To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living?

ObjectiveIn nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs.DesignObservational, cross-sectional AL data linked to publicly reported NH measures.Setting and ParticipantsRandom sample of 250 AL communities and the full sample of 3371 NHs in 7 states.MethodsWe calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects.ResultsThe prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = −0.03; 95% confidence interval (CI) −0.50 to −0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs’ prescribing rates (b = 0.43; 95% CI 0.16–0.70; P = .002).Conclusions and ImplicationsThis study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.     

Progestins can mimic, inhibit and potentiate the actions of androgens

There is an extensive background on the androgen responsiveness of the mouse kidney which can be demonstrated histologically by hypertrophy of the Bowman's capsule and the proximal convoluted tubule. Although androgens increase many renal proteins, beta-glucuronidase and ODC are distinguished by exquisite genetic regulation of the magnitude of the response induced by testosterone. Both the qualitative and quantitative expression of the genes for these enzymes are strain specific, and are dependent upon regulatory alleles. Ornithine decarboxylase is of particular interest since the response of this enzyme is rapid compared to that of beta-glucuronidase. Recent studies using a newly developed androgen receptor assay have demonstrated that the duration of retention of the androgen receptor complex in the nucleus correlates with the magnitude of the androgenic response. Progestins can mimic, inhibit, or potentiate the action of androgens. These responses have been termed the androgenic, antiandrogenic and synandrogenic actions of progestins, respectively. The androgenic and antiandrogenic action of this class of steroids are manifest on many tissues and on many endpoints within a given organ. These effects are believed to involve an early step(s) of androgen action which is common to all sensitive tissues. Results to date suggests that this early step involves the androgen receptor. By contrast, the synandrogenic action of progestins is limited in that it is not observed on all tissues, and not even on all endpoints within a single organ. In the mouse kidney, the synandrogenic actions of progestins have been most extensively studied on beta-glucuronidase. With this enzyme this unusual response to progestins can be demonstrated only in mice which carry the Gus-ra allele. This observation suggests that the potentiating action of progestins on beta-glucuronidase is manifest directly on the Gus gene complex. It is not certain at this time whether a similar mechanism is involved in the potentiation of androgen action on other organs such as the prostate. The androgenic action of progestins is believed to be similar to that of other androgens. Androgenic progestins such as MPA bind to the androgen receptors and translocate them to nuclei. This is followed by a dose dependent increase of proteins similar to what is observed after testosterone administration. In addition, the regulatory genes which modulate androgen action have the same effect on the androgenic effect of progestins. The fact that the potency of progestins such as MPA is less than that of testosterone is believed to relate in part to their lower affinity for the androgen receptors.(ABSTRACT TRUNCATED AT 400 WORDS)     

Forecasting the global burden of Alzheimer’s disease

BackgroundOur goal was to forecast the global burden of Alzheimer’s disease and evaluate the potential impact of interventions that delay disease onset or progression.MethodsA stochastic, multistate model was used in conjunction with United Nations worldwide population forecasts and data from epidemiological studies of the risks of Alzheimer’s disease.ResultsIn 2006, the worldwide prevalence of Alzheimer’s disease was 26.6 million. By 2050, the prevalence will quadruple, by which time 1 in 85 persons worldwide will be living with the disease. We estimate about 43% of prevalent cases need a high level of care, equivalent to that of a nursing home. If interventions could delay both disease onset and progression by a modest 1 year, there would be nearly 9.2 million fewer cases of the disease in 2050, with nearly the entire decline attributable to decreases in persons needing a high level of care.ConclusionsWe face a looming global epidemic of Alzheimer’s disease as the world’s population ages. Modest advances in therapeutic and preventive strategies that lead to even small delays in the onset and progression of Alzheimer’s disease can significantly reduce the global burden of this disease.     

Clinical trial with subdermal implants containing norgestrienone

Norgestrienone implants delivering approximately 225 μg/day were tested clinically for contraceptive effectiveness and acceptability in 145 women. Five pregnancies occurred in 2259 woman-months of use, one in the 11th month, one in the 15th and three in the 16th month of use. Continuation rate at 12 months was 86.7. The number of bleeding runs and bleeding days was increased in approximately 12% of the subjects. Ten percent of the patients had no bleeding in the first 90 days of treatment. Changes in bleeding pattern led to closures in four cases. Headache and signs of mild androgenicity were among the leading side effects. Blood and urine analysis throughout the study showed normal values of 17 different parameters, but a tendency to lower cholesterolemia not associated with changes in thyroid hormone levels, was observed in several patients. Cortisol was found slightly under the lower normal range in one subject without clinical manifestations of hypoadrenalism. It is concluded that norgestrienone implants should be replaced every twelve months for maximal contraceptive effect and because of their efficacy and good acceptability, evaluation of their long term use is warranted.     

Collagen bands: A new vaginal delivery system for contraceptive steroids

This study was undertaken to investigate the effects on ovarian function, bleeding control and plasma levels of d-norgestrel (d-Ng) in women using Silastic intravaginal rings designed to deliver steroid from a collagen band impregnated with d-Ng and estradiol benzoate (EB). Bands containing d-Ng at two different concentration levels were used. The estradiol levels in plasma were not affected by the EB content of the IVRs. Ovulation occurred in one out of eighteen cycles studied. Breakthrough bleeding or spotting occurred in 18 per cent of the treatment days and was more common with IVRs of a lower d-Ng content. Higher but more variable plasma levels of d-Ng were observed in subjects using IVRs of the higher d-Ng content. After removal of the IVR an elimination half life for d-Ng of 18.9 hours was found. It is concluded that collagen can be used for vaginal administration of d-Ng but that EB does not affect the estradiol plasma levels or the incidence of breakthrough bleeding.     

The effect of structural aberrations of the chromosomes on reproductive fitness in man

Methods are presented to estimate relative fitness of carriers as a function of fertility, survival, are generation time in pedigrees under incomplete ascertainment. A large sample of diverse chromosomal aberrations reveals significant effects on all three parameters, giving a relative fitness of .769 +/- .039. There is no significant shift in segregation frequency. Implications of these results for population dynamics of structural rearrangements are discussed. The following paper applies these methods to specific classes of aberrations.     

Bayesian methods for meta‐analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta‐analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C‐reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes. Copyright © 2010 John Wiley & Sons, Ltd.