Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care

The purpose of this study was to assess the prevalence of prenatal and postpartum depression screening in a large health system and to identify covariates for screening, with a specific focus in understanding disparities in practice. A retrospective cohort of women with deliveries in 2016 was created using electronic health records. Primary outcomes were depression screening during pregnancy and the first 3 months postpartum. Generalized linear mixed models with women nested within clinic were used to determine the effect of maternal and clinical characteristics on depression screening. The sample included 7548 women who received prenatal care at 35 clinics and delivered at 10 hospitals. The postpartum sample included 7059 women who returned within 3 months for a postpartum visit. Of those, 65.1% were screened for depression during pregnancy, and 64.4% were screened postpartum. Clinic site was the strongest predictor of screening, accounting for 23–30% of the variability in screening prevalence. There were no disparities identified with regard to prenatal screening. However, several disparities were identified for postpartum screening. After adjusting for clinic, women who were African American, Asian, and otherwise non-white (Native American, multi-racial) were less likely to be screened postpartum than white women (AOR (CI)’s 0.81 (0.65, 1.01), 0.64 (0.53, 0.77), and 0.44 (0.21, 0.96), respectively). Women insured by Medicaid/Medicare, a proxy for low-income, were less likely to be screened postpartum than women who were privately insured (AOR (CI) 0.78 (0.68, 0.89)). National guidelines support universal depression screening of pregnant and postpartum women. The current study found opportunities for improvement in order to achieve universal screening and to deliver equitable care.

     

Characterization of melanocyte stimulating hormone receptor variant alleles in twins with red hair

The association between MSHR coding region variation and hair colour in humans has been examined by genotyping 25 red haired and 62 non-red Caucasians, all of whom were 12 years of age and members of a twin pair study. Twelve amino acid substitutions were seen at 11 different sites, nine of these being newly described MSHR variants. The previously reported Val92Met allele shows no association with hair colour, but the three alleles Arg151Cys, Arg160Trp and Asp294His were associated with red hair and one Val60Leu variant was most frequent in fair/blonde and light brown hair colours. Variant MSHR genotypes are associated with lighter skin types and red hair (P < 0.001). However, comparison of the MSHR genotypes in dizygotic twin pairs discordant for red hair colour indicates that the MSHR gene cannot be solely responsible for the red hair phenotype, since five of 13 pairs tested had both haplotypes identical by state (with three of the five having both identical by descent). Rather, it is likely that additional modifier genes exist, making variance in the MSHR gene necessary but not always sufficient, for red hair production.      

Ursodeoxycholic acid ingestion after ileal resection

The effect of ursodeoxycholic acid ingestion on biliary bile acids and biliary lipids was studied in six patients after ileal resection. All patients had bile acid malabsorption, as documented by increased breath and fecal excretion of¹⁴C after oral administration of [1-¹⁴C] cholylglycine. Fasting duodenal bile was collected by intubation before and seven days after ursodeoxycholic acid administration (4 g/day), and biliary bile acid and lipid composition were determined. Ursodeoxycholic acid ingestion increased the percentage of ursodeoxycholic acid in bile tenfold (3.6±2.6% vs 38.6±12.0%) and decreased chenodeoxycholic acid in bile by approximately 40%. Before ursodeoxycholic acid ingestion, bile was supersaturated in all patients. After ursodeoxycholic acid ingestion, cholesterol saturation decreased in all six patients by an average of 43%, and bile became unsaturated in five. Ursodeoxycholic acid ingestion had no effect on stool frequency. We conclude that, as in subjects with an intact enterohepatic circulation, ursodeoxycholic acid therapy has litholytic potential in patients after ileal resection.This work was supported by NIH Grants AM 15887 and RR 585 and by the Mayo Foundation. Part of this work was reported at the 1979 meeting of the American Gastroenterological Association and published in abstract form.At the time this work was done, Dr. LaRusso was a Teaching and Research Scholar of the American College of Physicians.     

Hepatic processing of transforming growth factor beta in the rat. Uptake, metabolism, and biliary excretion.

Transforming growth factor beta (TGF beta), a recently discovered polypeptide, modulates growth of normal and neoplastic cells. Since little is known concerning in vivo disposition of TGF beta, we performed studies to examine the hepatic processing of biologically active 125I-TGF beta in the rat. After intravenous injection, 125I-TGF beta disappeared from the plasma with an initial t1/2 of 2.2 min; partial hepatectomy delayed the plasma disappearance of 125I-TGF beta by 80%. 60 min after intrafemoral injection, 63% of the recovered label was present in liver and/or bile; by 90 min, most of the label removed by the liver (83%) had been slowly excreted into bile. Nearly all the label in bile (96%) was soluble in trichloracetic acid and not immunoprecipitable by specific antiserum. Colchicine and vinblastine inhibited cumulative biliary excretion of label by 28 and 37%, respectively; chloroquine and leupeptin each increased the amount of label in bile that was precipitable by trichloracetic acid and that coeluted with authentic 125I-TGF beta on molecular sieve chromatography. There was efficient first-pass hepatic extraction of 125I-TGF beta (36%) in the isolated perfused rat liver, which was inhibited by unlabeled TGF beta (but not by epidermal growth factor, EGF) and by lectins in a dose-dependent manner; prolonged fasting also decreased clearance (26%). After fractionation of liver by differential or isopycnic centrifugation, radiolabel codistributed with marker enzymes for lysosomes. The results indicate rapid, extensive, inhibitable, and organ-selective extraction of TGF beta by the liver. After extraction, TGF beta undergoes efficient transhepatic transport, extensive intracellular metabolism, and slow but complete biliary excretion of its metabolites. Liver fractionation studies and pharmacologic manipulations suggest that these processes are associated with organelles that include microtubules and lysosomes. The data suggest that the liver is a major target tissue or site of metabolism for biologically active TGF beta.     

Aquaporin-8 is involved in water transport in isolated superficial colonocytes from rat proximal colon

Water is an essential nutrient because it must be introduced from exogenous sources to satisfy metabolic demand. Under physiologic conditions, the colon can absorb and secrete considerable amounts of water even against osmotic gradients, thus helping to maintain the body fluid balance. Here we describe studies on both aquaporin (AQP) expression and function using cells isolated from the superficial and lower crypt regions of the rat proximal colon. The expression of AQP-3, -4, and -8 in isolated colonocytes was determined by semiquantitative RT-PCR and by immunoblotting. The localization of AQP-8 in the colon was evaluated by immunohistochemistry. A stopped-flow light scattering method was used to examine osmotic water movement in isolated colonocytes. Moreover, the contribution of AQP-8 to overall water movement through isolated colonocytes was studied using RNA interference technology. Colonocytes from the proximal colon express AQP-3, -4, and -8 with increasing concentrations from the lower crypt cells toward those on the surface. Osmotic water permeability was higher in surface than in crypt colonocytes (P < 0.05); it was significantly inhibited by the water channel blocker dimethyl sulfoxide, and reversed by beta-mercaptoethanol (P < 0.05). Immunohistochemistry revealed a strong AQP-8 labeling in the apical membrane of the superficial colonocytes. Inhibition of aquaporin-8 expression by small interfering RNA significantly decreased osmotic water permeability (approximately 38%; P < 0.05). Current results indicate that aquaporin-8 may play a major role in water movement through the colon by acting on the apical side of the superficial cells.     

Determinants of fasting and postprandial serum bile acid levels in healthy man

The relationship between serum levels of conjugates of cholic acid measured by radioimmunoassay, bile acid absorption, and hepatic clearance was studied in order to define the determinants of fasting and postprandial serum bile acids in healthy man. Acute or chronic interruption of the enterohepatic circulation caused a significant decrease in basal serum levels of cholyl conjugates, while liquid or solid meals caused a marked and reproducible increase in serum cholyl conjugates. A temporal correlation was demonstrated postprandially or after intravenous cholecystokinin between intestinal transit of bile acids and simultaneous changes in levels of serum cholyl conjugates. Finally, the plasma disappearance of intravenously injected cholylglycine was shown to be unaffected by serum levels of endogenous cholyl conjugates. These data are consistent with the interpretation that, in the presence of normal hepatic function, the major determinant of serum bile acids is their rate of intestinal absorption.     

A novel incentive system for faculty in an academic medical center

The need to contain health care costs has led some physicians to become salaried employees of health care organizations. However, the use of nonfinancial incentives for physicians in such an environment has not been broadly explored. The authors describe a novel incentive system that is designed to promote continuing high-quality care and to increase patient access to health care while enhancing clinical and academic productivity and physician satisfaction. Key components of this system include annual targets, flexibility in meeting these targets, and ability to convert clinical productivity generated in excess of what was necessary to meet the target to support scholarly activities. This system led to increased faculty productivity, improved patient access, enhanced scholarly activity, and overall enhanced career satisfaction.     

Potential roles of tumor suppressor genes and microsatellite instability in hepatocellular carcinogenesis in southern African blacks

MAJOR POINTS OF THE COMMENTED ARTICLE Cumulative loss of heterozygosity (LOH) of chromosomal regions and tumor suppressor genes has been reported in hepatocellular carcinomas (HCCs) from China, Japan, and Korea. In this issue of the World Journal of Gastroenterology,Martins et al[1] report an analysis of LOH and microsatellite instability in HCCs from a group of 20 southern African blacks. Six known tumor suppressor genes-p53, RB1, BRCA1, BRCA2,WT1, and E-cadherin-were analyzed for LOH. In addition, the p53 gene was analyzed for the codon 249 mutation that is commonly found in subjects exposed to high levels of dietary aflatoxin B1.