A scoping review of core outcome sets and their 'mapping' onto real-world data using prostate cancer as a case study.

BACKGROUND: A Core Outcomes Set (COS) is an agreed minimum set of outcomes that should be reported in all clinical studies related to a specific condition. Using prostate cancer as a case study, we identified, summarized, and critically appraised published COS development studies and assessed the degree of overlap between them and selected real-world data (RWD) sources. METHODS: We conducted a scoping review of the Core Outcome Measures in Effectiveness Trials (COMET) Initiative database to identify all COS studies developed for prostate cancer. Several characteristics (i.e., study type, methods for consensus, type of participants, outcomes included in COS and corresponding measurement instruments, timing, and sources) were extracted from the studies; outcomes were classified according to a predefined 38-item taxonomy. The study methodology was assessed based on the recent COS-STAndards for Development (COS-STAD) recommendations. A 'mapping' exercise was conducted between the COS identified and RWD routinely collected in selected European countries. RESULTS: Eleven COS development studies published between 1995 and 2017 were retrieved, of which 8 were classified as 'COS for clinical trials and clinical research', 2 as 'COS for practice' and 1 as 'COS patient reported outcomes'. Recommended outcomes were mainly categorized into 'mortality and survival' (17%), 'outcomes related to neoplasm' (18%), and 'renal and urinary outcomes' (13%) with no relevant differences among COS study types. The studies generally fulfilled the criteria for the COS-STAD 'scope specification' domain but not the 'stakeholders involved' and 'consensus process' domains. About 72% overlap existed between COS and linked administrative data sources, with important gaps. Linking with patient registries improved coverage (85%), but was sometimes limited to smaller follow-up patient groups. CONCLUSIONS: This scoping review identified few COS development studies in prostate cancer, some quite dated and with a growing level of methodological quality over time. This study revealed promising overlap between COS and RWD sources, though with important limitations; linking established, national patient registries to administrative data provide the best means to additionally capture patient-reported and some clinical outcomes over time. Thus, increasing the combination of different data sources and the interoperability of systems to follow larger patient groups in RWD is required.

The moderating effect of childhood disadvantage on the associations between smoking and occupational exposure and lung function; a cross sectional analysis of the UK Household Longitudinal Study (UKHLS).

BACKGROUND: Lung function is lower in people with disadvantaged socio-economic position (SEP) and is associated with hazardous health behaviours and exposures. The associations are likely to be interactive, for example, exposure to socially patterned environmental tobacco smoke (ETS) in childhood is associated with an increased effect of smoking in adulthood. We hypothesise that disadvantaged childhood SEP increases susceptibility to the effects of hazards in adulthood for lung function. We test whether disadvantaged childhood SEP moderates smoking, physical activity, obesity, occupational exposures, ETS and air pollution's associations with lung function. METHODS: Data are from the Nurse Health Assessment (NHA) in waves two and three of the United Kingdom Household Longitudinal Study (UKHLS). Analysis is restricted to English residents aged at least 20 for women and 25 for men, producing a study population of 16,339. Lung function is measured with forced expiratory volume in the first second (FEV1) and standardised to the percentage of expected FEV1 for a healthy non-smoker of equivalent age, gender, height and ethnicity (FEV1%). Using STATA 14, a mixed linear model was fitted with interaction terms between childhood SEP and health behaviours and occupational exposures. Cross level interactions tested whether childhood SEP moderated household ETS and neighbourhood air pollution's associations with FEV1%. RESULTS: SEP, smoking, physical activity, obesity, occupational exposures and air pollution were associated with lung function. Interaction terms indicated a significantly stronger negative association between disadvantaged childhood SEP and currently smoking (coefficient -6.47 %, 95% confidence intervals (CI): 9.51 %, 3.42 %) as well as with formerly smoking and occupational exposures. Significant interactions were not found with physical activity, obesity, ETS and air pollution. CONCLUSION: The findings suggest that disadvantaged SEP in childhood may make people's lung function more susceptible to the negative effects of smoking and occupational exposures in adulthood. This is important as those most likely to encounter these exposures are at greater risk to their effects. Policy to alleviate this inequality requires intervention in health behaviours through public health campaigns and in occupational health via health and safety legislation.

Outcomes for individuals turned down for living kidney donation.

BACKGROUND: A better understanding of the consequences of being turned down for living kidney donation could help transplant professionals to counsel individuals considering donation. METHODS: In this exploratory study, we used survey instruments and qualitative interviews to characterize nonmedical outcomes among individuals turned down for living kidney donation between July 1, 2010 and December 31, 2013. We assembled a comparator group of kidney donors. RESULTS: Among 83 turned-down donors with contact information at a single center, 43 (52%) participated in the study (median age 53 years; 53% female; 19% black). Quality of life, depression, financial stress, and provider empathy scores were similar between individuals turned down for donation (n = 43) and donors (n = 128). Participants selected a discrete choice response to a statement about the overall quality of their lives; 32% of turned-down donors versus 7% of donors (P < 0.01) assessed that their lives were worse after the center's decision about whether they could donate a kidney. Among turned-down donors who reported that life had worsened, 77% had an intended recipient who was never transplanted, versus 36% among individuals who assessed life as the same or better (P = 0.02). In interviews, the majority of turned-down donors reported emotional impact, including empathy, stress, and other challenges, related to having someone in their lives with end-stage kidney disease. CONCLUSIONS: Generic instruments measuring quality of life, depression, financial stress, and provider empathy revealed no significant differences between kidney donors and turned-down donors. However, qualitative interviews revealed preliminary evidence that some turned-down donors experienced emotional consequences. These findings warrant confirmation in larger studies.

Social patterning in grip strength and in its association with age; a cross sectional analysis using the UK Household Longitudinal Study (UKHLS).

BACKGROUND: Grip strength in early adulthood and midlife is an important predictor of disability, morbidity and mortality in later life. Understanding social patterning in grip strength at different life stages could improve insight into inequalities in age-related decline and when in the life course interventions could prevent the emergence of inequalities. METHODS: Using United Kingdom Household Longitudinal Study (UKHLS) data on 19,292 people aged 16 to 99, fractional polynomial models were fitted to identify which function of age best described its association with grip strength. Linear regressions were used to establish whether socio-economic position (SEP), as measured by maternal education, highest educational qualification and income, was associated with grip strength. To test whether the association between age and grip strength was modified by SEP, interactions between SEP and the age terms were added. Differentiation was used to identify the age at which grip strength was highest for men and women and predicted levels of grip strength at peak were compared. RESULTS: SEP is significantly associated with grip strength on all SEP measures, except education for men. Grip strength is highest at a younger age, and less strong for all measures of disadvantage for women and most measures for men. Interaction terms were not statistically significant indicating that the association between age and grip strength was not modified by SEP. Grip strength peak was 29.3 kg at age 33 for women with disadvantaged childhood SEP compared with 30.2 kg at age 35 for women with advantaged childhood SEP. CONCLUSION: The SEP differences in age and level of peak grip strength could be indicative of decline in muscle strength beginning earlier and from a lower base for disadvantaged groups. This could impact on the capacity for healthy ageing for those with disadvantaged SEP.

Two Randomized Controlled Pilot Trials of Social Forces to Improve Statin Adherence among Patients with Diabetes.

BACKGROUND: Medication nonadherence is an important obstacle to cardiovascular disease management. OBJECTIVE: To improve adherence through real-time feedback based on theories of how social forces influence behavior. DESIGN: Two randomized controlled pilot trials called PROMOTE and SUPPORT. Participants stored statin medication in wireless-enabled pill bottles that transmitted adherence data to researchers. PARTICIPANTS: Adults with diabetes and a history of low statin adherence based on pharmacy refills (i.e., Medication Possession Ratio [MPR] <80% in the pre-randomization screening period). INTERVENTION: In PROMOTE, each participant was randomized to 1) weekly messages in which that participant's statin adherence was compared to that of other participants (comparison), 2) weekly summaries of that participant's statin adherence (summary), or 3) control. In SUPPORT, each participant identified another person (the Medication Adherence Partner [MAP]) to receive reports about that participant's adherence, and was randomized to 1) daily reports to MAP, 2) weekly reports to MAP, 3) reports to MAP only if dose was missed, or 4) control. MAIN OUTCOMES MEASURE: Adherence measured by pill bottle. KEY RESULTS: Among 45,000 health plan members contacted by mail, <1% joined the trial. Participants had low baseline MPRs (median = 60%, IQR 41-72%) but high pill-bottle adherence (90% in PROMOTE, 92% in SUPPORT) during the trial. In PROMOTE (n = 201) and SUPPORT (n = 200), no intervention demonstrated significantly better adherence vs. CONTROL: In a subgroup of PROMOTE participants with the lowest pre-study MPR, pill-bottle-measured adherence in the comparison arm (89%) was higher than the control (86%) and summary (76%) arms, but differences were non-significant (p = 0.10). CONCLUSIONS: Interventions based on social forces did not improve medication adherence vs. control over a 3-month period. Given the low percentage of invited individuals who enrolled, the studies may have attracted participants who required little encouragement to improve adherence other than study participation.

Participant Perceptions of a Free Fresh Produce Market at a Health Center.

OBJECTIVE: To examine participant perceptions of a free, monthly produce market at a health center in Massachusetts. DESIGN: Participants were recruited at a produce market between June 2019 and January 2020 and engaged in a 30-65-minute focus group (n = 3 English language; n = 2 Spanish; n = 2 Arabic) conducted by trained facilitators using a semistructured guide. PARTICIPANTS: Adults (n = 49) who had attended the market at least twice in the previous 6 months. MAIN OUTCOME MEASURES: Participant-reported facilitators, barriers, perceived benefits, and opportunities for improvement. ANALYSIS: Conventional content analysis. RESULTS: Reported facilitators included accessibility (eg, convenient location and timing), program experience (eg, positive volunteer interactions), and characteristics of goods and services (eg, acceptable variety of produce). Barriers fell under similar themes and included transportation challenges, poor weather, and insufficient quantity of produce for larger households. Participants perceived the market as improving diet and finances and offered suggestions for improvement: distributing nonproduce foods (eg, meat) or nonfood items (eg, toiletries) and augmenting existing initiatives aimed to help attendees make use of the produce (eg, handing out recipe cards). CONCLUSIONS AND IMPLICATIONS: The produce market was widely accepted, and targeted areas for improvement were identified. Findings may improve existing and future charitable produce markets among diverse populations.

Addressing the role of edaravone in the management of amyotrophic lateral sclerosis and gaps in care and access: expert panel recommendations.

A virtual key opinion leader (KOL) and payer discussion was held on December 5, 2020. In attendance were 2 KOLs, both specialists in amyotrophic lateral sclerosis (ALS) at leading clinics in the United States, and 6 managed care executives from US regional health plans. The objective of this panel was to share opinions, ideas, and information around the treatment of ALS with edaravone, gaps in management and guidelines, and potential solutions. The panel concluded that coverage criteria for edaravone may need to be reassessed and treatment guidelines could be revisited to include a determination of place in therapy for edaravone.

Providing Food Assistance During the COVID-19 Pandemic: A Case Study of a Free Produce Market at a Health Care Center.

The COVID-19 pandemic has worsened economic precarity and nearly doubled food insecurity in the United States. We describe how a free produce market at a Massachusetts health center adapted to exponentially increase its reach and offerings while continuing to safely distribute food to a low-income community during the pandemic.

Behavioral health conditions and potentially preventable diabetes-related hospitalizations in the United States: Findings from a national sample of commercial claims data.

OBJECTIVE: To characterize the relationship between potentially preventable hospitalizations (PPHs) for diabetes and behavioral health conditions in commercially insured working-age persons with diabetes in the United States. RESEARCH DESIGN AND METHODS: We retrospectively analyzed medical and pharmacy claims from services rendered between 2011 and 2013 for 229,039 adults with diabetes. Diabetes PPHs were identified using the Agency for Healthcare Research and Quality's Prevention Quality Indicators v6.0 logic. We used negative binomial-logit hurdle regression models to explore the adjusted relationships between diabetes PPHs and schizophrenia, bipolar, depression, anxiety, adjustment disorder, alcohol use disorder, and drug use disorder. RESULTS: A total of 4,521 diabetes PPHs were experienced by 3,246 of the persons in the sample. The 20.83% of persons with one or more behavioral health conditions experienced 43.62% (1,972/4,521; 95% CI 42.18%-45.07%) of all diabetes PPHs, and the 7.14% of persons with more than one diagnosed behavioral health condition experienced 24.77% (1,120/4,521; 95% CI 23.54%-26.05%) of all diabetes PPHs. After adjusting for sociodemographic and physical health covariates, patients with depression, schizophrenia, drug or alcohol use disorders, or multiple behavioral health conditions were at significantly increased risk of experiencing at least one diabetes PPH, while patients with depression, drug use disorder, or multiple behavioral health conditions were at significantly increased risk of experiencing recurring diabetes PPHs over time. CONCLUSIONS: A number of behavioral health conditions are associated with diabetes PPHs, which are often preventable with timely, high-quality outpatient care. The results of this study will enable clinicians, payers, and policy-makers to better focus outpatient care interventions and resources within the population of persons with diabetes.

The age- and sex-specific decline of the 20s proteasome and the Nrf2/CncC signal transduction pathway in adaption and resistance to oxidative stress in Drosophila melanogaster.

Hallmarks of aging include loss of protein homeostasis and dysregulation of stress-adaptive pathways. Loss of adaptive homeostasis, increases accumulation of DNA, protein, and lipid damage. During acute stress, the Cnc-C (Drosophila Nrf2 orthologue) transcriptionally-regulated 20S proteasome degrades damaged proteins in an ATP-independent manner. Exposure to very low, non-toxic, signaling concentrations of the redox-signaling agent hydrogen peroxide (H2O2) cause adaptive increases in the de novo expression and proteolytic activity/capacity of the 20S proteasome in female D. melanogaster (fruit-flies). Female 20S proteasome induction was accompanied by increased tolerance to a subsequent normally toxic but sub-lethal amount of H2O2, and blocking adaptive increases in proteasome expression also prevented full adaptation. We find, however, that this adaptive response is both sex- and age-dependent. Both increased proteasome expression and activity, and increased oxidative-stress resistance, in female flies, were lost with age. In contrast, male flies exhibited no H2O2 adaptation, irrespective of age. Furthermore, aging caused a generalized increase in basal 20S proteasome expression, but proteolytic activity and adaptation were both compromised. Finally, continual knockdown of Keep1 (the cytosolic inhibitor of Cnc-C) in adults resulted in older flies with greater stress resistance than their age-matched controls, but who still exhibited an age-associated loss of adaptive homeostasis.

The Mitochondrial Lon Protease Is Required for Age-Specific and Sex-Specific Adaptation to Oxidative Stress.

Multiple human diseases involving chronic oxidative stress show a significant sex bias, including neurodegenerative diseases, cancer, immune dysfunction, diabetes, and cardiovascular disease. However, a possible molecular mechanism for the sex bias in physiological adaptation to oxidative stress remains unclear. Here, we report that Drosophila melanogaster females but not males adapt to hydrogen peroxide stress, whereas males but not females adapt to paraquat (superoxide) stress. Stress adaptation in each sex requires the conserved mitochondrial Lon protease and is associated with sex-specific expression of Lon protein isoforms and proteolytic activity. Adaptation to oxidative stress is lost with age in both sexes. Transgenic expression of transformer gene during development transforms chromosomal males into pseudo-females and confers the female-specific pattern of Lon isoform expression, Lon proteolytic activity induction, and H2O2 stress adaptation; these effects were also observed using adult-specific transformation. Conversely, knockdown of transformer in chromosomal females eliminates the female-specific Lon isoform expression, Lon proteolytic activity induction, and H2O2 stress adaptation and produces the male-specific paraquat (superoxide) stress adaptation. Sex-specific expression of alternative Lon isoforms was also observed in mouse tissues. The results develop Drosophila melanogaster as a model for sex-specific stress adaptation regulated by the Lon protease, with potential implications for understanding sexual dimorphism in human disease.

Medical comorbidity in women and men with bipolar disorders: a population-based controlled study.

OBJECTIVE: Rarely has validated information on chronic medical comorbidity been presented for persons with bipolar disorder. To deliver appropriate health services, it is important to understand the prevalence of chronic medical conditions in this population. This study examines chronic medical comorbidity using validated methodology in persons with bipolar disorder. METHODS: This is a retrospective study of a 100% sample of administrative claims (1996-2001) from Wellmark Blue Cross Blue Shield. Three thousand five hundred fifty-seven subjects had bipolar I disorder and did not have claims for schizophrenia or schizoaffective disorder. Controls had no documented claims for psychiatric conditions. Using validated methodology, inpatient and outpatient claims were used to determine prevalence of 44 chronic medical conditions. Odds ratios (ORs) were adjusted for age, gender, residence, and nonmental healthcare utilization. RESULTS: Persons with bipolar disorder were young (mean age, 38.8 years) and significantly more likely to have medical comorbidity, including three or more chronic conditions (41% versus 12%, p < .001) compared with controls. Elevated ORs were found for conditions spanning all organ systems. Hyperlipidemia, lymphoma, and metastatic cancer were the only conditions less likely to occur in persons with bipolar disorder. CONCLUSION: Bipolar disorders are associated with substantial chronic medical burden. Familiarity with conditions affecting this population may assist in programs aimed at providing medical care for the chronically mentally ill.

Comorbidity profile of dementia patients in primary care: are they sicker?

OBJECTIVES: To compare the medical comorbidity of older patients with and without dementia in primary care. DESIGN: Cross-sectional study. SETTING: Wishard Health Services, which includes a university-affiliated, urban public hospital and seven community-based primary care practice centers in Indianapolis. PARTICIPANTS: Three thousand thirteen patients aged 65 and older attending seven primary care centers in Indianapolis, Indiana. MEASUREMENTS: An expert panel diagnosed dementia using International Classification of Diseases, 10th Revision, criteria. Comorbidity was assessed using 10 physician-diagnosed chronic comorbid conditions and the Chronic Disease Score (CDS). RESULTS: Patients with dementia attending primary care have on average 2.4 chronic conditions and receive 5.1 medications. Approximately 50% of dementia patients in this setting are exposed to at least one anticholinergic medication, and 20% are prescribed at least one psychotropic medication. After adjusting for patients' age, race, and sex, patients with and without dementia have a similar level of comorbidity (mean number of chronic medical conditions, 2.4 vs 2.3, P=.66; average CDS, 5.8 vs 6.2, P=.83). CONCLUSION: Multiple medical comorbid conditions are common in older adults with and without dementia in primary care. Despite their cholinergic deficit, a substantial proportion of patients with dementia are exposed to anticholinergic medications. Models of care that incorporate this medical complexity are needed to improve the treatment of dementia in primary care.

The influence of type and severity of mental illness on receipt of screening mammography.

BACKGROUND: Women with mental illness may be at risk for failure to receive recommended preventive services such as mammography. Little is known about whether the type or severity of mental illness influences receipt of preventive services. OBJECTIVE: To measure the influence of type and severity of mental illness on receipt of mammography. DESIGN: Retrospective study of administrative claims data, 1996 to 2001. SUBJECTS: Privately insured women age 40 to 64 years, with and without claims for mental illness, and who were eligible for mammography between 1996 and 2001. MEASUREMENT: Odds ratios (OR) for receipt of screening mammography, any mammography, and follow-up mammography, adjusted for age, rural location, utilization of nonmental health services, and severity and type of the mental disorder. Severity measures were based on utilization of outpatient and inpatient mental health services and presence of comorbid substance use disorder. RESULTS: Women with any mental disorder were significantly less likely to receive mammography than controls. This was strongly influenced by severity of mental illness (any mammography: moderate severity OR 0.62; confidence interval [CI] 0.59 to 0.66: high severity OR 0.38; CI 0.33 to 0.43). Whereas severity contributed to lower receipt of mammography among women with mood and anxiety disorders, women with psychotic, alcohol, and substance abuse disorders had decreased odds for receipt of mammography regardless of severity. CONCLUSIONS: Women with mental disorders are at risk for failure to receive mammography, a recommended preventive service. Women with severe mental illness or psychotic and substance abuse disorders should be targeted to ensure delivery of mammography.

Medical comorbidity in women and men with schizophrenia: a population-based controlled study.

BACKGROUND: Persons with persistent mental illness are at risk for failure to receive medical services. In order to deliver appropriate preventive and primary care for this population, it is important to determine which chronic medical conditions are most common. OBJECTIVE: We examined chronic medical comorbidity in persons with schizophrenia using validated methodologies. DESIGN: Retrospective analysis of longitudinal administrative claims data from Wellmark Blue Cross/Blue Shield of Iowa. PARTICIPANTS: Subjects with schizophrenia or schizoaffective disorder (N=1,074), and controls (N=726,262) who filed at least 1 claim for medical services, 1996 to 2001. MEASUREMENTS: Case subjects had schizophrenia as the most clinically predominant psychotic disorder, based on psychiatric hospitalization, psychiatrist diagnoses, and outpatient care. Controls had no claims for any psychiatric comorbidity. Using a modified version of the Elixhauser Comorbidity Index, inpatient and outpatient claims were used to determine the prevalence of 46 common medical conditions. Odds ratios (ORs) were adjusted for age, gender, residence, and nonmental health care utilization using logistic regression. RESULTS: Subjects with schizophrenia were significantly more likely to have 1 or more chronic conditions compared with controls. Adjusted OR (95% confidence interval [CI]) were 2.62 (2.09 to 3.28) for hypothyroidism, 1.88 (1.51 to 2.32) for chronic obstructive pulmonary disease, 2.11 (1.36 to 3.28) for diabetes with complications, 7.54 (3.55 to 15.99) for hepatitis C, 4.21 (3.25 to 5.44) for fluid/electrolyte disorders, and 2.77 (2.23 to 3.44) for nicotine abuse/dependence. CONCLUSIONS: Schizophrenia is associated with substantial chronic medical burden. Familiarity with conditions affecting persons with schizophrenia may assist programs aimed at providing medical care for the mentally ill.

Mental disorders and revascularization procedures in a commercially insured sample.

OBJECTIVE: The objective of this study was to determine if receipt of revascularization was similar among commercially insured adults with mental disorders compared with people without mental disorders. METHODS: This was a retrospective analysis of a 100% sample of Blue Cross/Blue Shield of Iowa administrative claims data, 1996 to 2001. Logistic regression was used to calculate unadjusted and adjusted odds ratios (OR) for receipt of angioplasty (PTCA) and bypass graft surgery (CABG) within 30 days of discharge. RESULTS: A total of 3368 adults, aged 18 to 64 years, were hospitalized for myocardial infarction (MI) and 40% (n = 1342) had a mental disorder. Subjects with mental disorders were more likely to be younger, female, urban residents, and to have increased cardiovascular and medical comorbidity. They were similarly likely as subjects without mental disorders to have received PTCA (OR, 1.10; 95% confidence interval [CI], 0.95-1.29) and CABG (OR, 0.89; 95% CI, 0.71-1.11) in analyses adjusted for demographic and clinical characteristics. Revascularization rates did not differ by mental disorder type, with few exceptions. CONCLUSIONS: Receipt of revascularization was similar for patients with and without mental disorders. Our results may differ from previous findings as a result of the younger population studied and increased comorbidity in people with mental disorders, which may have resulted in a contraindication for surgical intervention. Conversely, the increased burden of comorbidity could suggest that these patients should have received PTCA at higher rates because of the better prognosis associated with revascularization as compared with medical management. Prospective analyses with review of clinical data and behavioral risk factors are necessary to determine why some patients with mental illness may be less likely to receive cardiac interventions.

Telephonic case-finding of major depression in a Medicaid chronic disease management program for diabetes and heart failure.

OBJECTIVE: Major depression is common in low-income and chronically ill persons and is a barrier for effective chronic disease care. We evaluated a Medicaid-sponsored strategy for detecting depressive symptoms in adults with diabetes or congestive heart failure. METHODS: Using a two-item screening tool, 890 adults enrolled in the Indiana Chronic Disease Management Program were assessed by telephone for depressive symptoms between December 2003 and March 2004. A subset of 386 participants also completed the eight-item Patient Health Questionnaire (PHQ-8) depression measure. Antidepressant use was examined using pharmacy claims. RESULTS: Depressed mood or anhedonia was reported by 51% of participants. About one in four participants had a PHQ-8 score indicating a high risk for major depression (score >or=10). The two-item screen was 96% sensitive [95% confidence interval (CI), 89-99%] and 60% specific (95% CI, 54-65%) for identifying members at high risk for depression by the full PHQ-8 instrument. Only half of participants with high-risk PHQ-8 scores had a pharmacy claim indicating that an antidepressant medication was filled within 120 days of the depression screening. CONCLUSIONS: A two-stage, telephonic approach involving the PHQ-8 instrument for Medicaid members with either depressed mood or anhedonia could identify two clinically depressed persons for every nine members screened.

Incarceration and veterans of the first Gulf War.

OBJECTIVE: This study investigated the prevalence of incarceration and the association with deployment among veterans of the first Persian Gulf War (GW). METHODS: A structured telephone interview of military personnel from Iowa deployed to the Persian Gulf and a comparison sample of nondeployed military personnel was conducted. The interview consisted of validated questions, validated instruments, and investigator-derived questions to assess relevant medical and psychiatric conditions. A total of 4,886 subjects were randomly drawn from one of four study domains, i.e., GW regular military, GW National Guard/Reserve, non-GW regular military, or non-GW National Guard/Reserve. Symptoms of medical conditions, psychiatric disorders, and health care utilization were the main outcome measures. RESULTS: Nearly one-quarter (845 of 3,695 subjects, 22.9%) had been incarcerated at some point before the interview ("ever incarcerated"). Ever incarcerated veterans had a higher frequency of psychiatric and medical comorbidity and higher rates of health care utilization. Ever incarcerated status was associated with male gender, enlisted rank, lower educational levels, low levels of military preparedness, discharge from service, cigarette smoking, antisocial traits, court martial and/or other military discipline, having seen a mental health professional, and having used illegal drugs. GW veterans who participated in combat had a modestly higher risk for incarceration after the GW than did noncombatants (odds ratio, 1.6; 95% confidence interval, 1.0-2.5). CONCLUSIONS: Military recruits with a history of incarceration more often displayed problematic behaviors, more often developed psychiatric/medical conditions, and had high rates of health care utilization. A history of incarceration may be a behavioral marker for substance abuse, antisocial behavior, and mental illness. Importantly, GW deployment carried no increased risk of subsequent incarceration overall.

Relationship between depression and pancreatic cancer in the general population.

OBJECTIVE: Prior research suggesting a relationship between pancreatic cancer and depression conducted on clinical populations has been subject to recall bias. We reexamined this association using longitudinal population-based data. METHODS: This was a retrospective cohort study using longitudinal insurance claims data. RESULTS: Men with mental disorders were more likely to develop pancreatic cancer than those without psychiatric claims (odds ratio 2.4, confidence interval 1.15-4.78). Depression more commonly preceded pancreatic cancer than it did other gastrointestinal malignancies (odds ratio 4.6, confidence interval 1.07-19.4) or all other cancers (odds ratio 4.1, confidence interval 1.05-16.0). CONCLUSIONS: Depression and pancreatic cancer are associated in the general population.

Occurrence of cancer among people with mental health claims in an insured population.

OBJECTIVE: The objective of this research is to determine whether people with mental disorders are at increased risk for the subsequent development of malignancies compared with people without mental disorders. METHODS: This is a retrospective cohort study of administrative claims data. The study population included 722,139 adults who filed at least one medical claim from 1989 to 1993. The mental disorder cohort included people with a) one psychiatric hospitalization, b) one outpatient psychiatrist visit, or c) two outpatient mental health claims occurring at least 6 months before a cancer claim. The controls were subjects filing claims for medical services who had no mental health visits. We calculated age-stratified odds ratios (ORs) for development of malignancy. RESULTS: People with mental disorders were no more or less likely to develop a malignancy than those without after adjusting for age (women: OR, 1.03; 95% confidence interval [CI], 0.95-1.12; men: OR, 1.10; 95% CI, 0.97-1.24). People with mental disorders, however, developed cancer at younger ages and had increased odds of primary central nervous system tumors (women: OR, 2.12; 95% CI, 1.40-3.21; men: OR, 2.09; 95% CI, 1.22-3.59) and respiratory system cancers (women: OR, 1.57; 95% CI, 1.13-2.19; men: OR, 1.52; 95% CI, 1.09-2.12). CONCLUSIONS: Insured people with mental disorder claims had an increased risk of certain malignancies and developed malignancies at younger ages. The increased odds of respiratory tumors are likely secondary to increased rates of smoking among people with mental disorders and support use of smoking cessation interventions in this population. The increased odds for brain tumors may reflect only the early presence of mental symptoms, or a true association between the two conditions. Further study of these findings is mandated.