CpG-island fragments from the HNRPA2B1/CBX3 genomic locus reduce silencing and enhance transgene expression from the hCMV promoter/enhancer in mammalian cells

BACKGROUND: The hCMV promoter is very commonly used for high level expression of transgenes in mammalian cells, but its utility is hindered by transcriptional silencing. Large genomic fragments incorporating the CpG island region of the HNRPA2B1 locus are resistant to transcriptional silencing. RESULTS: In this report we describe studies on the use of a novel series of vectors combining the HNRPA2B1 CpG island with the hCMV promoter for expression of transgenes in CHO-K1 cells. We show that the CpG island gives at least twenty-fold increases in the levels of EGFP and EPO observed in pools of transfectants, and that transgene expression levels remain high in such pools for more than 100 generations. These novel vectors also allow facile isolation of clonal CHO-K1 cell lines showing stable, high-level transgene expression. CONCLUSION: Vectors incorporating the hnRPA2B1 CpG island give major benefits in transgene expression from the hCMV promoter, including substantial improvements in the level and stability of expression. The utility of these vectors for the improved production of recombinant proteins in CHO cells has been demonstrated

Impact of the COVID-19 pandemic on antidepressant and antipsychotic use among children and adolescents: a population-based study

BackgroundThe COVID-19 pandemic was associated with increases in the prevalence of depression, anxiety and behavioural problems among children and youth. Less well understood is the influence of the pandemic on antidepressant and antipsychotic use among children. This is important, as it is possible that antidepressants and antipsychotics were used as a “stop-gap” measure to treat mental health symptoms when in-person access to outpatient care and school-based supportive services was disrupted. Furthermore, antipsychotics and antidepressants have been associated with harm in children and youth. We examined trends in dispensing of these medications two years following the pandemic among children 18 years of age and under in Ontario, Canada.MethodsWe conducted a population-based time-series study of antidepressant and antipsychotic medication dispensing to children and adolescents ≤18 years old between September 1, 2014, and March 31, 2022. We measured monthly population-adjusted rates of antidepressant and antipsychotics obtained from the IQVIA Geographic Prescription Monitor (GPM) database. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of antidepressants and antipsychotics occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected use of these drugs.ResultsOverall, we found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. Specifically, we observed an immediate step decrease in antidepressant dispensing associated with a structural break in April 2020 (−55.8 units per 1,000 individuals; 95% confidence intervals [CI] CI: −117.4 to 5.8), followed by an increased monthly trend in the rate of antidepressant dispensing of 13.0 units per 1,000 individuals (95% CI: 10.2–15.9). Antidepressant dispensing was consistently greater than predicted from September 2020 onward. Antipsychotic dispensing increased immediately following a June 2020 structural break (26.4 units per 1,000 individuals; 95% CI: 15.8–36.9) and did not change appreciably thereafter. Antipsychotic dispensing was higher than predicted at all time points from June 2020 onward.ConclusionWe found higher-than-expected dispensing of antidepressants and antipsychotics in children and youth. These increases were sustained through nearly two years of observation and are especially concerning in light of the potential for harm with the long-term use of antipsychotics in children. Further research is required to understand the clinical implications of these findings

Evidence from an Applied Research Health Question (AHRQ): Healthcare utilization of HIV patients before and after admission to Casey House, a specialized HIV hospital

Introduction The Applied Health Research Question (AHRQ) portfolio is an initiative funded by the Ontario Ministry of Health and Long-Term Care, leveraging the linked data and the scientific expertise at ICES to answer questions from Knowledge Users that have a direct impact on healthcare policy, planning or practice. Objectives and Approach A request from Casey House, a specialty HIV hospital located in Toronto, ON, was reviewed and approved by the ICES AHRQ Team to evaluate patient healthcare utilization and costs. The purpose was to support the design of programs and services, improve transitions from healthcare settings to community services, and inform continuous quality improvement initiatives. Using inpatient records, hospital admissions to Casey House were identified in fiscal years 2009-2014. Inpatient, emergency, outpatient and home care visits were characterized before and after admission. Using the Ontario Drug Benefit Claims, antiretroviral (ARV) prescription fills were examined 7 days post discharge. Results Between April 1, 2009 and March 31, 2015, 268 HIV patients had one or more hospital admissions to Casey House. The majority of Casey House patients had an Aggregated Diagnosis Group (ADG) ≥ 10 (79%) or Resource Utilization Band (RUB) = 5 (78%), indicating a high co-morbidity burden. Rate of emergency department usage declined from 4.61 to 2.46 per person-year, before and after Casey House admission (p < 0.0001). Conversely, home care visits increased from 24.29 to 35.63 per person-year and family physician visits increased from 18.33 to 22.59 per person-year before and after Casey House admission (both p < 0.0001). Interestingly, 89% did not fill an ARV prescription within 7 days of Casey House discharge, however 76% followed up with an outpatient HIV visit within 30 days. Conclusion/Implications Healthcare utilization differed before and after admission to Casey House. Follow-up post-discharge warrants further examination to increase ARV prescription fills. Data from this AHRQ has facilitated future policy and programming changes. Results have been disseminated throughout the Toronto HIV research community to generate discussion on quality improvement in this population

Validation of Case-Finding Algorithms Derived from Administrative Data for Identifying Adults Living with Human Immunodeficiency Virus Infection

OBJECTIVE: We sought to validate a case-finding algorithm for human immunodeficiency virus (HIV) infection using administrative health databases in Ontario, Canada. METHODS: We constructed 48 case-finding algorithms using combinations of physician billing claims, hospital and emergency room separations and prescription drug claims. We determined the test characteristics of each algorithm over various time frames for identifying HIV infection, using data abstracted from the charts of 2,040 randomly selected patients receiving care at two medical practices in Toronto, Ontario as the reference standard. RESULTS: With the exception of algorithms using only a single physician claim, the specificity of all algorithms exceeded 99%. An algorithm consisting of three physician claims over a three year period had a sensitivity and specificity of 96.2% (95% CI 95.2%-97.9%) and 99.6% (95% CI 99.1%-99.8%), respectively. Application of the algorithm to the province of Ontario identified 12,179 HIV-infected patients in care for the period spanning April 1, 2007 to March 31, 2009. CONCLUSIONS: Case-finding algorithms generated from administrative data can accurately identify adults living with HIV. A relatively simple "3 claims in 3 years" definition can be used for assembling a population-based cohort and facilitating future research examining trends in health service use and outcomes among HIV-infected adults in Ontario

Health Services Utilization among Persons Living with Human Immunodeficiency Virus Infection in Ontario

The goals of this dissertation were to investigate aspects of the health services utilization of marginalized persons living with HIV (PLWH), including women, recent immigrants, heterosexual men and individuals living in low income neighborhoods. In the first study, an algorithm of three physician claims for HIV-infection within a three-year period was validated for case-ascertainment of PLWH in administrative databases. The sensitivity and specificity of the algorithm were 96.2% [95% confidence intervals (CI) 95.2% to 97.9%] and 99.6% (95% CI 99.1% to 99.8%), respectively. The algorithm was used to conduct a population-based study examining rates of hospitalization among all PLWH receiving care in Ontario. The introduction of combination antiretroviral therapy was associated with more pronounced reductions in rates of total (-89.9 vs. -60.5 per 1000 PLWH; p = 0.003) and HIV-related hospitalizations (- 56.9 vs. -36.3 per 1000 PLWH; p < 0.001) among men relative to women. Between 2002 and 2008, higher rates of total hospitalization were associated with female sex [adjusted relative rate (aRR) 1.15; 95% CI: 1.05 to 1.27] and low socioeconomic status (aRR 1.21; 95% CI: 1.14 to 1.29). Higher rates of HIV-related hospitalizations were associated with low socioeconomic status (aRR 1.30; 95% CI: 1.17 to 1.45). Recent immigrants had lower rates of both total (aRR 0.70; 95% CI 0.61 to 0.80) and HIV-related hospitalizations (aRR 0.77; 95% CI 0.61 to 0.96). Finally, a theoretically-informed qualitative study was conducted to characterize the help-seeking experiences of heterosexual men living with HIV. The results indicate that without the symbolic appeal of women and the social connections of gay men, heterosexual men lack the composition of capital required to benefit fully from or improve their positions within the existing HIV health and social service fields. The findings of this dissertation illustrate important disparities in health services utilization among PLWH in Ontario.Ph

Recent Immigrants Show improved Clinical Outcomes at a Tertiary Care HIV Clinic

BACKGROUND: In recent years, the proportion of patients attending tertiary care HIV clinics who are recent immigrants to Canada has increased dramatically.METHODS: Among patients first seen at the Toronto Hospital Immunodeficiency Clinic (Toronto, Ontario) between January 1, 2000 and August 31, 2009, the time to death from the first positive HIV test was compared between individuals who had immigrated to Canada within 10 years of their first visit and individuals who were either Canadian-born or who had immigrated more than 10 years before their first clinic visit. In addition, for the antiretroviral-naive patients in these two groups who initiated combination antiretroviral therapy, the time to and the duration of virologic suppression were compared.RESULTS: In a multivariable proportional hazards (PH) model, recent immigrant status was associated with decreased mortality (HR 0.11, P=0.03) after adjusting for age, CD4 count and the risk factor for men having sex with men. In multivariable PH models, recent female immigrants achieved virologic suppression more quickly (HR 1.51, P=0.02), while male immigrants (HR 1.14, P=0.44) and female nonimmigrants (HR 0.90, P=0.61) had similar times to virologic suppression as male nonimmigrants, respectively, after adjusting for the year of and viral load at combination antiretroviral therapy initiation. When pregnant women were removed from the analysis, there were no significant differences in the rates of virologic rebound according to sex or immigration status.DISCUSSION: Despite the perceived barriers of newcomers to Canada, mortality was lower among recent immigrants and virologic suppression was achieved more quickly in recent female immigrants.Peer Reviewe

The impact of drug reimbursement policy on rates of testosterone replacement therapy among older men.

Despite a lack of data describing the long-term efficacy and safety of testosterone replacement therapy (TRT), prescribing of testosterone to older men has increased with the availability of topical formulations. The magnitude of this increase and the impact of formulary restrictions on testosterone prescribing are poorly characterized.We conducted a time series analysis using the linked health administrative records of men aged 66 years or older in Ontario, Canada between January 1, 1997 and March 31, 2012. We used interventional autoregressive integrated moving average models to examine the impact of a restrictive drug reimbursement policy on testosterone prescribing and examined the demographic profile of men initiating testosterone in the final 2 years of the study period.A total of 28,477 men were dispensed testosterone over the study period. Overall testosterone prescribing declined 27.9% in the 6 months following the implementation of the restriction policy (9.5 to 6.9 men per 1000 eligible; p<0.01). However, the overall decrease was temporary and testosterone use exceeded pre-policy levels by the end of the study period (11.0 men per 1000 eligible), largely driven by prescriptions for topical testosterone (4.8 men per 1000 eligible). Only 6.3% of men who initiated testosterone had a documented diagnosis of hypogonadism, the main criteria for TRT reimbursement according to the new policy.Government-imposed restrictions did not influence long-term prescribing of testosterone to older men. By 2012, approximately 1 in every 90 men aged 66 or older was being treated with TRT, most with topical formulations