Pretreatment Attrition and Formal Withdrawal During Treatment and Their Predictors: An Exploratory Study of the Anxiety Online Data

Background

Although in its infancy, the field of e-mental health interventions has been gaining popularity and afforded considerable research attention. However, there are many gaps in the research. One such gap is in the area of attrition predictors at various stages of assessment and treatment delivery.

Objective

This exploratory study applied univariate and multivariate analysis to a large dataset provided by the Anxiety Online (now called Mental Health Online) system to identify predictors of attrition in treatment commencers and in those who formally withdrew during treatment based on 24 pretreatment demographic and personal variables and one clinical measure.

Methods

Participants were assessed using a complex online algorithm that resulted in primary and secondary diagnoses in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Those who received a primary or secondary diagnosis of 1 of 5 anxiety disorders (generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and panic disorder) were offered an online 12-week disorder-specific treatment program.

Results

Of 9394 potential participants, a total of 3880 clients enrolled and 5514 did not enroll in one of the treatment programs following the completion of pretreatment assessment measures (pretreatment attrition rate: 58.70%). A total of 3199 individuals did not formally withdraw from the 12-week treatment cycle, whereas 142 individuals formally dropped out (formal withdrawal during treatment dropout rate of 4.25%). The treatment commencers differed significantly (P<.001-.03) from the noncommencers on several variables (reason for registering, mental health concerns, postsecondary education, where first heard about Anxiety Online, Kessler-6 score, stage of change, quality of life, relationship status, preferred method of learning, and smoking status). Those who formally withdrew during treatment differed significantly (P=.002-.03) from those who did not formally withdraw in that they were less likely to express concerns about anxiety, stress, and depression; to rate their quality of life as very poor, poor, or good; to report adequate level of social support; and to report readiness to make or were in the process of making changes.

Conclusions

This exploratory study identified predictors of pretreatment attrition and formal withdrawal during treatment dropouts for the Anxiety Online program.

Trial Registration

Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).     

Gender-related subcomponent differences in high type a subjects

Thirty Type A males and 30 Type A females were administered an expanded version of the Structured Interview designed to assess 11 Type A subcomponents. The purpose was to determine whether males and females follow different subcomponent routes in achieving their Type A status. As predicted, males scored higher than females on two of four anger-related variables. Contrary to prediction, males scored higher than females on the subcomponent of exaggerated social control. These findings were interpreted as providing some support for the notion of differing gender-related subcomponent routes for achieving Type A status. These findings also may have implications for the higher incidence of coronary heart disease in high TABP males vs. females.     

Resumption of migraine preventive treatment with CGRP(-receptor) antibodies after a 3-month drug holiday: a real-world experience

BackgroundMigraine frequency increases after the cessation of successful preventive treatment with CGRP(-receptor) monoclonal antibodies (mAbs). In this study, we aimed to evaluate the course of migraine after treatment resumption.MethodsPatients with migraine, who started treatment with the same CGRP(-R) mAb after a three-month drug holiday were included in this analysis. We collected headache data at four prospective visits: 1) during the four weeks before the initial mAb treatment (baseline); 2) during the four weeks before the last mAb injection; 3) in weeks 13–16 of the drug holiday; 4) in weeks 9–12 after treatment restart. Outcomes were the changes in monthly migraine days (MMD), monthly headache days (MHD), monthly days with acute medication use (AMD) and Headache Impact Test-6 (HIT-6) scores across the observation period.ResultsThis study included 39 patients (erenumab n = 16; galcanezumab/ fremanezumab n = 23). MMD decreased from 12.3 ± 6.3 at the end of the drug holiday to 7.8 ± 5.5 three months after treatment restart (p = 0.001). The improvement after treatment resumption was similar to the response in the initial treatment period (baseline: 12.3 ± 6.3 MMD vs. 7.5 ± 5.2 MMD before treatment interruption). MHD and AMD showed a significant improvement after treatment restart. HIT-6 scores decreased, indicating a diminished impact of headache on everyday life.ConclusionsReinitiation of treatment with CGRP(-R) mAbs after a drug holiday leads to a significant reduction of migraine frequency and medication use as well as improvement in quality of life.     

Episodic memory: Neuronal codes for what,where, and when

Episodic memory is defined as the ability to recall events in a spatiotemporal context. Formation of such memories is critically dependent on the hippocampal formation and its inputs from the entorhinal cortex. To be able to support the formation of episodic memories, entorhinal cortex and hippocampal formation should contain a neuronal code that follows several requirements. First, the code should include information about position of the agent (“where”), sequence of events (“when”), and the content of the experience itself (“what”). Second, the code should arise instantly thereby being able to support memory formation of one‐shot experiences. For successful encoding and to avoid interference between memories during recall, variations in location, time, or in content of experience should result in unique ensemble activity. Finally, the code should capture several different resolutions of experience so that the necessary details relevant for future memory‐based predictions will be stored. We review how neuronal codes in entorhinal cortex and hippocampus follow these requirements and argue that during formation of episodic memories entorhinal cortex provides hippocampus with instant information about ongoing experience. Such information originates from (a) spatially modulated neurons in medial entorhinal cortex, including grid cells, which provide a stable and universal positional metric of the environment; (b) a continuously varying signal in lateral entorhinal cortex providing a code for the temporal progression of events; and (c) entorhinal neurons coding the content of experiences exemplified by object‐coding and odor‐selective neurons. During formation of episodic memories, information from these systems are thought to be encoded as unique sequential ensemble activity in hippocampus, thereby encoding associations between the content of an event and its spatial and temporal contexts. Upon exposure to parts of the encoded stimuli, activity in these ensembles can be reinstated, leading to reactivation of the encoded activity pattern and memory recollection.     

A stage-specific sialoglycoprotein in encysting cells of Entamoeba invadens

A novel sialoglycoprotein with an apparent molecular mass of approximately 250 kDa was detected on the surface of cysts of Entamoeba invadens. Sialic acid was identified in this glycoprotein by gas chromatography after methanolysis; N-acetyl- and N-glycolyl neuraminic acid were identified by thin layer chromatography in hydrolysates of partially purified preparations of the 250 kDa glycoprotein as well as in whole cysts. The sialoglycoprotein is stage-specific and could be detected by binding of wheat germ agglutinin and a specific monoclonal antibody (JAM3) only to precysts and mature cysts but not to trophozoites. A 250 kDa protein could be metabolically labeled with [35S]methionine. This, together with the absence of such a glycoprotein in the encystation medium, suggests that the 250 kDa sialoglycoprotein is not an adsorbed serum glycoprotein. Indirect evidence suggests that the parasite may utilize serum components as a source for sialic acid.     

The usefulness of serum troponin levels in evaluating cardiac injury

The diagnosis and clinical significance of blunt cardiac injury remains controversial. Cardiac troponin I is not found in skeletal muscle and has a high sensitivity for myocardial ischemia or injury. We hypothesized that normal troponin levels 4 to 6 hours postinjury would effectively exclude the diagnosis of cardiac contusion. A prospective evaluation of all blunt trauma patients older than 16 and admitted with the possible diagnosis of blunt cardiac injury was undertaken. Patients in whom this diagnosis was considered had an electrocardiogram (EKG) on admission, serum troponin, CPK and isoenzymes 4 to 6 hours postinjury, and admission with overnight telemetry. Other laboratory data and radiographic imaging was obtained as indicated. Seventy-two patients met criteria for entry into the study. Data was incomplete or inaccurately obtained on six patients, and they were excluded. Forty patients had normal troponins and normal EKG's on admission and were discharged the following day without any untoward effect. Sixteen patients were admitted with abnormal EKGs. All of these 16 patients had normal troponins 4 to 6 hours after their injury. They all did well and were discharged the following day. Ten patients had elevated troponins 4 to 6 hours after injury. One died two days later from refractory cardiogenic shock. Another was noted to have severely depressed left ventricular function by echocardiography. The other eight patients sustained no cardiac sequelae and were discharged once recovered from injuries. In the hemodynamically stable patient a normal troponin 4 to 6 hours after injury excludes clinically significant blunt cardiac injury. This holds true whether the admission EKG is normal or not. An elevated troponin does not definitively diagnose a clinically significant contusion. However, these patients should be monitored at least for 24 hours. Patients suspicious for cardiac contusions who have normal troponins and no other serious injuries may be safely discharged to go home from the emergency department.     

Corticosteroid use in the intensive care unit: at what cost?

HYPOTHESIS: Corticosteroid use has a significant effect on morbidity and mortality in the intensive care unit (ICU). DESIGN: Case-control study. SETTING: Burn-trauma ICU in a level 1 trauma center. PATIENTS: All patients who received corticosteroids while in the ICU from January 1, 2002, to December 31, 2003 (n = 100), matched by age and Injury Severity Score with a control group (n = 100). INTERVENTIONS: None. MAIN OUTCOME MEASURES: We considered the following 7 outcomes: pneumonia, bloodstream infection, urinary tract infection, other infections, ICU length of stay (LOS), ventilator LOS, and mortality. RESULTS: Cases and controls had similar APACHE II (Acute Physiology and Chronic Health Evaluation II) scores and medical history. In univariate analysis, the corticosteroid group had a significant increase in pneumonia (26% vs 12%; P<.01), bloodstream infection (19% vs 7%; P<.01), and urinary tract infection (17% vs 8%; P<.05). In multivariate models, corticosteroid use was associated with an increased rate of pneumonia (odds ratio [OR], 2.64; 95% confidence interval [CI], 1.21-5.75) and bloodstream infection (OR, 3.25; 95% CI, 1.26-8.37). There was a trend toward increased urinary tract infection (OR, 2.31; 95% CI, 0.94-5.69), other infections (OR, 2.57; 95% CI, 0.87-7.67), and mortality (OR, 1.89; 95% CI, 0.81-4.40). Patients in the ICU who received corticosteroids had a longer ICU LOS by 7 days (P<.01) and longer ventilator LOS by 5 days (P<.01). CONCLUSIONS: Corticosteroid use is associated with increased rate of infection, increased ICU and ventilator LOS, and a trend toward increased mortality. Caution must be taken to carefully consider the indications, risks, and benefits of corticosteroids when deciding on their use.     

The angiogenic peptide pleiotrophin (PTN/HB-GAM) is expressed in fracture healing: an immunohistochemical study in rats

Introduction Formation of new blood vessels is essential for the process of fracture healing.Materials and methods We investigated the expression of the angiogenic factor pleiotrophin/HB-GAM in a closed fracture model in rats by immunohistochemical methods.Results Histologically, 5 days after fracture the callus was predominantly composed of fibrous tissue. On day 10 a prominent chondral callus connected both ends of the fractured tibia. There was a continuous transition from the chondral callus to the newly formed bone adjacent to the corticalis of the tibia. On day 15 the amount of woven bone had increased, and in 3 of 5 animals the proximal and distal tibiae were connected by a bridge of woven bone. Pleiotrophin could be immunostained in fibroblasts and endothelial cells of the fibrous tissue between the fractured tibia ends. The chondral callus remained largely pleiotrophin-negative. Only single chondrocytes adjacent to the newly formed bone were pleiotrophin-positive. On days 10 and 15 strong immunoreactivity for pleiotrophin in the well vascularized, newly formed, woven bone was detectable. Osteoblasts, endothelial cells and fibroblasts were strongly pleiotrophin-positive.Conclusions These results show the presence of the angiogenic peptide pleiotrophin during fracture healing.     

Low awareness of COPD among physicians

Introduction: Early identification of patients with chronic obstructive pulmonary disease (COPD) in the health care system followed by successful smoking cessation may prevent rapid lung function deterioration, development of severe COPD and respiratory failure. Objectives: The aim of this study was to determine the frequency of under‐diagnosed chronic obstructive lung diseases among current smokers. Materials and methods: The under‐diagnosis of COPD among smokers was determined in subjects who participated in a screening procedure aimed at recruiting COPD patients for a smoking cessation programme. In order to identify current smokers, a questionnaire was sent out to persons who had been on sick leave for various reasons certified by a physician for more than 2 weeks. Subjects who stated that they currently smoked more than eight cigarettes per day were invited to perform a lung function test. Results: A total of 3887 subjects performed spirometry, i.e. forced expiratory volume in 1 s and forced expirations, and among these, 674 (17.3%) had COPD according to the European Respiratory Society (ERS) consensus guidelines. Of those, 103 (17.3%) had physician‐diagnosed COPD. Productive cough was reported by 16.6% of the COPD subjects. Despite the fact that smokers were on sick leave certified by a physician, more than 80% of those with COPD had no previous diagnosis. As the COPD diagnosis cannot be based on reported symptoms, a spirometry on persons at risk must be performed. Conclusion: The awareness of COPD among primary care physicians has to increase and smokers above the age of 40, with and without respiratory symptoms, have to undergo spirometry if it is regarded important to establish the COPD diagnosis at an early stage. Please cite this paper as: Sundblad B‐M, Larsson K and Nathell L. Low awareness of COPD among physicians. The Clinical Respiratory Journal 2008; 2: 11–16.