Igor Karp

Determinants of Emergency Department Visits by Older Adults: A Systematic Review

OBJECTIVESnTo conduct a systematic review of the literature on the determinants of hospital emergency department (ED) visits by elders, using a modification of the Andersen behavioral model of health services, adapted to explain ED utilization.nnnMETHODSnRelevant articles were identified through MEDLINE and a search of reference lists and personal files. Studies of populations aged 65 or older in which ED visits were a study outcome were included if they were: original, not restricted to a particular medical condition, written in English or French, and investigated one or more determinants. Data were abstracted and checked by two authors using a standard protocol.nnnRESULTSnFourteen studies (reported in 15 articles) were reviewed, 10 community-based and four using clinical samples. Among ten studies that measured multiple determinants, determinants reported from multivariate analyses included measures of need (perceived and evaluated health status, prior utilization), predisposing factors (health beliefs and sociodemographic variables), and enabling factors (physician availability, regular source of care, family resources, geographical access to services).nnnCONCLUSIONSnNeed is usually the primary determinant of ED visits in older people. Controlling for need, predisposing and enabling factors that promote access to primary medical care are associated with reduced ED utilization.

Recent corticosteroid use and recent disease activity: Independent determinants of coronary heart disease risk factors in systemic lupus erythematosus?

OBJECTIVEnSystemic lupus erythematosus (SLE) is characterized by a markedly elevated risk for coronary heart disease (CHD), the exact pathogenesis of which is unknown. In particular, the causal roles of corticosteroid therapy and SLE disease activity, and whether their putative effects are mediated through conventional risk factors, remain unclear.nnnMETHODSnData abstracted retrospectively from the charts at 11,359 clinic visits for 310 patients with SLE to the Montreal General Hospital were used to investigate the associations of recent corticosteroid dose and recent Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score with 8 CHD risk factors (total serum cholesterol, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein cholesterol, apolipoprotein B [Apo B], triglycerides, systolic blood pressure [BP], body mass index, and blood glucose) and the aggregate estimate of 2-year CHD risk. Separate multivariable linear regression models estimated the mutually-adjusted effects of average daily corticosteroid dose and average SLEDAI score within the past year on the current level of each risk factor while adjusting for age, sex, cumulative damage score, disease duration, and, where appropriate, use of relevant medications.nnnRESULTSnHigher past-year corticosteroid dose was independently associated with significantly higher overall 2-year CHD risk and with higher levels of all 8 individual risk factors. Higher past-year lupus disease activity was independently associated with higher overall 2-year CHD risk, lower HDL cholesterol, and higher values of systolic BP, Apo B, triglycerides, and blood glucose.nnnCONCLUSIONnIn SLE, both recent use of corticosteroids and recent lupus activity are independently associated with higher values of several well-recognized CHD risk factors and overall 2-year CHD risk.

Risk factors for tobacco dependence in adolescent smokers.

Objective: To study the incidence of conversion to tobacco dependence (TD) and the prevalence of the TD state in relation to several potential determinants in a sample of adolescent smokers. Methods: Questionnaires were administered every 3–4 months to document TD symptoms, amount of cigarette consumption, and depression symptoms in a prospective cohort of 1293 grade 7 students in a convenience sample of 10 schools. Results: Over 54 months of follow-up, 113 of 344 novice smokers converted to TD. The referent series for the analysis of incidence comprised 823 person-surveys. The prevalence series included 1673 person-surveys, contributed by 429 smokers. Conversion to TD and TD status were associated with the intensity of recent (that is, past 3-month) cigarette consumption (adjusted incidence rate ratio (aIRR) 1.63 (95% confidence interval (CI) 1.36 to 1.97) and adjusted prevalence odds ratio (aPOR) 1.35 (95% CI 1.23 to 2.48) per 100 cigarettes per month), slowest CYP2A6 activity (aIRR 4.19 (95% CI 1.38 to 12.76) and aPOR 2.30 (95% CI 1.29 to 4.09)), depression score (aIRR 1.61 (95% CI 1.17 to 2.21) and aPOR 1.47 (95% CI 1.22, 1.75) per 1-unit change). Additional determinants included, for conversion to TD, time since onset of cigarette use (aIRR 0.76 (95% CI 0.58 to 1.00) per year) and, for the TD state, positive TD status six months ago (aPOR 3.53 (95% CI 2.41 to 5.19)). Conclusions: TD risk in adolescents is associated with intensity of recent cigarette consumption, while the role of more distant cigarette consumption appears small; subjects with slow nicotine metabolism and those with more depression symptoms are at increased risk of becoming tobacco dependent. The risk of being tobacco dependent is considerably higher in subjects who had previously developed the TD state.

Association Between Cigarette Smoking and C-Reactive Protein in a Representative, Population-Based Sample of Adolescents

Although related to inflammatory markers in adults, little is known about the association between cigarette smoking and C-reactive protein (CRP) in adolescent smokers. We examined the association between high-sensitivity CRP (hs-CRP) concentrations and smoking in youth. We used data from a cross-sectional, province-wide survey of a representative sample of youth conducted in Quebec, Canada, in 1999. Data were collected in self-report questionnaires completed by participants and their parents. Participants provided a fasting blood sample, and anthropometric measures were undertaken by trained technicians. The present analysis pertains to 1,501 adolescents aged 13 and 16 years who completed questionnaires and for whom blood samples were available. The independent association between a six-category indicator of smoking status and elevated hs-CRP, defined as a value at least in the 90th percentile of the age- and sex-specific CRP distribution, was assessed in multiple logistic regression analyses controlling for potential confounders. Relative to never-smokers, the odds ratios (95% confidence intervals) for puffers (i.e., never smoked a whole cigarette), those who smoked but not in the past month, light past-month smokers, moderate past-month smokers, and heavy past-month smokers were 1.04 (0.55-1.98), 1.76 (1.06-2.94), 1.39 (0.70-2.76), 2.07 (0.96-4.42), and 2.40 (1.18-4.88), respectively. Our data suggest a positive association between smoking status and elevated CRP in adolescents, and in particular among heavier past-month smokers. Damage related to cigarette smoking may begin soon after tobacco use initiation, reinforcing the preventive message that no level of smoking is safe in youth.

Effects of antiperspirant aluminum percent composition and mode of application on mock microcalcifications in mammography.

OBJECTIVEnActive ingredients in antiperspirants - namely, aluminum-based complexes - can produce radiopaque particles on mammography, mimicking microcalcifications. The present study was designed to investigate whether the appearance of antiperspirant induced radiopaque particles observed on mammograms is dependent on the percentage of aluminum-based complexes in antiperspirants and/or on their mode of application.nnnMETHODSnA total of 43 antiperspirants with aluminum-based complex percentages ranging between 16% and 25% were tested. Each antiperspirant was applied to a single use plastic shield and then placed on an ultrasound gel pad, simulating breast tissue. Two experiments were performed, comparing antiperspirants based on (1) their percentage of aluminum-based complexes (20 antiperspirants) and (2) their mode of applications (solid, gel, and roll-on) (26 antiperspirants). Two experienced, blinded radiologists read images produced in consensus and assessed the appearance of radiopaque particles based on their density and shape.nnnRESULTSnIn experiment 1, there was no statistically significant association between the percent aluminum composition of invisible solid antiperspirants and the density or shape of the radiopaque particles (p-values>0.05). In experiment 2, there was a statistically significant association between the shape of the radiopaque particles and the mode of application of the antiperspirant (p-value=0.0015).nnnCONCLUSIONSnOur study suggests that the mammographic appearance of the radiopaque antiperspirant particles is not related to their percent composition of aluminum complexes. However, their mode of application appears to influence the shape of radiopaque particles, solid antiperspirants mimicking microcalcifications the most and roll-on antiperspirants the least.

Sex Differences in Depression Treatment and Impact on Outcomes Following Premature Acute Coronary Syndrome

Aims: Access to anti-depressants, and prognosis in younger depressed men and women with acute coronary syndrome (ACS) requires further investigation. We assessed the prevalence of depression, antidepressant prescription, and the association of depression with major adverse cardiovascular events (MACE) in men and women with premature ACS. nMethods and results: 1071 ACS men and women (≤ 55 years) were recruited between January 2009 and April 2013 into GENESIS PRAXY, a multicentre prospective observational cohort study, from 24 hospitals in Canada, one in the US and one in Switzerland. Depression was measured by self-report using the Diagnostic and Statistical Manual of Mental Disorders criteria. Prescription of antidepressants at baseline and 12 months, and MACE over 12 months, were assessed using medical chart review and self-report. Depression was present in 20% of men and 32% of women. Only 1% of men and women with no antidepressants at hospital admission were prescribed antidepressants at hospital discharge. Depressed men were 3 times less likely than depressed women to be prescribed antidepressants. The determinants of antidepressants at 12 months included the presence of cardiovascular risk factors in men, and the presence of depression in women. In sex-specific Cox regressions, depressed men had a 2.57 times greater risk of MACE compared with non-depressed men (95% CI: 1.53-4.32), which difference was not seen in women (HR=0.71, 95% CI=0.28-1.81). nConclusion: Despite a decade of sensitization, depression still needs to be better treated after ACS, especially in young men, given that depression is a potent risk factor for adverse outcomes.