Modeling Co-Occurring Depression and Anxiety in Patients with an Acute Coronary Syndrome: A Dissertation

The purpose of the current project is to illustrate the application of advanced statistical techniques to address research questions about depression and anxiety in patients with an acute coronary syndrome (ACS). The first study, using data from 100 patients who were randomized into a clinical trial of cognitive behavioral therapy, used bivariate mixed models to determine trajectories of depression and anxiety after an ACS, to examine the effects of cognitive behavioral therapy (CBT) on depression and anxiety, and to determine if anxiety and depression symptoms change at the same rate with CBT treatment as indicated by joint modeling of these two psychiatric disorders. The findings suggest that depression and anxiety are highly correlated and persistent in patients with an ACS both at baseline and over time. The intervention used in the present investigation does not appear to uncouple the association between anxiety and depression, suggesting that CBT has comparable effects on both psychiatric disorders. The second study used latent transition analysis to identify symptomatology profiles of depression, anxiety, and functional impairment in patients with an ACS, describe changes over time (two, three and six-month follow-up) in patient’s acute symptom profiles, and determine if patients receiving CBT showed signs of remission in depression, anxiety and impaired function earlier than patients that received usual care. A three-class model was selected to identify and describe these acute symptom profiles. One class was characterized by patients with both psychiatric disorders and impaired function, the second by patients with psychiatric disorders but normal function, and the third by patients with anxiety but without depression, and having normal function. There was moderate improvement in depression, anxiety and functional status for control patients, but this improvement was less evident than in the treatment group. Women showed a better response to CBT than men. The third study used latent class and latent transition analysis to determine symptom profiles of depression and anxiety in patients with an ACS using the Hospital Anxiety Depression Scale; a secondary study goal was to examine the effects of age and gender on these symptom patterns. A two-class model was selected to describe depression and anxiety symptomatology profiles. Class I (76% of patients at baseline) was labeled as “severe depression and some anxiety” whereas Class II (24% of patients at baseline) was labeled as “mild depression and distress anxiety”. More than 70% of older patients continued to have severe depression and anxiety at follow-up and a large proportion of these patients who reported mild depression and anxiety at baseline showed worsening of symptoms at follow-up. The current study demonstrates that patients with depression and anxiety after an ACS can be identified on the basis of the symptoms that they present. This is particularly important to identifying individuals at potential risk for developing clinical complications after an ACS

Trends in the Frequency, Patient Characteristics, Management, and in-Hospital Outcomes of Diabetic Patients Presenting with Acute Myocardial Infarction

Background: Diabetic patients have more complications and higher hospital mortality rates after an acute myocardial infarction (AMI) than patients without diabetes (DM). Increased morbidity and mortality among diabetic patients suffering an AMI is especially concerning given the increasing prevalence of obesity and diabetes in the U.S. and worldwide. The objectives of this study were to describe recent trends in the frequency, patient characteristics, treatment practices, and in-hospital outcomes associated with STEMI and NSTEMI in diabetic compared with non-diabetic patients hospitalized with AMI. Methods: We reviewed the medical records of 6,903 persons, known to be either diabetic (n =2,329) or non-diabetic (n=4,574 ) who were hospitalized for STEMI or NSTEMI between 1997 and 2009 at all 11 greater Worcester medical centers. Results: Diabetic patients presenting with both STEMI and NSTEMI were more likely to be older, female, and obese, and to have a higher prevalence of comorbidities compared with non-diabetics. Diabetic patients were more likely to develop important in-hospital complications including heart failure (39% vs.27%),and atrial fibrillation (18% vs.16%), and had a longer hospital stay (6.3 days vs.5.4 days) compared to non-diabetics. Diabetic patients were significantly more likely to be treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker and a diuretic. The proportion of patients undergoing cardiac catheterization during their index hospitalization for AMI approximately doubled during the period under study, while the proportion treated with PCI increased by 3 to 4-fold. The proportion of diabetic and non-diabetic patients undergoing cardiac catheterization was similar, though diabetics were less likely to be treated with PCI and more likely to receive CABG than non-diabetics. In-hospital mortality was significantly higher among diabetics than non-diabetics for both STEMI (13% vs. 10%) and NSTEMI (11% vs. 9%) Conclusions: During the period 1997 to 2009, the use of effective therapies for all patients presenting with AMI has improved, with a concomitant decrease in in-hospital complications and mortality . Nonetheless, diabetic patients experienced , more complications, and worse in-hospital outcomes compared to non-diabetics

Prescribing Patterns of Antipsychotic Medication in a Long-Term Care Psychiatric Hospital

Introduction: In spite of recent pharmacologic advances, psychopharmacological treatment of patients with severe mental illness has remained a challenging task. Despite limited supporting evidence, the use of polypharmacy (prescription of more than one antipsychotic drug for an individual patient) has become a frequent approach. Polypharmacy has been associated with an increased incidence of adverse effects. Objective: To explore patterns of prescribing antipsychotic agents in a long-term inpatient facility. To examine the prevalence of polypharmacy and its association with age, sex, ethnicity and legal status in a sample of individuals with diverse psychiatric diagnoses. To determine the association of antipsychotic agents (single agent and polypharmacy use) and increased body mass index (BMI). Method: We examined the prescribing of antipsychotic drugs in a sample of 234 in-patients, during a 2-month period in a long term in-patient facility in Central Massachusetts during 2013. We performed a comprehensive review of patients ‘medical records and collected information on: age, sex, ethnicity, admission date, body mass index, primary and secondary diagnoses, and legal status (voluntary versus involuntary). We examined the use of the selected antipsychotic agents (haloperidol, clozapine, olanzapine, and risperidone) as well as determined median dose in milligrams for each agent. We created an additive score of antipsychotic to explore prescribing patterns in the described in-patients population and investigated the association of various demographic factors, diagnoses (affective versus psychotic disorder) with polipharmacy. We calculated the frequency of antipsychotic agents use in combination, and particularly determined the frequency of polypharmacy in patients receiving clozapine. Finally, we examined the association of high body mass index (\u3e25) with the use of particular antipsychotic agents alone, as well as with the use of polypharmacy

C–H insertion as a key step to spiro-oxetanes, scaffolds for drug discovery

A new route to spiro-oxetanes, potential scaffolds for drug discovery, is described. The route is based on the selective 1,4-C–H insertion reactions of metallocarbenes, generated from simple carbonyl precursors in flow or batch mode, to give spiro-β-lactones that are rapidly converted into spiro-oxetanes. The three-dimensional and lead like-properties of spiro-oxetanes is illustrated by the conversion of the 1-oxa-7-azaspiro[3,5]nonane scaffold into a range of functionalized derivatives

Multiple cardiovascular comorbidities and acute myocardial infarction: temporal trends (1990–2007) and impact on death rates at 30 days and 1 year

BACKGROUND: The objectives of this community-based study were to examine the overall and changing (1990-2007) frequency and impact on 30-day and 1-year death rates from multiple cardiovascular comorbidities in adults from a large central New England metropolitan area hospitalized with acute myocardial infarction (AMI). METHODS: The study population consisted of 9581 patients hospitalized with AMI at all 11 medical centers in the metropolitan area of Worcester, MA, during 10 annual periods between 1990 and 2007. The comorbidities examined included atrial fibrillation, diabetes, heart failure, hypertension, and stroke. RESULTS: Thirty-five percent of participants had a single diagnosed cardiovascular comorbidity, 25% had two, 12% had three, and 5% had four or more comorbidities. Between 1990 and 2007, the proportion of patients without any of these comorbidities decreased significantly, while the proportion of patients with multiple comorbidities increased significantly during the years under study. An increasing number of comorbidities was associated with higher 30-day and 1-year postadmission death rates in patients hospitalized with AMI. CONCLUSION: Patients hospitalized with AMI carry a significant burden of comorbid cardiovascular disease that adversely impacts their 30-day and longer-term survival. Increased attention to the management of AMI patients with multiple cardiovascular comorbidities is warranted

Age, Multiple Chronic Conditions, and COVID-19: A literature review

BACKGROUND: Various patient demographic and clinical characteristics have been associated with poor outcomes for individuals with coronavirus disease 2019 (COVID-19). To describe the importance of age and chronic conditions in predicting COVID-19 related outcomes. METHODS: Search strategies were conducted in PubMed/MEDLINE. Daily alerts were created. RESULTS: A total of 28 studies met our inclusion criteria. Studies varied broadly in sample size (n=21 to more than 17,000,000). Participants mean age ranged from 48 years to 80 years and the proportion of male participants ranged from 44%-82%. The most prevalent underlying conditions in patients with COVID-19 were hypertension (range: 15% - 69%), diabetes (8% - 40%), cardiovascular disease (4% - 61%), chronic pulmonary disease (1% - 33%), and chronic kidney disease (range 1% - 48%). These conditions were each associated with an increased in-hospital case fatality rate ranging from 1% to 56%. Overall, older adults have a substantially higher case fatality rate (CFR) as compared with younger individuals affected by COVID-19 (42% for those \u3c 65 vs 65% \u3e 65 years ). Only one study examined the association of chronic conditions and the risk of dying across different age groups; their findings suggested similar trends of increased risk in those \u3c 65 and those \u3e 65 years as compared to those without these conditions. CONCLUSIONS: There has been a traditional, single condition approach to consideration of how chronic conditions and advancing age relate to COVID-19 outcomes. A more complete picture of the impact of burden of multimorbidity and advancing patient age is needed

Decade-long trends (1999-2009) in the characteristics, management, and hospital outcomes of patients hospitalized with acute myocardial infarction with prior diabetes and chronic kidney disease

BACKGROUND: Despite the increasing magnitude and impact, there are limited data available on the clinical management and in-hospital outcomes of patients who have diabetes mellitus (DM) and chronic kidney disease (CKD) at the time of hospitalization for acute myocardial infarction (AMI). The objectives of our population-based observational study in residents of central Massachusetts were to describe decade-long trends (1999-2009) in the characteristics, in-hospital management, and hospital outcomes of AMI patients with and without these comorbidities. METHODS: We reviewed the medical records of 6,018 persons who were hospitalized for AMI on a biennial basis between 1999 and 2009 at all eleven medical centers in central Massachusetts. Our sample consisted of the following four groups: DM with CKD (n=587), CKD without DM (n=524), DM without CKD (n=1,442), and non-DM/non-CKD (n=3,465). RESULTS: Diabetic patients with CKD were more likely to have a higher prevalence of previously diagnosed comorbidities, to have developed heart failure acutely, and to have a longer hospital stay compared with non-DM/non-CKD patients. Between 1999 and 2009, there were marked increases in the prescribing of beta-blockers, statins, and aspirin for patients with CKD and DM as compared to those without these comorbidities. In-hospital death rates remained unchanged in patients with DM and CKD, while they declined markedly in patients with CKD without DM (20.2% dying in 1999; 11.3% dying in 2009). CONCLUSION: Despite increases in the prescribing of effective cardiac medications, AMI patients with DM and CKD continue to experience high in-hospital death rates

La enseñanza de la higiene mental en la carrera de Psicología

La magnitud y extensión de los problemas que afectan la salud psicológica indican que los métodos convencionales de Ia clásica higiene mental, basados en el criterio preventivo individual, en el diagnóstico y tratamiento precoces y en el perfeccionamiento de la asistencia, no son ya útiles ni adecuados para un enfoque profiláctico dentro de las modernas orientaciones de la salud publica. Los iniciadores del movimiento de higiene mental, a comienzos de siglo, proclamaron la abolición de la enfermedad mental mediante la aplicación de algunas reglas psicológicas para una existencia higiénica. (Párrafo extraído del texto a modo de resumen)Departamento de Psicologí

Magnitude of and Prognostic Factors Associated With 1-Year Mortality After Hospital Discharge for Acute Decompensated Heart Failure Based on Ejection Fraction Findings

BACKGROUND: Limited data exist about the magnitude of and the factors associated with prognosis within 1 year for patients discharged from the hospital after acute decompensated heart failure. Data are particularly limited from the more generalizable perspective of a population-based investigation and should be further stratified according to currently recommended ejection fraction (EF) findings. METHODS AND RESULTS: The hospital medical records of residents of the Worcester, Massachusetts, metropolitan area who were discharged after acute decompensated heart failure from all 11 medical centers in central Massachusetts during 1995, 2000, 2002, 2004, and 2006 were reviewed. The average age of the 4025 study patients was 75 years, 93% were white, and 44% were men. Of these, 35% (n=1414) had reduced EF ( \u3c /=40%), 13% (n=521) had borderline preserved EF (41-49%), and 52% (n=2090) had preserved EF ( \u3e /=50%); at 1 year after discharge, death rates were 34%, 30%, and 29%, respectively (P=0.03). Older age, a history of chronic obstructive pulmonary disease, systolic blood pressure findings \u3c 150 mm Hg on admission, and hyponatremia were important predictors of 1-year mortality for all study patients, whereas several comorbidities and physiological factors were differentially associated with 1-year death rates in patients with reduced, borderline preserved, and preserved EF. CONCLUSIONS: This population-based study highlights the need for further contemporary research into the characteristics, treatment practices, natural history, and long-term outcomes of patients with acute decompensated heart failure and varying EF findings and reinforces ongoing discussions about whether different treatment guidelines may be needed for these patients to design more personalized treatment plans

Clinically Meaningful Change in Quality of Life and Associated Factors Among Older Patients With Atrial Fibrillation

Background: Among older patients with atrial fibrillation, there are limited data examining clinically meaningful changes in quality of life (QoL). We examined the extent of, and factors associated with, clinically meaningful change in QoL over 1-year among older adults with atrial fibrillation. Methods and Results: Patients from cardiology, electrophysiology, and primary care clinics in Massachusetts and Georgia were enrolled in a cohort study (2015-2018). The Atrial Fibrillation Effect on Quality-of-Life questionnaire was used to assess overall QoL and across 3 subscales: symptoms, daily activities, and treatment concern. Clinically meaningful change in QoL (ie, difference between 1-year and baseline QoL score) was categorized as either a decline ( \u3c /=-5.0 points), no clinically meaningful change (-5.0 to +5.0 points), or an increase ( \u3e /=+5.0 points). Ordinal logistic models were used to examine factors associated with QoL changes. Participants (n=1097) were on average 75 years old, 48% were women, and 87% White. Approximately 40% experienced a clinically meaningful increase in QoL and 1 in every 5 patients experienced a decline in QoL. After multivariable adjustment, women, non-Whites, those who reported depressive and anxiety symptoms, fair/poor self-rated health, low social support, heart failure, or diabetes mellitus experienced clinically meaningful declines in QoL. Conclusions: These findings provide insights to the magnitude of, and factors associated with, clinically meaningful change in QoL among older patients with atrial fibrillation. Assessment of comorbidities and psychosocial factors may help identify patients at high risk for declining QoL and those who require additional surveillance to maximize important clinical and patient-centered outcomes