risk among older adults. [ABSTRACT FROM AUTHOR]

Objective: To examine the associations of worry about affording care and reporting financial difficulties with benefit finding in long-term cancer survivors.Methods: Long-term survivors of cancer (n = 547) in 3 integrated health care delivery systems completed the Medical Expenditure Panel Survey Cancer Survivorship Supplement. The relationship between benefit finding (becoming a stronger person, coping better, and making positive changes) and the potentially interacting factors of worry about affording care and financial difficulties was examined using multivariate logistic regression models.Results: Of the total sample, 20% reported worry and 15% reported financial difficulty. Among those who reported no worry, financial difficulty was positively associated with becoming a stronger person (odds ratio [OR] = 2.89, 95% CI: 1.07, 7.80). Coping better was not associated with worry, financial difficulties, or the interaction of the two. Among those with no financial difficulty, worry was positively associated with making positive changes (OR = 2.64, 95% CI: 1.41, 4.96), and among those reporting no worry, financial difficulty had a non-significant positive association with making positive changes (OR = 1.98, 95% CI: 0.91, 4.31). Among those reporting worry, having financial difficulties was associated with lower odds of making positive changes (OR = 0.32, 95% CI: 0.13, 0.78).Conclusions: Our results suggest a complex relationship between financial difficulty, worry, and benefit finding. The combination of worry about affording care and financial difficulty needs to be addressed and further studied among cancer survivors, as the presence of both, but not alone, was negatively associated with making positive changes, an aspect of benefit finding. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether higher cumulative proton pump inhibitor (PPI) exposure is associated with greater dementia risk. Design: Prospective population‐based cohort study. Setting: Kaiser Permanente Washington, an integrated healthcare delivery system in Seattle, Washington. Participants: Individuals aged 65 and older without dementia at study entry (N = 3,484). Measurements: Participants were screened for dementia every 2 years, and those who screened positive underwent extensive evaluation. Dementia outcomes were determined using standard diagnostic criteria. Time‐varying PPI exposure was determined from computerized pharmacy data and consisted of total standardized daily doses (TSDDs) dispensed to an individual in the prior 10 years. We also assessed duration of use. Multivariable Cox regression was used to estimate the association between PPI exposure and time to dementia or Alzheimer's disease (AD). Results: Over a mean follow‐up of 7.5 years, 827 participants (23.7%) developed dementia (670 with possible or probable AD). PPI exposure was not associated with risk of dementia (P = .66) or AD (P = .77). For dementia, the risk for specific levels of cumulative exposure compared to no use was: 365 TSDDs (HR 0.87, 95% CI 0.65–1.18), 1,095 TSDDs (HR 0.99, CI 0.75–1.30) and 1,825 TSDDs (HR 1.13, CI 0.82–1.56). These TSDD levels represent approximately 1, 3 and 5 years of daily use respectively. Duration of PPI use was not associated with dementia outcomes either. Conclusion: Proton pump inhibitor use was not associated with dementia risk, even for people with high cumulative exposure. Although there are other safety concerns with long‐term PPI use, results from our study do not support that these medications should be avoided out of concern about dementia risk. [ABSTRACT FROM AUTHOR]

Purpose Although prescription opioids have been associated with higher motor vehicle crash (MVC) risk, it is unknown whether health system initiatives to better manage chronic opioid therapy (COT) can reduce MVC risk at the population level. Methods We conducted an interrupted time series population-level cohort study at Group Health (GH), between January 2006 and September 2014, comparing MVC risk among COT patients who were GH members receiving care in either group practice or contracted care settings. Group practice COT risk reduction initiatives were implemented in two phases: (1) altered prescribing expectations and (2) multifaceted initiatives. These initiatives did not exist in the contracted care network. We compared the adjusted quarterly rate of MVC between group practice and contracted care patients over time using a modified Poisson regression model for a binary outcome. Results A total of 32 691 COT patients (27.4% from contracted care) met eligibility criteria and experienced a total of 1956 MVCs during study follow-up (mean, 8.1 quarters per person), of which 810 were serious injury crashes. Crash rates were not significantly different between the patient groups within any of the time periods. Analyses stratified by concurrent prescription of a sedative hypnotic or benzodiazepine found no significant difference between the group practice and contracted care patients. There was a modest elevation of MVC risk for high-dose patients relative to former COT patients who stopped receiving opioids. Conclusions The risk of MVC was not mitigated in a large cohort of COT patients exposed to a health plan policy initiative that substantially lowered mean opioid dose. Copyright © 2016 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To develop three prognostic indices of varying degree of required detail for 2-year pneumonia risk in older adults. Design Retrospective cohort study. Setting Group Health ( GH), an integrated healthcare delivery system. Participants Community-dwelling dementia-free individuals aged 65 and older who had been GH members for at least 2 years before start of follow-up and were enrolled in the Adult Changes in Thought study (N = 3,375; development cohort, n = 2,250; validation cohort, n = 1,125. Measurements Potential pneumonia risk factors were identified from questionnaire data and interviewer assessments of functional status, medical history, smoking and alcohol use, cognitive function, personal care, and problem solving. Risk factors were also identified based on physical measures such as grip strength and gait speed and administrative database information on comorbid illnesses, laboratory tests, and prescriptions dispensed. Incident community-acquired pneumonia was defined presumptively from administrative data and validated using medical record review. Results Participants (59% female) contributed 12,998 visits at which risk factors were assessed; 642 pneumonia events were observed during follow-up. Age, sex, chronic obstructive pulmonary disease, congestive heart failure, body mass index, and use of inhaled or oral corticosteroids were critical predictors in all prognostic indices. A risk score based on these seven variables, information on which is commonly available in electronic medical records ( EMRs), had equal or better performance (c-index = 0.69 in the validation cohort) than scores including more-detailed data such as functional status. Conclusion Data commonly available in EMRs can stratify older adults into groups with varying subsequent 2-year pneumonia risk. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the associations between anesthesia and dementia or Alzheimer's disease ( AD) risk using prospectively collected data. Design Cohort study. Participants Community-dwelling members of the Adult Changes in Thought cohort aged 65 and older and free of dementia at baseline (N = 3,988). Measurements Participants self-reported all prior surgical procedures with general or neuraxial (spinal or epidural) anesthesia at baseline and reported new procedures every 2 years. People undergoing high-risk surgery with general anesthesia, other surgery with general anesthesia, and other surgery with neuraxial anesthesia exposures were compared with those with no surgery and no anesthesia. Cox proportional hazards models were used to estimate hazard ratios ( HRs) and 95% confidence intervals ( CIs) for dementia and AD associated with time-varying lifetime and recent (past 5 years) anesthesia exposures. Results At baseline, 254 (6%) people reported never having anesthesia; 248 (6%) had had one or more high-risk surgeries with general anesthesia, 3,363 (84%) had had one or more other surgeries with general anesthesia, and 123 (3%) had had one or more surgeries with neuraxial anesthesia. High-risk surgery with general anesthesia was not associated with greater risk of dementia (HR = 0.86, 95% CI = 0.58-1.28) or AD (HR = 0.95, 95% CI = 0.61-1.49) than no history of anesthesia. People with any history of other surgery with general anesthesia had a lower risk of dementia (HR = 0.63, 95% CI = 0.46-0.85) and AD (HR = 0.65, 95% CI = 0.46-0.93) than people with no history of anesthesia. There was no association between recent anesthesia exposure and dementia or AD. Conclusion Anesthesia exposure was not associated with of dementia or AD in older adults. [ABSTRACT FROM AUTHOR]

Objectives To determine whether prescription opioid use is associated with higher dementia risk or greater cognitive decline. Design Prospective cohort study. Setting Group Health, an integrated healthcare delivery system. Participants Community-dwelling individuals aged 65 and older without dementia with at least 10 years of Group Health enrollment at baseline (N = 3,434; median age 74). Measurements The Cognitive Abilities Screening Instrument (CASI) was administered every 2 years. Low scores triggered detailed evaluation, and a multidisciplinary committee assigned dementia diagnoses. From computerized pharmacy data, cumulative opioid exposure was defined as total standardized doses (TSDs) dispensed over 10 years (excluding the most recent year because of possible prodromal symptoms). For comparison, use of nonsteroidal anti-inflammatory drugs (NSAIDs), characterized similarly, was examined. Dementia risk was analyzed using Cox proportional hazards models and CASI trajectory using linear regression models and generalized estimating equations. Results Seven hundred ninety-seven participants (23%) developed dementia over a mean follow-up of 7.3 years; 637 (19%) had possible or probable Alzheimer's disease. For cumulative opioid use, the hazard ratios (HRs) for dementia were 1.06 (95% confidence interval (CI) = 0.88-1.26) for 11 to 30 TSDs, 0.88 (95% CI = 0.70-1.09) for 31 to 90 TSDs, and 1.29 (95% CI = 1.02-1.62) for 91 or more TSDs, versus 0 to 10 TSDs. A similar pattern was seen for NSAID use. Heavier opioid use was not associated with more-rapid cognitive decline. Conclusion People with the heaviest opioid or NSAID use had slightly higher dementia risk than people with little or no use. These results may reflect an effect of chronic pain on cognition or residual confounding. Although opioids have other risks, little evidence of long-term cognitive harm specific to opioids was found. [ABSTRACT FROM AUTHOR]

Objectives To determine whether use of anticholinergics is associated with risk of community-acquired pneumonia in older adults. Design Population-based case-control study. Setting An integrated healthcare delivery system in Washington State. Participants Data from a nested case-control study of community-dwelling immunocompetent adults aged 65 to 94 were analyzed. Pneumonia cases (n = 1,039) were ascertained according to International Classification of Diseases, Ninth Revision, codes from 2000 to 2003 and validated using chart review. Controls (n = 2,022) were matched 2:1 to cases according to age, sex, and year. Measurements Anticholinergic medication exposure was ascertained using prescription data; acute use was defined as one or more prescription fills 90 days or less before the index date (date of pneumonia diagnosis), past use was defined as one or more prescription fills within the prior year but none within 90 days, and chronic use was defined as three or more prescription fills within the prior year. The reference group was those with no fills in the prior year. Conditional logistic regression was used to analyze the association between anticholinergic use and pneumonia, adjusted for comorbidities. Results Acute use of anticholinergics was observed in 59% of cases and 35% of controls (adjusted odds ratio ( aOR) = 2.55, 95% confidence interval ( CI) = 2.08-3.13) and past use in 17% of cases and 23% of controls ( aOR = 1.19, 95% CI = 0.92-1.53). Chronic use of anticholinergics was observed in 53% of cases and 36% of controls ( aOR 2.07, 95% CI = 1.68-2.54). Results were not different for high- and low-potency anticholinergic medications. Conclusion In older adults, anticholinergic medication use is associated with pneumonia risk, adding to substantial evidence suggesting that these medications are high risk. [ABSTRACT FROM AUTHOR]

ABSTRACT Purpose This study aimed to develop Natural Language Processing (NLP) approaches to supplement manual outcome validation, specifically to validate pneumonia cases from chest radiograph reports. Methods We trained one NLP system, ONYX, using radiograph reports from children and adults that were previously manually reviewed. We then assessed its validity on a test set of 5000 reports. We aimed to substantially decrease manual review, not replace it entirely, and so, we classified reports as follows: (1) consistent with pneumonia; (2) inconsistent with pneumonia; or (3) requiring manual review because of complex features. We developed processes tailored either to optimize accuracy or to minimize manual review. Using logistic regression, we jointly modeled sensitivity and specificity of ONYX in relation to patient age, comorbidity, and care setting. We estimated positive and negative predictive value (PPV and NPV) assuming pneumonia prevalence in the source data. Results Tailored for accuracy, ONYX identified 25% of reports as requiring manual review (34% of true pneumonias and 18% of non-pneumonias). For the remainder, ONYX's sensitivity was 92% (95% CI 90-93%), specificity 87% (86-88%), PPV 74% (72-76%), and NPV 96% (96-97%). Tailored to minimize manual review, ONYX classified 12% as needing manual review. For the remainder, ONYX had sensitivity 75% (72-77%), specificity 95% (94-96%), PPV 86% (83-88%), and NPV 91% (90-91%). Conclusions For pneumonia validation, ONYX can replace almost 90% of manual review while maintaining low to moderate misclassification rates. It can be tailored for different outcomes and study needs and thus warrants exploration in other settings. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between dynamic measures of renal function ascertained over time and onset of dementia. Design Prospective community cohort study. Setting Group Health, Seattle, Washington. Participants Two thousand nine hundred sixty-eight adults aged 65 and older followed for the development of dementia over a median of 6.0 years (interquartile range 3.1-10.1 years). Measurements Time-varying measures of renal function were constructed based on 49,340 serum creatinine measurements and included average estimated glomerular filtration rate (eGFR), eGFR trajectory, and variability in eGFR around this trajectory over 5-year exposure windows. The association between these three eGFR exposure measures and risk of dementia was estimated using a Cox regression model adjusted for other participant characteristics. Time-varying measures of urine protein by dipstick were also adjusted for in sensitivity analyses. Results Participants with a lower eGFR had a higher incidence of dementia, but this did not reach statistical significance in adjusted analyses (omnibus P = .14). There were trends toward a higher adjusted incidence of dementia in participants with positive eGFR trajectories (omnibus P = .07) and greater variability in eGFR (omnibus P = .04) over time. The results of sensitivity analyses, including those in which time-varying measures of proteinuria were included, were consistent with those of the primary analysis. Conclusion In a community cohort of older adults followed for a median of 6 years, strong associations were not found between measures of kidney disease severity and progression and incident dementia. [ABSTRACT FROM AUTHOR]

ABSTRACT Purpose To test whether angiotensin-converting enzyme (ACE) inhibitor use is associated with decreased risk of community-acquired pneumonia in older adults. Methods We analyzed data from a nested case-control study of community-dwelling, immunocompetent adults aged 65-94 within an integrated healthcare delivery system. Cases of ambulatory and hospitalized pneumonia from 2000 to 2003 were identified from International Classification of Disease, version 9, codes and validated using medical record review. Controls were matched to cases by age, sex, and calendar year. Using health plan pharmacy data, we defined current use as filling ≥2 prescriptions during the 180 days prior to the case's diagnosis date. We calculated standardized doses per day using World Health Organization defined daily doses. Multivariable conditional logistic regression estimated adjusted odds ratios (ORs) for pneumonia in relation to ACE inhibitor use, adjusting for comorbidity, functional and cognitive status, and other covariates from medical record review and pharmacy data. Results Current use of ACE inhibitors was seen in 23% (242/1039) of cases and 21% (433/2022) of controls. Lisinopril accounted for 95% of prescriptions. The OR for pneumonia comparing current use to no current use was 0.99 (95% confidence interval [CI] 0.83-1.19). The OR for use of more than two standardized daily doses per day was 1.39 (95% CI 0.93-2.06) compared to no current use. Conclusions ACE inhibitor use is not associated with reduced pneumonia risk in community-dwelling older adults. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This paper presents the hardware development and testing of a new concept for air sampling via the integration of a prototype spore trap onboard an unmanned aerial system (UAS). We propose the integration of a prototype spore trap onboard a UAS to allow multiple capture of spores of pathogens in single remote locations at high or low altitude, otherwise not possible with stationary sampling devices. We also demonstrate the capability of this system for the capture of multiple time-stamped samples during a single mission. Wind tunnel testing was followed by simulation, and flight testing was conducted to measure and quantify the spread during simulated airborne air sampling operations. During autonomous operations, the onboard autopilot commands the servo to rotate the sampling device to a new indexed location once the UAS vehicle reaches the predefined waypoint or set of waypoints (which represents the region of interest). Time-stamped UAS data are continuously logged during the flight to assist with analysis of the particles collected. Testing and validation of the autopilot and spore trap integration, functionality, and performance is described. These tools may enhance the ability to detect new incursions of spores. © 2011 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Objectives To examine whether use of opioids or benzodiazepines is associated with risk of community-acquired pneumonia in older adults. Design Population-based case-control study. Setting An integrated healthcare delivery system. Participants Community-dwelling, immunocompetent adults aged 65 to 94 from 2000 to 2003. Presumptive pneumonia cases were identified from health plan automated data and validated through medical record review. Two controls were selected for each case with pneumonia, matched on age, sex, and calendar year. Measurements Information about opioid and benzodiazepine use came from computerized pharmacy data. Information on covariates including comorbid illnesses and functional and cognitive status came from medical record review and electronic health data. Results One thousand thirty-nine validated cases of pneumonia and 2,022 matched controls were identified. One hundred forty-four (13.9%) cases and 161 (8.0%) controls used prescription opioids (adjusted odds ratio ( OR) = 1.38, 95% confidence interval ( CI) = 1.08-1.76 vs nonuse). Risk was highest for opioids categorized as immunosuppressive based on immunological studies ( OR = 1.88, 95% CI = 1.26-1.79 vs nonuse), whereas for nonimmunosuppressive opioids the OR was 1.23 (95% CI = 0.89-1.69). Risk was highest in the first 14 days of use ( OR = 3.24, 95% CI = 1.64-6.39 vs nonuse). For long-acting opioids, the OR was 3.43 (95% CI = 1.44-8.21) versus nonuse, whereas for short-acting opioids, it was 1.27 (95% CI = 0.98-1.64). No greater risk was seen for current benzodiazepine use compared to nonuse ( OR = 1.08, 95% CI = 0.80-1.47). Conclusion Use of opioids but not benzodiazepines was associated with pneumonia risk. The differences in risk seen for different opioid regimens warrant further study. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine whether histamine-2 receptor antagonist medications (H2RAs) are associated with a lower incidence of all-cause dementia or Alzheimer's disease (AD), as some studies have suggested. DESIGN: Prospective population-based cohort SETTING: Group Health, an integrated health maintenance organization, Seattle, Washington. PARTICIPANTS: Two thousand nine hundred twentythree participants aged 65 and older without dementia at baseline, with initial recruitment between 1994 and 1996. MEASUREMENTS: Follow-up occurred every 2 years to identify incident dementia and AD using standard criteria. Exposure to H2RAs was determined based on automated pharmacy data. Three aspects of exposure (time-varying) were examined based on standard daily dose (SDD): cumulative use, intensity of use (highest SDD in any prior 2- year window), and cumulative use stratified according to recency (1DS3 years vs 43 years before). RESULTS: Over amean follow-up of 6.7 years, 585 subjects developed dementia (453 developed AD). Total cumulative exposurewas not associatedwith dementia (P5.35; omnibus test) or AD (P5.23). The adjusted hazard ratios for the highest exposure category (41,080SDDs) compared with light or no use were 1.28 (95% confidence interval (CI)50.95DS1.72) for dementia and 1.41 (95% CI51.00DS 1.97) for AD. Intensity of use was not associated with dementia (P5.39) or AD (P5.63). Examining exposure according to recent and distant cumulative use also showed no association with dementia (P5.11) or AD (P5.30). CONCLUSION: No associationwas found between H2RA use and risk of all-cause dementia or AD using more-detailed and -extensive information about past H2RA use than any prior study. [ABSTRACT FROM AUTHOR]

Purpose To examine whether use of proton pump inhibitors (PPIs) and H2 blockers is associated with increased pneumonia risk. Methods We conducted a population-based, nested case-control study within Group Health, an integrated healthcare delivery system. Among community-dwelling, immunocompetent adults aged 65-94, we identified presumptive cases of ambulatory and hospitalized community-acquired pneumonia in 2000-2003 from ICD-9 codes and validated them by medical record review ( N = 1125). Controls were selected, matched to cases on age, sex, and calendar year ( N = 2235). Current PPI or H2 blocker use was ascertained from computerized pharmacy records. Comorbid illnesses and other characteristics were ascertained by medical record review. Multivariable conditional logistic regression was used to examine the association between medication use and pneumonia risk. We conducted sensitivity analyses using only administrative and pharmacy data to assess how these results differed from our primary results. Results The prevalence of PPI or H2 blocker use was 21% (241/1125) for pneumonia cases and 16% (350/2235) for controls (adjusted odds ratio [OR] 1.03, 95% CI 0.86-1.24, compared to nonuse). No increased risk was seen for recent initiation. The prevalence of PPI use was 12% (132/1125) for cases and 7% (160/2235) for controls (adjusted OR 1.13, 95% CI 0.88-1.44). Analyses using only administrative and pharmacy data yielded risk estimates farther from the null (adjusted OR 1.32, 95% CI 1.17-1.49, for current PPI use versus nonuse). Conclusions Use of PPIs and H2 blockers is not associated with increased pneumonia risk in older adults. The increased risk observed in some prior studies may reflect confounding. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Presents an abstract of the article 'Economic Payoff from Subsidized Labor Mobility,' by Rod Walker, which examined the results of labor mobility pilot studies in the United States.