Analysis of body condition indices reveals different ecotypes of the Antillean manatee

Assessing the body condition of wild animals is necessary to monitor the health of the population and is critical to defining a framework for conservation actions. Body condition indices (BCIs) are a non-invasive and relatively simple means to assess the health of individual animals, useful for addressing a wide variety of ecological, behavioral, and management questions. The Antillean manatee (Trichechus manatus manatus) is an endangered subspecies of the West Indian manatee, facing a wide variety of threats from mostly human-related origins. Our objective was to define specific BCIs for the subspecies that, coupled with additional health, genetic and demographic information, can be valuable to guide management decisions. Biometric measurements of 380 wild Antillean manatees captured in seven different locations within their range of distribution were obtained. From this information, we developed three BCIs (BCI₁ = UG/SL, BCI₂ = W/SL³, BCI₃ = W/(SL*UG²)). Linear models and two-way ANCOVA tests showed significant differences of the BCIs among sexes and locations. Although our three BCIs are suitable for Antillean manatees, BCI₁ is more practical as it does not require information about weight, which can be a metric logistically difficult to collect under particular circumstances. BCI₁ was significantly different among environments, revealing that the phenotypic plasticity of the subspecies have originated at least two ecotypes-coastal marine and riverine-of Antillean manatees.

Validation of a case definition for depression in administrative data against primary chart data as a reference standard

BACKGROUND

Because the collection of mental health information through interviews is expensive and time consuming, interest in using population-based administrative health data to conduct research on depression has increased. However, there is concern that misclassification of disease diagnosis in the underlying data might bias the results. Our objective was to determine the validity of International Classification of Disease (ICD)-9 and ICD-10 administrative health data case definitions for depression using review of family physician (FP) charts as the reference standard.

METHODS

Trained chart reviewers reviewed 3362 randomly selected charts from years 2001 and 2004 at 64 FP clinics in Alberta (AB) and British Columbia (BC), Canada. Depression was defined as presence of either: 1) documentation of major depressive episode, or 2) documentation of specific antidepressant medication prescription plus recorded depressed mood. The charts were linked to administrative data (hospital discharge abstracts and physician claims data) using personal health numbers. Validity indices were estimated for six administrative data definitions of depression using three years of administrative data.

RESULTS

Depression prevalence by chart review was 15.9-19.2% depending on year, region, and province. An ICD administrative data definition of '2 depression claims with depression ICD codes within a one-year window OR 1 discharge abstract data (DAD) depression diagnosis' had the highest overall validity, with estimates being 61.4% for sensitivity, 94.3% for specificity, 69.7% for positive predictive value, and 92.0% for negative predictive value. Stratification of the validity parameters for this case definition showed that sensitivity was fairly consistent across groups, however the positive predictive value was significantly higher in 2004 data compared to 2001 data (78.8 and 59.6%, respectively), and in AB data compared to BC data (79.8 and 61.7%, respectively).

CONCLUSIONS

Sensitivity of the case definition is often moderate, and specificity is often high, possibly due to undercoding of depression. Limitations to this study include the use of FP charts data as the reference standard, given the potential for missed or incorrect depression diagnoses. These results suggest that that administrative data can be used as a source of information for both research and surveillance purposes, while remaining aware of these limitations.

Strategies for improving physician documentation in the emergency department: a systematic review

BACKGROUND

Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown.

METHODS

We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation.

RESULTS

Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results.

CONCLUSIONS

Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.

Validity of Canadian discharge abstract data for hypertension and diabetes from 2002 to 2013

BACKGROUND

Surveillance using coded administrative health data has shown that the prevalence of hypertension and diabetes in Canada increased substantially between 1998 to 2008. These findings require an assumption that the validity of hypertension and diabetes coding is stable over time. We tested this assumption by examining temporal trends in the validity of coding for hypertension and diabetes in the Canadian hospital Discharge Abstract Database.

METHODS

We used the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database, a clinical registry, as the reference standard to evaluate the validity of the Discharge Abstract Database in recording hypertension and diabetes in Alberta. The APPROACH database contains data for all Alberta residents who have undergone cardiac catheterization and includes prospective ascertainment of comorbid conditions before each procedure. We linked patient data between the 2 databases for 2002 to 2013 using patient provincial health number. Temporal trends in sensitivity, specificity, positive predictive value, negative predictive value and Cohen κ were calculated for both hypertension and diabetes in the Discharge Abstract Database.

RESULTS

We matched 63 483 patients between the APPROACH database and the Discharge Abstract Database. The validity of the Discharge Abstract Database for hypertension and diabetes remained mostly consistent over time. Between 2002 and 2013, sensitivity, specificity, positive predictive value and negative predictive value ranged from 66% to 87% for hypertension and from 81% to 98% for diabetes; the corresponding κ scores ranged from 0.50 to 0.62 and from 0.80 to 0.89. No significant differences in the validity of coding were found across age, sex or hospital location subgroups.

INTERPRETATION

The validity of coding for hypertension and diabetes in the Discharge Abstract Database remained fairly consistent between 2002 and 2013. Our findings support the use of the Discharge Abstract Database for hypertension and diabetes surveillance in hospital settings.

Depressive symptoms in a treated multiple sclerosis cohort

Background: Recent side effect data from clinical trials of interferon beta in multiple sclerosis (MS) have failed to confirm that these medications are associated with an increased risk of depression. However, these studies have used highly selected samples and the results may not be generalizable to real world settings. Methods: C linical data on subjects from southern A lberta who have applied for, or are receiving, public reimbursement for MS treatment are maintained in a database at the University of C algary Multiple Sclerosis C linic. Depression ratings obtained using the C enter for Epidemiological Studies Depression Rating Scale (C ES-D) are included in this database. In the current analysis, these longitudinal data were used to determine whether depressive symptoms were associated with disease-modifying treatments. Results: A t baseline, ratings were available for 163 subjects. Those choosing interferon beta resembled those choosing glatiramer acetate in most respects. During follow-up, no differences were observed in the prevalence or incidence of depression and C ES-D scores were not found to differ between the treatment groups. Conclusions: The failure to identify higher rates of depression both in previous intervention studies and in the current observational study provides confirmation that these drugs are not substantially associated with the occurrence of depression.

Regional variation of multiple sclerosis prevalence in Canada

Objective: To describe the regional distribution of multiple sclerosis (MS) prevalence in Canada, controlling for age and sex. Methods: This study used data from the Canadian Community Health Survey, a large general health survey (n=131,535) conducted in 2000/2001. Subjects aged 18 and over were included in the current analysis (n=116,109). The presence of MS was determined by self-report. Prevalence was computed in five regions (Atlantic, Quebec, Ontario, Prairies and British Columbia). Logistic regression was used to compare regions and examine for confounding/interaction by age and sex. Results: The overall Canadian MS prevalence was 240 per 100 000 (95%CI: 210-280). Prevalence ranged from 180 (95%CI: 90-260) in Quebec to 350 (95%CI: 230-470) in Atlantic Canada. Logistic regression revealed no statistical difference between the odds of MS in Quebec, Ontario and British Columbia adjusted for age and sex. The adjusted odds of MS in the Prairies and Atlantic regions were significantly higher than in the other regions combined, with odds ratios of 1.7 (95%CI: 1.1-2.4, p<0.01) and 1.6 (95%CI: 1.1-2.4, p<0.05) respectively. Sensitivity analysis demonstrated similar prevalence in the nonaboriginal/nonimmigrant group (n=96 219). Conclusion: Results suggest that Canadian MS prevalence differs by region. If validated, these regional differences may facilitate investigation of environmental influences.

Effect of physician specialist alternative payment plans on administrative health data in Calgary: a validation study

BACKGROUND

There are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary.

METHODS

We conducted a survey of physician specialists to determine their plan status and obtained consent to use physicians' claims data from 4 acute care hospitals in Calgary. Inpatient and emergency department services were identified from the Discharge Abstract Database for Alberta (Canadian Institute for Health Information) and the Alberta Ambulatory Care Classification System database. We linked services to claims by Alberta physicians from 2002 to 2009 by using unique patient and physician identifiers. After identifying the proportion of claims submitted, we reviewed inpatient charts to determine the completeness of submissions as defined by positive predictive value.

RESULTS

Of 182 physicians who responded to the survey, 94 (51.6%) used fee-for-service plans exclusively and 51 (28.0%) used alternative payment plans exclusively. Overall completeness of physician submissions for claims was 91.8% for physicians using fee-for-service plans and 90.0% for physicians using alternative payment plans. Submission rate varied by medical specialty (surgery: 92.4% for fee for service v. 88.6% for alternative payment; internal medicine: 94.1% v. 91.3%; neurology: 95.1% v. 91.0%; and pediatrics: 95.1% v. 89.3%). Among claims submitted, the physician accuracies for billing of medical conditions were 87.8% for fee-for-service and 85.0% for alternative payment.

INTERPRETATION

Overall submission rates and accuracy in recording diagnoses by physicians who used both plans were high. These findings show that the implementation of alternative payment plan programs in Alberta may not have an impact on the quality of physician claims data.

Exploring physician specialist response rates to web-based surveys

Background

Survey research in healthcare is an important tool to collect information about healthcare delivery, service use and overall issues relating to quality of care. Unfortunately, physicians are often a group with low survey response rates and little research has looked at response rates among physician specialists. For these reasons, the purpose of this project was to explore survey response rates among physician specialists in a large metropolitan Canadian city.

Methods

As part of a larger project to look at physician payment plans, an online survey about medical billing practices was distributed to 904 physicians from various medical specialties. The primary method for physicians to complete the survey was via the Internet using a well-known and established survey company (www.surveymonkey.com). Multiple methods were used to encourage survey response such as individual personalized email invitations, multiple reminders, and a draw for three gift certificate prizes were used to increase response rate. Descriptive statistics were used to assess response rates and reasons for non-response.

Results

Overall survey response rate was 35.0%. Response rates varied by specialty: Neurology/neurosurgery (46.6%); internal medicine (42.9%); general surgery (29.6%); pediatrics (29.2%); and psychiatry (27.1%). Non-respondents listed lack of time/survey burden as the main reason for not responding to our survey.

Conclusions

Our survey results provide a look into the challenges of collecting healthcare research where response rates to surveys are often low. The findings presented here should help researchers in planning future survey based studies. Findings from this study and others suggest smaller monetary incentives for each individual may be a more appropriate way to increase response rates.

Systematic review and assessment of validated case definitions for depression in administrative data

BACKGROUND

Administrative data are increasingly used to conduct research on depression and inform health services and health policy. Depression surveillance using administrative data is an alternative to surveys, which can be more resource-intensive. The objectives of this study were to: (1) systematically review the literature on validated case definitions to identify depression using International Classification of Disease and Related Health Problems (ICD) codes in administrative data and (2) identify individuals with and without depression in administrative data and develop an enhanced case definition to identify persons with depression in ICD-coded hospital data.

METHODS

(1) Systematic review: We identified validation studies using ICD codes to indicate depression in administrative data up to January 2013. (2) VALIDATION: All depression case definitions from the literature and an additional three ICD-9-CM and three ICD-10 enhanced definitions were tested in an inpatient database. The diagnostic accuracy of all case definitions was calculated [sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV)].

RESULTS

(1) Systematic review: Of 2,014 abstracts identified, 36 underwent full-text review and three met eligibility criteria. These depression studies used ICD-9 and ICD-10 case definitions. (2) VALIDATION: 4,008 randomly selected medical charts were reviewed to assess the performance of new and previously published depression-related ICD case definitions. All newly tested case definitions resulted in Sp >99%, PPV >89% and NPV >91%. Sensitivities were low (28-35%), but higher than for case definitions identified in the literature (1.1-29.6%).

CONCLUSIONS

Validating ICD-coded data for depression is important due to variation in coding practices across jurisdictions. The most suitable case definitions for detecting depression in administrative data vary depending on the context. For surveillance purposes, the most inclusive ICD-9 & ICD-10 case definitions resulted in PPVs of 89.7% and 89.5%, respectively. In cases where diagnostic certainty is required, the least inclusive ICD-9 and -10 case definitions are recommended, resulting in PPVs of 92.0% and 91.1%. All proposed case definitions resulted in suboptimal levels of sensitivity (ranging from 28.9%-35.6%). The addition of outpatient data (such as pharmacy records) for depression surveillance is recommended and should result in improved measures of validity.

Alcohol and drug use disorders among patients with myocardial infarction: associations with disparities in care and mortality

BACKGROUND

Because alcohol and drug use disorders (SUDs) can influence quality of care, we compared patients with and without SUDs on frequency of catheterization, revascularization, and in-hospital mortality after acute myocardial infarction (AMI).

METHODS

This study employed hospital discharge data identifying all adult AMI admissions (ICD-9-CM code 410) between April 1996 and December 2001. Patients were classified as having an SUD if they had alcohol and/or drug (not nicotine) abuse or dependence using a validated ICD-9-CM coding definition. Catheterization and revascularization data were obtained by linkage with a clinically-detailed cardiac registry. Analyses (controlling for comorbidities and disease severity) compared patients with and without SUDs for post-MI catheterization, revascularization, and in-hospital mortality.

RESULTS

Of 7,876 AMI unique patient admissions, 2.6% had an SUD. In adjusted analyses mortality was significantly higher among those with an SUD (odds ratio (OR) 2.02; 95%CI: 1.10-3.69), while there was a trend toward lower catheterization rates among those with an SUD (OR 0.75; 95%CI: 0.55-1.01). Among the subset of AMI admissions who underwent catheterization, the adjusted hazard ratio for one-year revascularization was 0.85 (95%CI: 0.65-1.11) with an SUD compared to without.

CONCLUSIONS

Alcohol and drug use disorders are associated with significantly higher in-hospital mortality following AMI in adults of all ages, and may also be associated with decreased access to catheterization and revascularization. This higher mortality in the face of poorer access to procedures suggests that these individuals may be under-treated following AMI. Targeted efforts are required to explore the interplay of patient and provider factors that underlie this finding.

Recommendations for optimal ICD codes to study neurologic conditions: a systematic review

OBJECTIVE

Administrative health data are frequently used for large population-based studies. However, the validity of these data for identifying neurologic conditions is uncertain.

METHODS

This article systematically reviews the literature to assess the validity of administrative data for identifying patients with neurologic conditions. Two reviewers independently assessed for eligibility all abstracts and full-text articles identified through a systematic search of Medline and Embase. Study data were abstracted on a standardized abstraction form to identify ICD code-based case definitions and corresponding sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs).

RESULTS

Thirty full-text articles met the eligibility criteria. These included 8 studies for Alzheimer disease/dementia (sensitivity: 8-86.5, specificity: 56.3-100, PPV: 60-97.9, NPV: 68.0-98.9), 2 for brain tumor (sensitivity: 54.0-100, specificity: 97.0-99.0, PPV: 91.0-98.0), 4 for epilepsy (sensitivity: 98.8, specificity: 69.6, PPV: 62.0-100, NPV: 89.5-99.1), 4 for motor neuron disease (sensitivity: 78.9-93.0, specificity: 99.0-99.9, PPV: 38.0-90.0, NPV: 99), 2 for multiple sclerosis (sensitivity: 85-92.4, specificity: 55.9-92.6, PPV: 74.5-92.7, NPV: 70.8-91.9), 4 for Parkinson disease/parkinsonism (sensitivity: 18.7-100, specificity: 0-99.9, PPV: 38.6-81.0, NPV: 46.0), 3 for spinal cord injury (sensitivity: 0.9-90.6, specificity: 31.9-100, PPV: 27.3-100), and 3 for traumatic brain injury (sensitivity: 45.9-78.0 specificity: 97.8, PPV: 23.7-98.0, NPV: 99.2). No studies met eligibility criteria for cerebral palsy, dystonia, Huntington disease, hydrocephalus, muscular dystrophy, spina bifida, or Tourette syndrome.

CONCLUSIONS

To ensure the accurate interpretation of population-based studies with use of administrative health data, the accuracy of case definitions for neurologic conditions needs to be taken into consideration.

Substantial changes in prescription recommendations for bipolar disorder in Canada: 2002-2010

OBJECTIVES

We examined trends in prescription recommendations for treatment of bipolar disorder (BD) in Canada during 2002-2010.

METHODS

Data collected by IMS Brogan in a database known as the Canadian Disease and Therapeutic Index were used for this analysis. These data are collected from a representative physician panel who record each drug recommendation and reason for recommendation in their practices for 2 consecutive days each calendar quarter of the year. Prescription patterns of medications for BD, including lithium, anticonvulsants, antipsychotic agents, anxiolytics, and antidepressants, were evaluated both for general practitioners and for specialists.

RESULTS

The number of prescription recommendations for BD increased by 72.1% from 2002 to 2009, and then dropped by 24.8% from 2009 to 2010. This increase from 2002 to 2009, and subsequent decrease from 2009 to 2010, was observed for all classes of medications. The overall increase from 2002 to 2010 was statistically significant for the atypical antipsychotics (P = 0.04). The largest change for an individual drug during this period was a 438% increase in recommendations for quetiapine (P = 0.01).

CONCLUSIONS

The number of prescription recommendations for BD increased substantially from 2002 to 2009 and sharply dropped in the following year. These results suggest that the influence of the concept of the bipolar spectrum and its promotion may have resulted in a substantial increase in treatment that has recently begun to wane.

Quantifying physical decline in juvenile neuronal ceroid lipofuscinosis (Batten disease)

OBJECTIVE

To use the Unified Batten Disease Rating Scale (UBDRS) to measure the rate of decline in physical and functional capability domains in patients with juvenile neuronal ceroid lipofuscinosis (JNCL) or Batten disease, a neurodegenerative lysosomal storage disorder. We have evaluated the UBDRS in subjects with JNCL since 2002; during that time, the scale has been refined to improve reliability and validity. Now that therapies are being proposed to prevent, slow, or reverse the course of JNCL, the UBDRS will play an important role in quantitatively assessing clinical outcomes in research trials.

METHODS

We administered the UBDRS to 82 subjects with JNCL genetically confirmed by CLN3 mutational analysis. Forty-four subjects were seen for more than one annual visit. From these data, the rate of physical impairment over time was quantified using multivariate linear regression and repeated-measures analysis.

RESULTS

The UBDRS Physical Impairment subscale shows worsening over time that proceeds at a quantifiable linear rate in the years following initial onset of clinical symptoms. This deterioration correlates with functional capability and is not influenced by CLN3 genotype.

CONCLUSION

The UBDRS is a reliable and valid instrument that measures clinical progression in JNCL. Our data support the use of the UBDRS to quantify the rate of progression of physical impairment in subjects with JNCL in clinical trials.

Chart documentation quality and its relationship to the validity of administrative data discharge records

The validity of administrative data may be vulnerable to how well physicians document medical charts. The objective of this study is to determine the relationship between chart documentation quality and the validity of administrative data. The charts for patients who underwent carotid endarterectomy were re-abstracted and rated for the quality of documentation. Poorly and well-documented charts were compared by patient, physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of the 2061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics. The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid administrative data, which reduces the communication of clinical information among healthcare providers.

Exercise prescription after fragility fracture in older adults: a scoping review

The purpose of this study is to identify and chart research literature on safety, efficacy, or effectiveness of exercise prescription following fracture in older adults. We conducted a systematic, research-user-informed, scoping review. The population of interest was adults aged ≥45 years with any fracture. "Exercise prescription" included post-fracture therapeutic exercise, physical activity, or rehabilitation interventions. Eligible designs included knowledge synthesis studies, primary interventional studies, and observational studies. Trained reviewers independently evaluated citations for inclusion. A total of 9,415 citations were reviewed with 134 citations (119 unique studies) identified: 13 knowledge syntheses, 95 randomized or controlled clinical trials, and 11 "other" designs, representing 74 articles on lower extremity fractures, 34 on upper extremity, eight on vertebral, and three on mixed body region fractures. Exercise prescription characteristics were often missing or poorly described. Six general categories emerged describing exercise prescription characteristics: timing post-fracture, person prescribing, program design, functional focus, exercise script parameters, and co-interventions. Upper extremity and ankle fracture studies focused on fracture healing or structural impairment outcomes, whereas hip fracture studies focused more on activity limitation outcomes. The variety of different outcome measures used made pooling or comparison of outcomes difficult. There was insufficient information to identify evidence-informed parameters for safe and effective exercise prescription for older adults following fracture. Key gaps in the literature include limited numbers of studies on exercise prescription following vertebral fracture, poor delineation of effectiveness of different strategies for early post-fracture mobilization following upper extremity fracture, and inconsistent details of exercise prescription characteristics after lower extremity fracture.

Group patient visits for Parkinson disease: a randomized feasibility trial

BACKGROUND

Group patient visits are medical appointments shared among patients with a common medical condition. This care delivery method has demonstrated benefits for individuals with chronic conditions but has not been evaluated for Parkinson disease (PD).

METHODS

We conducted a 12-month, randomized trial of group patient visits vs usual (one-on-one) care for patients with PD. Visits were led by one of 3 study physicians, included patients and caregivers, and lasted approximately 90 minutes. Those receiving group visits had 4 sessions over 12 months. The primary outcome measure was feasibility as measured by the ability to recruit participants and by the proportion of participants who completed the study. The primary efficacy outcome was quality of life as measured by the PD Questionnaire-39.

RESULTS

Thirty patients and 27 caregivers enrolled in the study. Thirteen of the 15 patients randomized to group patient visits and 14 of the 15 randomized to usual care completed the study. Quality of life measured 12 months after baseline between the 2 groups was not different (25.9 points for group patient visits vs 26.0 points for usual care; p = 0.99).

CONCLUSIONS

Group patient visits may be a feasible means of providing care to individuals with PD and may offer an alternative or complementary method of care delivery for some patients and physicians.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that group patient visits did not improve quality of life for individuals with PD over a 1-year period.

Frequency of antidepressant use in relation to recent and past major depressive episodes

OBJECTIVE

There has been a trend toward increasing antidepressant (AD) use in recent decades. We used data from the National Population Health Survey (NPHS) to determine whether this trend is continuing and to provide updated estimates of the frequency of use.

METHODS

The NPHS is a longitudinal general health survey that began collecting data in 1994. The NPHS evaluates past-year major depressive episodes (MDEs) using a brief diagnostic instrument. At each biannual interview (from 1994 to 2006) current medication use is recorded. We estimated the frequency with which ADs were taken by respondents (aged 12 years and older) with and without past-year MDEs. These frequencies were cross-tabulated by sex, year of interview, and the reported duration of symptoms.

RESULTS

ADs are taken by about 5.4% of the household population at any point in time. Most respondents taking ADs did not report past-year MDEs but 63.9% of respondents taking ADs in the absence of past-year episodes reported previous episodes or being diagnosed by a health professional with depression. This pattern is consistent with long-term treatment for relapse prevention. The overall frequency of use of ADs is increasing only in respondents without past-year episodes.

CONCLUSIONS

AD use among community residents with past-year MDEs is no longer increasing. The continued increase in the overall frequency of use may point toward broadening indications for AD treatment and may indicate that people are taking these medications for longer periods of time.

Do coder characteristics influence validity of ICD-10 hospital discharge data?

Background

Administrative data are widely used to study health systems and make important health policy decisions. Yet little is known about the influence of coder characteristics on administrative data validity in these studies. Our goal was to describe the relationship between several measures of validity in coded hospital discharge data and 1) coders' volume of coding (≥13,000 vs. <13,000 records), 2) coders' employment status (full- vs. part-time), and 3) hospital type.

Methods

This descriptive study examined 6 indicators of face validity in ICD-10 coded discharge records from 4 hospitals in Calgary, Canada between April 2002 and March 2007. Specifically, mean number of coded diagnoses, procedures, complications, Z-codes, and codes ending in 8 or 9 were compared by coding volume and employment status, as well as hospital type. The mean number of diagnoses was also compared across coder characteristics for 6 major conditions of varying complexity. Next, kappa statistics were computed to assess agreement between discharge data and linked chart data reabstracted by nursing chart reviewers. Kappas were compared across coder characteristics.

Results

422,618 discharge records were coded by 59 coders during the study period. The mean number of diagnoses per record decreased from 5.2 in 2002/2003 to 3.9 in 2006/2007, while the number of records coded annually increased from 69,613 to 102,842. Coders at the tertiary hospital coded the most diagnoses (5.0 compared with 3.9 and 3.8 at other sites). There was no variation by coder or site characteristics for any other face validity indicator. The mean number of diagnoses increased from 1.5 to 7.9 with increasing complexity of the major diagnosis, but did not vary with coder characteristics. Agreement (kappa) between coded data and chart review did not show any consistent pattern with respect to coder characteristics.

Conclusions

This large study suggests that coder characteristics do not influence the validity of hospital discharge data. Other jurisdictions might benefit from implementing similar employment programs to ours, e.g.: a requirement for a 2-year college training program, a single management structure across sites, and rotation of coders between sites. Limitations include few coder characteristics available for study due to privacy concerns.

Potentially inappropriate management of depressive symptoms among Ontario home care clients

OBJECTIVE

To examine the prevalence and correlates of potentially inappropriate pharmacotherapy (including potential under-treatment) for depression in adult home care clients.

METHODS

A cross-sectional study of clients receiving services from Community Care Access Centres in Ontario. Three thousand three hundred and twenty-one clients were assessed with the Resident Assessment Instrument for Home Care (RAI-HC). A score of 3 or greater on the Depression Rating Scale (DRS), a validated scale embedded within the RAI-HC, indicates the presence of symptoms of depression. Medications listed on the RAI-HC were used to categorize treatment into two groups: potentially appropriate and potentially inappropriate antidepressant drug therapy. Adjusted logistic regression models were used to explore relevant predictors of potentially inappropriate pharmacotherapy.

RESULTS

12.5% (n=414) of clients had symptoms of depression and 17% received an appropriate antidepressant. Over half of clients (64.5%) received potentially inappropriate pharmacotherapy (including potential under-treatment). Age 75 years or older, higher levels of caregiver stress and the presence of greater comorbidity were associated with a higher risk of potentially inappropriate pharmacotherapy in multivariate analyses. Documentation of any psychiatric diagnosis on the RAI-HC and receiving more medications were significantly associated with a greater likelihood of appropriate drug treatment.

CONCLUSION

Most clients with significant depressive symptoms were not receiving appropriate pharmacotherapy. Having a documented diagnosis of a psychiatric condition on the RAI-HC predicted appropriate pharmacotherapy. By increasing recognition of psychiatric conditions, the use of standardized, comprehensive assessment instruments in home care may represent an opportunity to improve mental health care in these settings.

Epidemiological associations between gambling behavior, substance use & mood and anxiety disorders

OBJECTIVE

To compare gambling behaviors in a random sample of community residents with and without mental disorders identified by the Composite International Diagnostic Interview (CIDI).

METHOD

A large national community survey conducted by Statistics Canada included questions about problems arising from gambling activities as per the Canadian Problem Gambling Index (CPGI). We compared respondents within three gambling severity categories (non-problem, low severity and moderate/high severity gambling) across three diagnostic groupings (mood/anxiety disorders, substance dependence/harmful alcohol use, no selected psychiatric disorder).

RESULTS

Of the 14,934 respondents age 18-64 years who engaged in at least one type of gambling activity in the previous 12 months, 5.8% fell in the low severity gambling category while 2.9% fell in the moderate/high severity category. Females accounted for 51.7% of the sample. The risk of moderate/high severity gambling was 1.7 times higher in persons with mood or anxiety disorder compared to persons with no selected disorder. For persons with substance dependence or harmful alcohol use, the risk of moderate/high severity gambling was 2.9 times higher. Persons with both mood/anxiety and substance/alcohol disorders were five times more likely to be moderate/high severity gamblers. The odds ratio for females was 0.6 and for those with less than post-secondary education it was 1.52. Differences in age and personal income were not significant.

CONCLUSIONS

Individuals in the community suffering from mood/anxiety disorders and substance dependence/harmful alcohol, and especially those with both, experience a higher risk for gambling problems. The treatment of these comorbidities should be integrated into any problem gambling treatment program.

Association of mood, anxiety, and substance use disorders with occupational status and disability in a community sample

OBJECTIVE

This study examined associations between mood disorders, anxiety disorders, substance dependence or harmful alcohol use, and occupational status and disability in a general population sample.

METHODS

Data from the Canadian Community Health Survey Cycle 1.2-Mental Health and Well-Being (CCHS-1.2), a representative cross-sectional survey, were analyzed. The total sample was narrowed to individuals between the ages of 18 and 64 years, the age range most likely to be working.

RESULTS

Of the 27,332 persons surveyed, 946 had a mood disorder only, 831 had an anxiety disorder only, 730 had substance dependence only, and 966 had more than one disorder. Twenty-three percent reported that during the previous week they were not at a job or were permanently unable to work (27% with mood disorder only, 30% with anxiety disorder only, and 20% with substance dependence only, and 34% with more than one disorder). In unadjusted analyses, mood and anxiety disorders were associated with absence from work during the week preceding the interview, whereas substance dependence was not. After adjustment for other variables using logistic regression, an association of substance dependence and work absence emerged. Each category of disorder was strongly associated with a greater likelihood of disability days or days spent in bed for mental health reasons.

CONCLUSIONS

On a population level, mood and anxiety disorders and substance dependence were associated both with not working during the week preceding the interview as well as an increase in reported disability or bed days. The strength of association appears to be stronger for mood and anxiety disorders.

Self-reported thyroid disease and mental disorder prevalence in the general population

OBJECTIVE

Community studies have failed to confirm that biochemically assessed thyroid status is significantly associated with psychopathology. However, it has been reported that self-reported thyroid disease is associated with symptoms of depression and anxiety. The objective of the current study was to determine whether self-reported thyroid disease is associated with elevated mental disorder prevalence in the general population.

METHOD

Data from the Canadian Community Health Survey (CCHS) 1.2: Mental Health and Well-being were used. The CCHS 1.2 included the World Mental Health version of the Composite International Diagnostic Interview and collected self-report data about professionally diagnosed chronic medical conditions, including thyroid disease.

RESULTS

Twelve-month and lifetime mental disorder prevalence was higher in subjects with thyroid disease than in subjects reporting no chronic conditions. For each condition examined (major depressive disorder, bipolar disorder, panic disorder/agoraphobia and social phobia), the 12-month and lifetime prevalence in subjects with thyroid disease resembled that of an aggregate category of subjects having other chronic conditions. After adjustment for age, sex and other chronic conditions, only social phobia was found to be associated with thyroid disease.

CONCLUSIONS

People with thyroid disease are not a particularly high-need group for mental disorder screening or intervention, at least not in the community population.

Volunteering for early phase gene transfer research in Parkinson disease

BACKGROUND

For early phase trials of novel interventions-such as gene transfer for Parkinson disease (PD)--whose focus is primarily on safety and tolerability, it is important that participants have a realistic understanding of the goals of such research. Recently, some have expressed concern that patients with PD may have unrealistic expectations.

METHODS

The authors examined why patients with PD might volunteer for invasive early phase research by interviewing 92 patients with PD and comparing those who would (n = 46) and those who would not (n = 46) participate in a hypothetical phase I gene-transfer study.

RESULTS

The two groups' demographic, clinical, functional, and quality of life measures, as well as their understanding of the research protocol, were similar. The groups did not differ on their perception of potential for personal benefit nor on the level of likelihood of benefit they saw as a precondition for volunteering. However, those willing to participate tended to perceive lower probability of risk, were tolerant of greater probability of risk, and were more optimistic about the phase I study's potential benefits to society. They also appeared more decisive and action-oriented than the unwilling group.

CONCLUSIONS

It is likely that the decision whether to participate in early phase PD gene transfer studies will depend mostly on patients' attitudes regarding risk, optimism about science, and an action orientation, rather than on their clinical, functional, or demographic characteristics.

Location of residence associated with the likelihood of patient visit to the preoperative assessment clinic

BACKGROUND

Outpatient preoperative assessment clinics were developed to provide an efficient assessment of surgical patients prior to surgery, and have demonstrated benefits to patients and the health care system. However, the centralization of preoperative assessment clinics may introduce geographical barriers to utilization that are dependent on where a patient lives with respect to the location of the preoperative assessment clinic.

METHODS

The association between geographical distance from a patient's place of residence to the preoperative assessment clinic, and the likelihood of a patient visit to the clinic prior to surgery, was assessed for all patients undergoing surgery at a tertiary health care centre in a major Canadian city. The odds of attending the preoperative clinic were adjusted for patient characteristics and clinical factors.

RESULTS

Patients were less likely to visit the preoperative assessment clinic prior to surgery as distance from the patient's place of residence to the clinic increased (adjusted OR = 0.52, 95% CI 0.44-0.63 for distances between 50-100 km, and OR = 0.26, 95% CI 0.21-0.31 for distances greater than 250 km). This 'distance decay' effect was remarkable for all surgical specialties.

CONCLUSION

The present study demonstrates that the likelihood of a patient visiting the preoperative assessment clinic appears to depend on the geographical location of patients' residences. Patients who live closest to the clinic tend to be seen more often than patients who live in rural and remote areas. This observation may have implications for achieving the goals of equitable access, and optimal patient care and resource utilization in a single universal insurer health care system.

Descriptive epidemiology of major depression in Canada

OBJECTIVE

The Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) is the first national study to use a full version of the Composite International Diagnostic Interview. For this reason, and because of its large sample size, the CCHS 1.2 is capable of providing the best currently available description of major depression epidemiology in Canada. Using the CCHS 1.2 data, our study aimed to describe the epidemiology of major depression in Canada.

METHOD

All estimates used appropriate sampling weights and bootstrap variance estimation procedures. The analysis consisted of estimating proportions supplemented by logistic regression modelling.

RESULTS

The lifetime prevalence of major depressive episode was 12.2%. Past-year episodes were reported by 4.8% of the sample; 1.8% reported an episode in the past 30 days. As expected, major depression was more common in women than in men, but the difference became smaller with advancing age. The peak annual prevalence occurred in the group aged 15 to 25 years. The prevalence of major depression was not related to level of education but was related to having a chronic medical condition, to unemployment, and to income. Married people had the lowest prevalence, but the effect of marital status changed with age. Logistic regression analysis suggested that the annual prevalence may increase with age in men who never married.

CONCLUSIONS

The prevalence of major depression in the CCHS 1.2 was slightly lower than that reported in the US and comparable to pan-European estimates. The pattern of association with demographic and clinical variables, however, is broadly similar. An increasing prevalence with age in single (never-married) men was an unexpected finding.

Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data

OBJECTIVES

Implementation of the International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system presents challenges for using administrative data. Recognizing this, we conducted a multistep process to develop ICD-10 coding algorithms to define Charlson and Elixhauser comorbidities in administrative data and assess the performance of the resulting algorithms.

METHODS

ICD-10 coding algorithms were developed by "translation" of the ICD-9-CM codes constituting Deyo's (for Charlson comorbidities) and Elixhauser's coding algorithms and by physicians' assessment of the face-validity of selected ICD-10 codes. The process of carefully developing ICD-10 algorithms also produced modified and enhanced ICD-9-CM coding algorithms for the Charlson and Elixhauser comorbidities. We then used data on in-patients aged 18 years and older in ICD-9-CM and ICD-10 administrative hospital discharge data from a Canadian health region to assess the comorbidity frequencies and mortality prediction achieved by the original ICD-9-CM algorithms, the enhanced ICD-9-CM algorithms, and the new ICD-10 coding algorithms.

RESULTS

Among 56,585 patients in the ICD-9-CM data and 58,805 patients in the ICD-10 data, frequencies of the 17 Charlson comorbidities and the 30 Elixhauser comorbidities remained generally similar across algorithms. The new ICD-10 and enhanced ICD-9-CM coding algorithms either matched or outperformed the original Deyo and Elixhauser ICD-9-CM coding algorithms in predicting in-hospital mortality. The C-statistic was 0.842 for Deyo's ICD-9-CM coding algorithm, 0.860 for the ICD-10 coding algorithm, and 0.859 for the enhanced ICD-9-CM coding algorithm, 0.868 for the original Elixhauser ICD-9-CM coding algorithm, 0.870 for the ICD-10 coding algorithm and 0.878 for the enhanced ICD-9-CM coding algorithm.

CONCLUSIONS

These newly developed ICD-10 and ICD-9-CM comorbidity coding algorithms produce similar estimates of comorbidity prevalence in administrative data, and may outperform existing ICD-9-CM coding algorithms.

Antidepressant utilization in Canada

OBJECTIVE

Antidepressant utilization can be used as an indicator of appropriate treatment for major depression. The objective of this study was to characterize antidepressant utilization in Canada, including the relationships of antidepressant use with sociodemographic variables, past-year and lifetime depression, number of past depressive episodes, and other possible indications for antidepressants.

METHOD

We examined data from the Canadian Community Health Survey (CCHS) Cycle 1.2. The CCHS was a nationally representative mental health survey (N=36,984) conducted in 2002 that included a diagnostic instrument for past-year and lifetime major depressive episodes and other psychiatric disorders and a record of past-year antidepressant use.

RESULTS

Overall, 5.8% of Canadians were taking antidepressants, higher than the annual prevalence of major depressive episode (4.8%) in the survey. Among persons with a past-year major depressive episode, the frequency of antidepressant use was 40.4%. After application of adjustments for probable successful outcomes of treatment, the estimated frequency of antidepressant use for major depression was more than 50%. Frequency of antidepressant treatment among those with a history of depression but without a past-year episode increased with the number of previous episodes. Among those taking antidepressants over the past year, only 33.1% had had a past-year episode of major depression. Migraine, fibromyalgia, anxiety disorder, or past depression was present in more than 60% of those taking antidepressants without a past-year episode of depression.

CONCLUSIONS

The CCHS results suggest that antidepressant use has increased substantially since the early 1990s, and also that these medications are employed extensively for indications other than depression.

Psychotropic medication use in Canada

BACKGROUND

Psychotropic medication use can be employed as an indicator of appropriate treatment for mental disorders. The Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) offers the first opportunity to characterize Canadian psychotropic medication use on a national level within diagnostic groups as assessed by a full version of the Composite International Diagnostic Interview (CIDI).

METHOD

We assessed the prevalence of antidepressant, sedative-hypnotic, mood stabilizer, psychostimulant, and antipsychotic use over 2 days overall and in subgroups defined by CIDI-diagnosed disorders and demographics. We employed sampling weights and bootstrap methods.

RESULTS

Overall psychotropic drug utilization was 7.2%. Utilization was higher for women and with increasing age. With any lifetime CIDI-diagnosed disorder assessed in the CCHS 1.2, utilization was 19.3%, whereas without such disorders, it was 4.1%. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly used antidepressants for those with a past-year major depressive episode (17.8%), followed by venlafaxine (7.4%). Among people aged 15 to 19 years, antidepressant use was 1.8% overall and 11.7% among those with past-year depression; SSRIs made up the majority of use. Sedative-hypnotics were used by 3.1% overall, increasing with age to 11.1% over 75 years.

CONCLUSIONS

International comparison is difficult because of different evaluation methods, but antidepressant use may be higher and antipsychotic use lower in Canada than in recent European and American reports. In light of the relative lack of contemporary evidence for antidepressant efficacy in adolescents, it is likely that antidepressant use among those aged 15 to 19 years will continue to decline. The increased use of sedative-hypnotics with age is of concern, given the associated risk of adverse effects among seniors.

Help-seeking behaviours of individuals with mood disorders

OBJECTIVES

This study had the following objectives: 1) to estimate the 12-month prevalence of conventional and unconventional mental health service use by individuals with major depressive disorder (MDD) or mania in the past year, and 2) to identify factors associated with the use of conventional mental health services by individuals with MDD or mania in the past year.

METHODS

We examined data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Respondents with MDD (n = 1563) or manic episodes (n = 393) in the past 12 months were included in this analysis.

RESULTS

An estimated 63.9% of respondents with MDD and 59.0% of those with manic episodes reported having used some type of help in the past 12 months; 52.9% of those with MDD and 49.0% of those with manic episodes used conventional mental health services. Approximately 21% of respondents with either MDD or manic episodes used natural health products specifically for emotional, mental health, and drug or alcohol use problems. Respondents who reported comorbid anxiety disorders and long-term medical conditions were more likely to have used conventional mental health services.

CONCLUSIONS

Relative to previous Canadian literature, our analysis suggests that the frequency of conventional mental health service use among persons with MDD has not increased significantly in the past decade. Further, the rate of conventional mental health service use by persons with manic episodes is unexpectedly low. These findings may reflect the lack of national initiatives targeting mood disorders in Canada. They have important implications for planning future education, promotion, and research efforts.

Comorbidity of major depression with substance use disorders

OBJECTIVES

In the Canadian adult population, we aimed to 1) estimate the 12-month prevalence of major depressive disorder (MDD) in persons with a diagnosis of harmful alcohol use, alcohol dependence, and drug dependence; 2) estimate the 12-month prevalence of harmful alcohol use, alcohol dependence, and drug dependence in persons with a 12-month and lifetime diagnosis of MDD; 3) identify socioeconomic correlates of substance use disorder-major depression comorbidity; 4) determine how comorbidity impacts the prevalence of suicidal thoughts; and 5) determine how comorbidity affects mental health care used.

METHODS

We examined data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2).

RESULTS

The 12-month prevalences of MDD in persons with a substance use disorder (SUD) were 6.9% for harmful alcohol use (95% confidence interval [CI], 5.2 to 8.5), 8.8% for alcohol dependence (95%CI, 6.6 to 11.0), and 16.1% for drug dependence (95%CI, 10.3 to 21.9). Conversely, the 12-month prevalences of harmful alcohol use, alcohol dependence, and drug dependence in persons with a 12-month diagnosis of MDD were 12.3% (95%CI, 9.4 to 15.2), 5.8% (95%CI, 4.3 to 7.3), and 3.2% (95%CI, 2.0 to 4.4), respectively. Regression modelling did not identify any socioeconomic predictors of SUD-MDD comorbidity. Substance dependence and MDD independently predicted higher prevalence of suicidal thoughts and mental health treatment use.

CONCLUSIONS

SUDs cooccur with a high frequency in cases of MDD. Clinicians and mental health services should consider routine assessment of SUDs in depression patients.

Long-term medical conditions and major depression: strength of association for specific conditions in the general population

BACKGROUND

The prevalence of major depression (MD) in persons with nonpsychiatric medical conditions is an indicator of clinical need in those groups, an indicator of the feasibility of screening and case-finding efforts, and a source of etiologic hypotheses. This analysis explores the prevalence of MD in the general population in relation to various long-term medical conditions.

METHODS

We used a dataset from a large-scale Canadian national health survey, the Canadian Community Health Survey (CCHS). The sample consisted of 115 071 subjects aged 18 years and over, randomly sampled from the Canadian population. The survey interview recorded self-reported diagnoses of various long-term medical conditions and employed a brief predictive interview for MD, the Composite International Diagnostic Interview Short Form for Major Depression. Logistic regression was used to adjust estimates of association for age and sex.

RESULTS

The conditions most strongly associated with MD were chronic fatigue syndrome (adjusted odds ratio [AOR] 7.2) and fibromyalgia (AOR 3.4). The conditions least strongly associated were hypertension (AOR 1.2), diabetes, heart disease, and thyroid disease (AOR 1.4 in each case). We found associations with various gastrointestinal, neurologic, and respiratory conditions.

CONCLUSIONS

A diverse set of long-term medical conditions are associated with MD, although previous studies might have lacked power to detect some of these associations. The strength of association in prevalence data, however, varies across specific conditions.

Measurement issues related to the evaluation and monitoring of major depression prevalence in Canada

Monitoring major depression prevalence is important because of the substantial impact of this condition on population health. Local or regional surveys using cost-efficient methods (e.g. data collection by telephone interview) may provide useful epidemiological data, as may the inclusion of brief diagnostic modules for major depression in general health surveys. In Canada, the Composite International Diagnostic Interview Short Form for Major Depression (CIDI-SFMD) has been widely employed for both purposes. The recent Canadian Community Health Survey 1.2 (2002), which employed a more detailed diagnostic interview (the World Mental Health 2000 CIDI), provides a standard against which to evaluate the performance of the CIDI-SFMD. A tendency to at times overestimate prevalence appears to be a characteristic of the CIDI-SFMD, and it has produced a broad range of prevalence estimates, suggesting a greater vulnerability to study-specific or contextual factors. However, the pattern of association of major depression with potential demographic determinants is not consistent with the classical "dilution" effect expected to occur with non-differential misclassification bias.

Adjustment to antidepressant utilization rates to account for depression in remission

Conventional estimates of antidepressant (AD) utilization in major depressive syndrome (MDS) have been low, but this may be partially because ongoing AD use by individuals with resolved MDS is not included. Valid estimates of AD utilization should include this ongoing use for MDS, but this is difficult since most surveys do not collect data on the reason for taking ADs. Only a proportion (f(dep)) of the nondepressed (nMDS) population taking ADs does so for depression. Published studies have not reported this proportion, and data required to estimate f(dep) are not usually available from surveys. The current study was performed to (1) estimate f(dep) by employing information on past history of depression, and (2) use the estimate to obtain an "adjusted" AD utilization rate, including resolved MDS subjects taking ADs. Data were collected in Calgary in 1998 and 1999 by random-digit dial telephone interview from consenting adults aged 18+ years. MDS was assessed using the Composite International Diagnostic Interview Short Form for Major Depression (CIDI-SFMD). Data were gathered on current medications, past depression, and current chronic physical illness. Of 2,542 respondents, 17.1% had MDS as defined by the CIDI-SFMD. A total of 20.2% of MDS and 3.2% of nMDS subjects were taking ADs. Of nMDS individuals taking ADs, 70.6% reported past depression (f(dep) = 70.6%). An "adjusted" AD utilization rate including this group was 28.2%. Physical illnesses that can be treated with ADs affected only 30.0% of nMDS subjects without past depression taking ADs. This study suggests that most individuals without active depression taking ADs do so for depression. AD utilization rates that ignore this group may be unrealistically low. AD use among nMDS subjects without previous depression is probably not primarily for physical illnesses. Limitations include the use of a brief predictive instrument for MDS, and self-report of past depression.

Major depression in multiple sclerosis: A population-based perspective

OBJECTIVE

To determine the prevalence of major depression in multiple sclerosis (MS) in a population-based sample controlling for nonspecific illness effects.

METHODS

This study used data from a large-scale national survey conducted in Canada: the Canadian Community Health Survey (CCHS). The analysis included 115,071 CCHS subjects who were 18 years or older at the time of data collection. The CCHS interview obtained self-reported diagnoses of MS and employed a brief predictive interview for major depression: the Composite International Diagnostic Interview Short Form for Major Depression. The 12-month period prevalence of major depression was estimated in subjects with and without MS and with and without other long-term medical conditions.

RESULTS

The prevalence of major depression was elevated in persons with MS relative to those without MS and those reporting other conditions. The association persisted after adjustment for age and sex (adjusted odds ratio = 2.3, 95% CI 1.6 to 3.3). Major depression prevalence in MS for those in the 18- to 45-year age range was high at 25.7% (95% CI 15.6 to 35.7).

CONCLUSIONS

The prevalence of major depression in the population with MS is elevated. This elevation is not an artifact of selection bias and exceeds that associated with having one or more other long-term conditions.

Dive shapes reveal temporal changes in the foraging behaviour of different age and sex classes of harbour seals (Phoca vitulina)

Classifying dives into two-dimensional shapes based on time and depth is an attempt to extract additional information about the behaviour of aquatic air-breathing predators. In some species, there is considerable circumstantial evidence that different dive shapes represent different behaviours. However, few studies have provided direct evidence of the relationship between dive shape and function. We classified over 283 000 dives of adults (31 males and 45 females) and suckling (13) and recently weaned (15) harbour seal (Phoca vitulina) pups into seven shapes using supervised discriminant function analysis. Changes in the percentage of U-shaped dives over time within adults and weaned pups were associated with changes in food intake derived from water-flux studies on subsets of the same individuals. The changes in the percentage of U-shaped dives were accompanied by roughly reciprocal changes in V-shaped dives, whereas there was little change in other dive shapes, indicating that V-shaped dives are not generally exhibited during foraging. Video of adult males (from an animal-borne video system) also showed that there was a strong but not exclusive association between foraging and U-shaped dives. Our results indicate that changes in the percentage of U-shaped dives may serve as a reasonable index of changes in foraging behaviour. However, behaviours of suckling pups and adult males during the breeding season cannot be easily inferred from dive shape alone.

Effects of a brief intervention on social support and psychiatric morbidity in breast cancer patients

(1) To cross-sectionally and longitudinally investigate relationships between the availability and adequacy of both close personal attachment and interactional support, and psychiatric morbidity in a sample of early stage breast cancer patients participating in a 6-week psychoeducational intervention. (2) To address the question of directionality in these longitudinal relationships. (3) To investigate the effects of the intervention on levels of social support. Eighty-nine women were enrolled in the study, and randomly assigned to either the treatment or control condition. They were evaluated with the Interview Schedule for Social Interaction (ISSI), the Beck Depression Inventory (BDI), the Global Severity Index (GSI) of the Symptom Checklist (SCL) -90-R, and the Structured Clinical Interview for DSM-III-R (SCID) at three time periods: baseline (pre-intervention), 1 year post-intervention and 2 years post-intervention. Relationships between social support and the psychiatric measures were evaluated both cross-sectionally and longitudinally. Cross-sectionally, there were strong associations at each time period between being diagnosed with a DSM-III-R Axis I disorder and having less adequate perceived social support from both close relationships and more distant social ties. Initial levels of psychiatric symptoms on the BDI and GSI were better predictors of later social support than initial social support variables were of later psychiatric symptoms. Participation in the group intervention did not result in changes in social support at 1 or 2 years post-intervention. Cross-sectionally, there was a strong relationship between social support and psychiatric morbidity in these patients with early-stage breast cancer. Longitudinally, it appeared that although social support influenced psychiatric symptomatology somewhat, the influence of psychiatric symptoms on social support was greater. This illustrates the importance of both working to bolster social support and dealing with psychiatric symptomatology in this population.

Predictors of quality of life 6 months and 1 year after acute myocardial infarction

BACKGROUND

Quality of life (QOL) is an increasingly important outcome measure after hospital admission for acute myocardial infarction (AMI). However, the ability to adjust these outcomes for differences between compared groups of patients is limited because the predictors of QOL after AMI are unknown.

METHODS

To identify any clinical, demographic, and psychosocial characteristics of patients at admission that were independent predictors of QOL 6 months and 1 year after AMI, we measured physical and mental QOL (Short Form-36 Physical and Mental Component summary scores) and overall QOL (EuroQol health perception scale) in a prospective cohort of 587 patients admitted at 10 hospitals in Quebec. A set of plausible multivariate linear regression models was created for each outcome measure with use of the Bayesian Information Criterion.

RESULTS

Mean physical, mental, and overall QOL scores corresponding to the time immediately before admission (baseline) were 45 (95% confidence interval [CI] 44-46), 47 (95% CI 46-48), and 70 (95% CI 68-72), respectively. By 1 year, mean physical, mental, and overall QOL scores were close to baseline (45 [95% CI 44-46], 48 [95% CI 47-49], and 73 [95% CI 71-74], respectively). The predictors of physical, mental, and overall QOL were similar at 6 months and 1 year. Important predictors of physical QOL were the corresponding score at baseline, age, and previous bypass surgery (beta coefficients at 1 year: 5 [per 10-point difference in baseline score], -1 [per 10-year age difference], 5.3; 95% CIs 4 to 5, -2 to -1, -9.2 to -1.3, respectively). Predictors of mental QOL were the corresponding score at baseline and depression (beta coefficients at 1 year: 3 [per 10-point difference in baseline score], -3 [per 10-point difference in depression score]; 95% CIs 2 to 4, -5 to -2, respectively). Predictors of overall QOL included the corresponding score at baseline and age (beta at 1 year: 2 [per 10-point score difference], -3 [per 10-year age difference]; 95% CIs 1 to 3, -4 to -1, respectively). Depression was also a predictor of impaired physical and overall QOL at 6 months (beta at 6 months: -1.6 [per 10-point score difference], -5.4 [per 10-point score difference]; 95% CIs -2.9 to -0.4, -7.7 to -3.2, respectively). No variables related to treatments received in-hospital were found in the most clinically relevant models.

CONCLUSIONS

These results suggest that age and psychosocial characteristics at baseline are the most important predictors of QOL after AMI. Other clinical characteristics and treatments received in-hospital do not appear to strongly affect patients' long-term perceptions of QOL.

Seasonal changes in buoyancy and diving behaviour of adult grey seals

Phocid seals go through dramatic seasonal changes in body mass and composition as a result of the spatial and temporal separation of foraging, reproduction and moulting. These changes in body fat content and body mass result in seasonal changes in buoyancy, which in turn may influence diving behaviour. We examined the longitudinal changes in buoyancy and diving behaviour of 14 adult grey seals (Halichoerus grypus) during two periods that represent maximal contrast in body mass and composition. During both the post-moulting (PM) and pre-breeding (PB) periods, grey seals were negatively buoyant. However, buoyancy increased by 47.9 % between the PM and PB periods. Descent rate was significantly faster during the PM period (1.0+/−0.07 m s(−1)) than during the PB period (0.7+/−0.06 m s(−1)), suggesting that seals were aided by negative buoyancy during the downward portion of dives. Ascent rate was also significantly faster during the PM period (0.8+/−0.06 m s(−1)) than during the PB period (0.6+/−0.05 m s(−1)), contradicting the prediction that more buoyant animals should ascend faster. The effects of drag could not account for this discrepancy. Dive depth and surface interval between dives did not differ significantly between the two periods. Similarly, the distribution of dive shapes used by individuals did not differ between the two periods. However, dive duration was significantly longer during the PB period than during the PM period (5.5+/−0.25 min compared with 4.4+/−0.24 min, respectively) as was time spent at the bottom of the dive (3.1+/−0.22 min compared with 2.5+/−0.15 min, respectively).

Progesterone stimulation of human insulin-like growth factor-binding protein-5 gene transcription in human osteoblasts is mediated by a CACCC sequence in the proximal promoter

Insulin-like growth factor-binding protein-5 (IGFBP-5) is produced by osteoblasts and potentiates insulin-like growth factor mitogenic stimulation in osteoblast cell cultures. Progesterone (PG) increased IGFBP-5 expression in normal human osteoblasts and increased IGFBP-5 transcription in U2 human osteosarcoma cells. We developed a chloramphenicol acetyltransferase reporter construct containing the human IGFBP-5 proximal promoter sequence, which includes TATA and CAAT boxes, and five putative PG response element half-sites. 10(-8) M PG increased promoter activity of this construct in U2 cells co-transfected with a PG receptor isoform A (PR(A)) expression vector. Analysis of 5' deletion constructs indicates that PG transactivation of IGFBP-5 promoter activity does not require the PG response element half-sites but does require the region -162 to -124 containing two tandem CACCC box sequences. Mutation of the proximal CACCC box at -139 eliminated PG transactivation. Gel shift assays using a -162 to -124 DNA fragment, U2 cell nuclear extracts, and purified PR(A) protein indicate that nuclear factors bind to a CACCC sequence at -139 and that PR(A) alters the pattern of transcription factor interaction with the CACCC sequence. Using a luciferase reporter construct containing base pairs -252 to +24 of the IGFBP-5 promoter, we found that both PR(A) and PR(B) isoforms mediated PG stimulation of promoter activity. These results suggest that PG may stimulate IGFBP-5 gene transcription via a novel mechanism involving PR and CACCC-binding factors.

Acute, nongenomic actions of the neuroactive gonadal steroid, 3 alpha-hydroxy-4-pregnen-20-one (3 alpha HP), on FSH release in perifused rat anterior pituitary cells

We have previously shown that the gonadal and neurosteroid, 3 alpha-hydroxy-4-pregnen-20-one (3 alpha HP), can selectively suppress gonadotrophin-releasing hormone (GnRH) induced follicle-stimulating hormone (FSH) release from static cultures of anterior pituitary cells during a 4-h incubation period. The actions appeared to be at the level of the gonadotroph membrane and the cell signaling pathway involving Ca2+ and protein kinase C (PKC). In order to investigate further if the effects of 3 alpha HP on FSH release are generated by nongenomic mechanisms, we monitored the short-term effects of 3 alpha HP using dispersed anterior pituitary cells in a low dead-volume perifusion system with short (< or = 5 min) exposures to the steroid. Pulses of GnRH (10(-8) or 10(-7) M) lasting 2-5 min resulted in marked peaks of FSH release, and the variation in FSH amounts released from the cells in a particular column were minimal if the interval between successive GnRH pulses was at least 3-4 h. A 5-min pulse of 3 alpha HP (10(-9) M) administered simultaneously with the GnRH pulse suppressed GnRH-induced FSH release. On the other hand, similar treatment with the stereoisomer 3 beta-hydroxy-4-pregnen-20-one (3 beta HP), had no effect, but progesterone and estradiol pulses augmented the GnRH-induced FSH release. Pretreatment of cells with a 5-min pulse of 3 alpha HP, at 120, 60, or 30 min prior to a GnRH pulse suppressed the GnRH-induced FSH release. The suppression of GnRH-induced FSH release by 3 alpha HP was only partial if the start of the 3 alpha HP pulse occurred 0.5 or 1.0 min after the start of the GnRH pulse, and no suppression occurred if the start of the 3 alpha HP pulse was delayed by 2-5 min. The FSH release elicited by 5-min pulses of the Ca2+ ionophore A23187, the Ca2+ agonist BAY K8644, the PKC activator phorbol 12-myristate 13-acetate (PMA), or phospholipase C (PLC) was suppressed by simultaneous pulses of 3 alpha HP. The suppression of FSH release by 3 alpha HP appeared to be stereospecific, since no suppression was observed with 5 alpha-pregnane-3,20-dione (5 alpha P) or 3 alpha-hydroxy-5 alpha-pregnan-20-one (5 alpha P3 alpha). In separate experiments, cells were treated with pulses of BSA conjugates of 3 alpha HP, 3 beta HP, or progesterone; the 3 alpha HP-BSA, but not the 3 beta HP-BSA or the progesterone-BSA, suppressed the GnRH-induced release of FSH. The results of this study provide the first evidence that 3 alpha HP exerts immediate (nongenomic) and direct effects on GnRH-induced FSH release by interacting at the level of the pituitary gonadotroph membrane and the phosphoinositol cell signaling cascade involving Ca2+.

Phosphorylation of human progesterone receptor by cyclin-dependent kinase 2 on three sites that are authentic basal phosphorylation sites in vivo

The human progesterone receptor (hPR) in T47D breast cancer cells is phosphorylated on at least nine different serine residues. We have previously reported the identification of five sites; three are hormone inducible (Ser102, Ser294 and Ser345), and their phosphorylation correlates with the timing of the change in receptor mobility on gel electrophoresis in response to hormone treatment. The other two sites, Ser81 and Ser162, along with the remaining sites, are basally phosphorylated and exhibit a general increase in phosphorylation in response to hormone. With the exception of Ser81, all of these sites are in Ser-Pro motifs, suggesting that proline-directed kinases are responsible for their phosphorylation. We now report that cyclin A-cyclin-dependent kinase-2 complexes phosphorylate hPR-B in vitro with a high stoichiometry on three sites that are authentic basal sites in vivo. One of these is Ser162, which has been described previously. The other two sites are identified here as Ser190 and Ser400. The specificity and stoichiometry of the in vitro phosphorylation suggest that hPR phosphorylation may be regulated in a cell cycle-dependent manner in vivo.

Stoichiometry and site-specific phosphorylation of human progesterone receptor in native target cells and in the baculovirus expression system

Human progesterone receptor (PR) in T47D breast cancer cells is phosphorylated on nine different serine residues; three are hormone-inducible (Ser102, Ser294, and Ser345), while others are basal but hormone-stimulated. In the present study, we have compared the phosphorylation state of native and recombinant PR expressed in a baculovirus insect cell system. Stoichiometric measurements showed that unliganded native PR in T47D cells was approximately 50% phosphorylated ( approximately 4 phosphates/PR) and became essentially 100% phosphorylated ( approximately 9 phosphates/PR) when bound to hormone. Unliganded PR expressed in Sf9 insect cells was phosphorylated with a similar stoichiometry ( approximately 3 phosphates/PR), but the phosphate content did not change with hormone addition. Site-specific phosphorylation analyzed by tryptic phosphopeptide mapping and manual peptide sequencing revealed that expressed PR bound to hormone in the Sf9 insect cells was phosphorylated on all the same sites as hormone-treated PR in T47D cells. Only minor differences were detected in the relative proportion of three sites (two basal sites and Ser345) and phosphorylation did not occur on alternate sites. Interestingly, unliganded baculovirus-expressed PR was constitutively phosphorylated on hormone inducible sites and was phosphorylated on basal sites to the same extent as hormone treated PR. Thus, in the absence of hormone, the phosphorylation state of baculovirus-expressed PR resembled that of the hyperphosphorylated native PR. In contrast to native PR, the expressed receptor in cytosols of Sf9 cells did not form a large oligomeric complex suggesting that hyperphosphorylation may be due to dissociation of the complex in the absence of hormone. This study demonstrating phosphorylation on correct sites with a stoichiometry similar to that of native PR indicates that overexpressed PR in the baculovirus system is suitable for in vitro structure/function studies.

Two types of anti-progestins have distinct effects on site-specific phosphorylation of human progesterone receptor

Human progesterone receptor (PR) is phosphorylated on multiple serine residues; three sites (Ser102, Ser294, and Ser345) are inducible by hormone agonist, while at least six others are basally phosphorylated and exhibit a general increase in response to hormone. In this study we have used high performance liquid chromatography phosphopeptide mapping and manual peptide sequencing to investigate how two different progestin antagonists, RU486 and ZK98299, affect site-specific phosphorylation of PR isolated from T47D breast cancer cells. As compared to the progestin agonist R5020, RU486 stimulated a similar increase in overall incorporation of [32P]phosphate per PR molecule (2.5-2.6-fold for PR-A and 2.1-fold for PR-B), and at the site-specific level, RU486 stimulated both the basal and inducible sites to the same extent as R5020. In contrast, ZK98299 produced only a minimal increase in overall phosphorylation (1.2-fold for PR-A and 1.1-fold for PR-B) which was due to a reduced stimulation of the basal sites and failure to induce any of the three hormone-dependent sites. No inappropriate phosphorylation sites were detected in response to either RU486 or ZK98299. In cotreatment studies, ZK98299 blocked the increase in overall phosphorylation of PR induced by R5020, demonstrating that the failure of this antagonist to stimulate specific phosphorylation sites is not due to an inefficient interaction with PR in the intact cell. These results indicate that the biological effects of RU486 are not mediated by an alternation in the phosphorylation state of PR, whereas failure to promote phosphorylation of certain sites may contribute to the antagonist action of ZK98299. Additionally these results support the concept of two mechanistic classes of anti-progestins that affect PR differently in vivo.

Identification of a group of Ser-Pro motif hormone-inducible phosphorylation sites in the human progesterone receptor

The human progesterone receptor (PR) is a member of the steroid/thyroid hormone superfamily of nuclear receptors. The receptor is expressed as two forms, PR-B and the shorter PR-A, which lacks the NH2-terminal 164 amino acids of PR-B; whereas PR-B seems to be predominantly a transcriptional activator, PR-A also functions as a repressor. Our previous studies of PR expressed in T47D breast cancer cells have shown that PR is a phosphoprotein whose phosphorylation is enhanced in response to hormone. There is an initial rapid (minutes) increase in phosphorylation followed by a slower, less substantial increase, which results in decreased mobility of the receptor on sodium dodecyl sulfate gels. We now report the identification of three phosphorylation sites, which are predominantly phosphorylated during the later phase of the response to hormone. These sites, Ser102, Ser294, and Ser345, are all found in Ser-Pro consensus sequences. Whereas Ser294 and Ser345 are common to PR-A and PR-B, Ser102 is unique to PR-B. Finally, we demonstrate that phosphorylation of Ser345 is associated with the altered mobility on sodium dodecyl sulfate gels.

Phosphorylation and progesterone receptor function

Four phosphorylation sites have been identified in the chicken progesterone receptor. Two of these sites exhibit basal phosphorylation which is enhanced upon treatment with hormone and two of the sites are phosphorylated in response to hormone. Mutation of one of these hormone dependent sites, Ser530 to Ala530, causes a decrease in transcriptional activation at low concentrations of hormone, but the activity is unaffected at high concentrations. However, the hormone binding of the mutant is unaffected suggesting that phosphorylation of Ser530 plays a role in facilitating the response of the receptor to low concentrations of hormone. The chicken progesterone receptor can be activated by modulators of kinases in the absence of hormone. The finding that signals initiated by tyrosine phosphorylation (through treatment with EGF) or through the dopamine receptor suggests that there are multiple means of activating chicken progesterone receptor. In contrast, the human progesterone receptor does not exhibit ligand independent activation; however, its activity in the presence of the agonist R5020 is enhanced by treatment with 8-Br-cAMP, an activator of protein kinase A, and treatment with 8-Br-cAMP causes the antagonist, RU486, to act as an agonist.

Progesterone receptor and the mechanism of action of progesterone antagonists

Currently available progesterone antagonists have been suggested to fall into two categories based on differences in how they interact with and inactivate the progesterone receptor (PR). The anti-progestin ZK98299 (Type I) impairs PR association with DNA, while Type II compounds (RU486, ZK112993, ZK98734) promote PR binding to DNA. Type II agents, therefore, appear to inhibit receptor activity at a step downstream of DNA binding, presumably failing to induce conformational changes in PR structure requird for enhancement of transcription. This paper discusses both published and unpublished data supporting the concept of two types of progestin antagonists. Using PR-mediated induction of reporter genes in breast cancer cells as an assay for biological response, both types of anti-progestins, after correction for difference in steroid binding affinity, inhibit progestin induction substoichiometrically. However, Type II anti-progestins are more potent, inhibiting at lower ratios of antagonist to agonist than ZK98299. This suggests that in addition to behaving by classical competitive mechanisms these compounds (in particular Type II) may exhibit additional activity as transrepressors of PR in the same cell bound to hormone agonist. Transrepression may occur by the combined mechanisms of heterodimerization and competition for binding to DNA. In support of this, mixed ligand dimers form readily in solution between a PR subunit bound to agonist and another bound to either type of anti-progestin, whereas these mixed ligand dimers bind poorly, if at all, to specific progesterone response elements (PREs) in vitro. Additionally, when added as a single ligand, Type II agents increase PR dimerization in solution and PR affinity for PREs as compared with single ligand dimers formed by progestin agonist. This contrasts with ZK98299, when given as a single ligand, which reduces PR affinity for PREs without disrupting solution dimerization. Thus the higher affinity of PR for PREs may account for the greater biological potency of Type II compounds as compared with ZK98299. As a further distinction between types of antiprogestins, ZK98299 minimally stimulates phosphorylation of PR whereas RU486 increases site-specific phosphorylation of PR in a manner indistinguishable from that of hormone agonist. Additionally, ZK98299 is not susceptible in vivo to functional switching to a partial agonist by cross talk with cAMP signal transduction pathways, as occurs with Type II compounds. Thus, ZK98299 under certain conditions may be a more pure antagonist than Type II compounds.

The 5'-flanking region of the ovine follicle-stimulating hormone-beta gene contains six progesterone response elements: three proximal elements are sufficient to increase transcription in the presence of progesterone

Progesterone (P4) can alter the synthesis and secretion of FSH from pituitary gonadotropes of sheep. In this study, the 5'-flanking region (4.7 kilobases) of the ovine FSH beta gene was tested for binding by human progesterone receptors (hPR), using an immunoprecipitation technique. Three fragments were bound by hPR. Competition experiments using homologous and heterologous DNA fragments revealed this binding to be specific and of high affinity (Kd = 1.2-47 nM). The fragment sequences were screened for potential P4 response elements (PREs). Six PRE-like elements were found among the three immunoprecipitated fragments. Band shift experiments discerned that each of these PRE-like sequences could be bound by hPR. In functional studies, each of the PRE-like elements could enhance the expression of a reporter gene driven by a heterologous promoter in a hormone-dependent manner. The 5'-flanking region of the ovine FSH beta gene was tested for P4 responsiveness using a luciferase reporter. In the presence of P4, there was a 2- to 3-fold increase in luciferase activity when the entire 4.7 kilobases of the 5'-flanking sequence were present, whereas no increase was seen in a construct that contained only 84 basepairs 5' to the transcription start site. This effect on transcription was dose dependent for P4. Deletion studies revealed that the three PRE-like elements closest to the transcription start site (-250 to -137) were sufficient to create the hormone-dependent enhancement. These results indicate that the 5'-flanking sequence of the ovine FSH beta gene contains sequences capable of being bound by hPR and may be responsible for the effects of P4 on FSH beta synthesis and secretion. This study is the first to show binding and function of PR for a gonadotropin gene.

The two faces of a steroid antagonist: when an antagonist isn't

Activation of protein kinase A potentiates the transcriptional response mediated by the glucocorticoid receptor in responsive fibroblasts and in mammary carcinoma cells. This potentiation is ligand-dependent and occurs in responsive fibroblasts and in mammary carcinoma cells. This potentiation is ligand-dependent and occurs without detectable change in the phosphorylation of receptor. The transcriptional response to glucocorticoid or progestin agonists can be blocked by potent antagonists like RU 486. However, upon activation of protein kinase A, the antagonist action of RU 486 on both receptors is blunted. Indeed, RU 486 can itself activate transcription of a hormone-responsive promoter. The conditional agonist activity is observed with type II antagonists, those which recapitulate many of the early steps of ligand-dependent receptor activation, but not type I antagonists, which do not. These studies have now been extended to antimineralocorticoids. In COS-1 cells transfected with a mineralocorticoid receptor expression vector, treatment with 8-BromocAMP potentiates the response to the agonist aldosterone and elicits additional agonist activity in mineralocorticoid antagonists. A model is proposed wherein type II antagonist-receptor complexes occupy receptor binding sites on the genome. The antagonist, however, fails to promote a receptor conformation that can interact productively with a coactivator mediating the communication between receptor and the basal transcription apparatus. Activation of protein kinase A results in the recruitment or activation of a coactivator that permits recovery of receptor-mediated activation function.(ABSTRACT TRUNCATED AT 250 WORDS)