Anxiety symptom levels are persistent in older adults with a mental disorder: A 33-month follow-up study.

OBJECTIVE: Anxiety symptoms are common in old age and have been suggested as risk factors for development of cognitive impairment and mortality. The objective of the present study was to investigate whether anxiety symptoms among older adults with a mental health diagnosis are persistent, and severity of anxiety predicts cognitive decline and mortality. METHODS: We collected data from 201 patients referred to specialist mental health service in a department of geriatric psychiatry. Of these, 150 were reexamined after 33 months, while 51 patients died before follow-up. Mean age (SD) at baseline among the patients that were reexamined was 73.4 (7.3) years, and 67% were women. The Geriatric Anxiety Inventory (GAI) was used to measure anxiety symptoms at baseline and follow-up. We investigated whether higher GAI scores at baseline were associated with persistence of anxiety. Associations with cognitive decline or mortality were also explored. The associations were estimated by use of trajectory analysis and regression models. RESULTS: Seventy-four percentages had the same level of anxiety symptoms, and 29% had a high level of anxiety at baseline and follow-up. GAI score at baseline was not associated with cognitive decline or mortality at 33-month follow-up. CONCLUSION: In a longitudinal study of anxiety symptoms among older adults in specialist mental health services, we demonstrate persistent high or low levels of anxiety symptoms. Anxiety trajectories over time were not predicted by patient characteristics. Also the level of anxiety cannot be used as predictor for future cognitive decline or mortality in a clinical population.

Anxiety Symptoms in Older Adults with Depression Are Associated with Suicidality.

OBJECTIVE: Anxiety symptoms are common in older adults with depression, but whether severe anxiety is associated with poorer outcomes of depression is unknown. The objective of the present study was to examine the association between severity of anxiety and severity of depression and physical illness, suicidality, and physical and cognitive functioning in older adults with depression. METHODS: We included 218 older adults with diagnoses of a depressive disorder according to the ICD-10 criteria; their mean age (SD) was 75.6 (7.2), and 67.0% were women. The Geriatric Anxiety Inventory (GAI) was used to measure the severity of anxiety symptoms. The Montgomery-Aasberg Depression Rating Scale (MADRS) was used to assess the severity of depression. We obtained information on the level of functioning with the Physical Self-Maintenance Scale (PSMS) by Lawton and Brody and on cognition with the Mini-Mental State Examination (MMSE) and the Clock-Drawing Test (CDT). Physical health was determined based on information regarding falls and weight loss and an assessment of each patient's general medical condition. The treating physician evaluated current suicidality in a comprehensive and standardized way. RESULTS: Higher GAI scores were significantly associated with scores on the MADRS (ß = 0.233, p = 0.002) and suicidality (ß = 0.206, p = 0.006). Levels of physical or cognitive functioning were not associated with the GAI score. CONCLUSION: The severity of anxiety symptoms was associated with the severity of depression and suicidality in older adults with depressive disorders. The results could indicate a need to focus greater attention on the treatment of anxiety and suicidality in older patients with depression.

Symptoms of Anxiety in Older Adults with Depression, Dementia, or Psychosis: A Principal Component Analysis of the Geriatric Anxiety Inventory.

AIMS: The primary aim of this study was to examine anxiety symptoms as measured by the Geriatric Anxiety Inventory (GAI) in older patients with depression, dementia, or psychotic disorders. The secondary aim was to conduct a principal component analysis (PCA) of the GAI and to examine whether its subscales differ between the 3 disorders. METHODS: We included data from 428 patients who were admitted to a department of geriatric psychiatry and examined according to a standardized protocol. The GAI was used to measure current anxiety symptoms. RESULTS: The GAI symptoms occurred more frequently in the group with depression than in the other 2 groups. The PCA of the GAI with oblimin rotation resulted in a 2-component solution, labelled as "worries" (explained variance 46.3%, Cronbach's α 0.92) and "physical symptoms" (explained variance 7.1%, Cronbach's α 0.85). CONCLUSION: The results indicate that in old age, anxiety is especially prevalent in depression. The 2-component solution indicates that the GAI measures 2 different aspects of anxiety with different symptomatology.

Anxiety among older psychiatric patients: a hidden comorbidity?

OBJECTIVES: Our aims were to explore prevalence of anxiety among patients admitted to departments of geriatric psychiatry for treatment of various diagnoses and to examine how often anxiety was registered as a previous or ongoing diagnosis. METHOD: In all, 473 patients admitted to one of five departments of geriatric psychiatry were included in a quality register and examined according to a standardized protocol. The Geriatric Anxiety Inventory (GAI) was used to measure anxiety during the first week after admission. Diagnoses were made at discharge. RESULTS: Using a cutoff on the GAI of 8/9, the prevalence of anxiety for the following diagnostic groups was depression 65.3%, psychosis 28%, dementia 38.8% and mania 33.3%. Of 24 patients with a primary diagnosis of anxiety, 66.7% scored above 8 on the GAI. Of 236 patients with a GAI score above 8, only 22 (9.3%) were reported to have a comorbid anxiety disorder by the treating psychiatrist. In a multiple regression analysis, we found that the severity of depression (beta 0.585, p < 0.001), being female (beta 0.096, p 0.028) and the use of antipsychotic drugs (beta 0.129, p 0.006) and anxiolytic drugs (beta 0.129, p 0.005) were associated with a higher GAI score. CONCLUSION: Anxiety is common in geriatric psychiatric patients, regardless of the primary diagnosis. Our findings suggest that anxiety is often a hidden comorbidity in various psychiatric disorders. A high score on the GAI was associated with the severity of depression, female gender and the use of antipsychotic and anxiolytic drugs.

Deaths from violent causes and accidents in Hordaland County 2003-04.

BACKGROUND: Studies of the epidemiology of deaths from violent causes can provide valuable information for the treatment of traumas. We wished to ascertain whether the victims had survivable injuries and were accessible for treatment at the time of discovery of the injury. The purpose was to identify areas of intervention that may help save lives. MATERIAL AND METHOD: An overview of deaths from violent causes in Hordaland County in 2003 and 2004 was retrieved from the Cause of Death Registry, and information from autopsy records, hospital records and police reports was reviewed. In each case, an assessment was made of whether the injuries were survivable. If the patient was alive and could be reached and treated at the time when the incident was reported, he/she was defined as accessible for treatment. RESULTS: Altogether 191 deaths were included. We assessed the injuries as survivable in 26 cases. A total of 18 of these 26 patients were also assessed as accessible for treatment. All of these 18 patients died from falls or traffic accidents. 11 of the 18 patients were in the age group 75 years or older; this age group accounted for 41 cases (21.5%) of the total material. The records showed that in 12 of these 18 cases, it had been decided following an overall assessment not to initiate, or to discontinue, further life-saving treatment. INTERPRETATION: A small number of patients were deemed to have sustained survivable injuries while also being accessible for treatment. The results indicate that primarily efforts to prevent injuries will help reduce the number of deaths from violent causes.

A Cross-National Analysis of the Psychometric Properties of the Geriatric Anxiety Inventory.

OBJECTIVES: Assessing late-life anxiety using an instrument with sound psychometric properties including cross-cultural invariance is essential for cross-national aging research and clinical assessment. To date, no cross-national research studies have examined the psychometric properties of the frequently used Geriatric Anxiety Inventory (GAI) in depth. METHOD: Using data from 3,731 older adults from 10 national samples (Australia, Brazil, Canada, The Netherlands, Norway, Portugal, Spain, Singapore, Thailand, and United States), this study used bifactor modeling to analyze the dimensionality of the GAI. We evaluated the "fitness" of individual items based on the explained common variance for each item across all nations. In addition, a multigroup confirmatory factor analysis was applied, testing for measurement invariance across the samples. RESULTS: Across samples, the presence of a strong G factor provides support that a general factor is of primary importance, rather than subfactors. That is, the data support a primarily unidimensional representation of the GAI, still acknowledging the presence of multidimensional factors. A GAI score in one of the countries would be directly comparable to a GAI score in any of the other countries tested, perhaps with the exception of Singapore. DISCUSSION: Although several items demonstrated relatively weak common variance with the general factor, the unidimensional structure remained strong even with these items retained. Thus, it is recommended that the GAI be administered using all items.

Complications and frequency of redo antireflux surgery in Denmark: a nationwide study, 1997-2005.

BACKGROUND: Outcomes after redo fundoplication (RF) in recurrent gastroesophageal reflux disease (GERD) are debatable, and they may include lower success rates with higher postoperative morbidity and mortality than outcomes after primary fundoplication (PF). However, data from large, nationwide studies are not available. Accordingly, the aim of the present study was to evaluate nationwide Danish data on RF in a nine-year period. METHOD: Data in the period from 1997 through 2005 were extracted from the National Patient Register. The following information was procured: frequency of RF, rate of conversion to open surgery, rate of complications requiring reoperation, and 30-day mortality. Data for RF were compared to PF. RESULTS: A total of 2589 fundoplications were performed in 2465 patients. Thus, 113 patients underwent a total of 124 RF (RF rate = 5.0%). Most RF (84.7%) were performed at high-volume departments. Patients who underwent RF were converted to open surgery more often (16.1% vs. 6.1% in PF) (P < 0.0001). The median postoperative hospital stay was 3 days after RF and 2 days after PF (P = 0.96). Following RF 1.6% of the patients had complications requiring surgery compared with 1.3% after PF (P = 0.79), and 30-day mortality was 0.81% after RF compared with 0.45% after PF (P = 0.57). CONCLUSION: This nationwide Danish study showed a low rate of redo fundoplication and a similar morbidity and mortality rate after redo surgery compared with that of primary surgery.

Organisation and quality of primary surgical intervention for ovarian cancer in Denmark.

BACKGROUND: The positive effect on survival of maximal primary cytoreductive surgery for ovarian cancer is well established, and the highest rates of optimal cytoreduction are achieved by gynecological oncologists. Danish women have not only one of the highest incidences of ovarian cancer, but also the highest mortality rate. From 1981 to 1989, the overall Danish optimal debulking rate was 25% in patients with stage III and IV tumors. The primary aim of the present study was, therefore, to evaluate the organisation and quality of current primary surgical intervention for ovarian cancer in Denmark. METHODS: All women diagnosed with epithelial ovarian carcinoma (DC56) were identified through the Danish National Patient Registry during the study period from 1 July 2002 to 31 December 2003, and surgical notes and histopathology were evaluated by a board of 7 gynecological-oncologists, focusing on maximal cytoreduction. RESULTS: For stage III, the nationwide optimal debulking rate was 39%, significantly higher in the major hospitals (49%) versus other hospitals (29%) (p<0.005). In 19% of cases, there was insufficient information to evaluate debulking from the surgical notes, significantly less at the major hospitals versus other hospitals (12 versus 25%, p<0.001). CONCLUSIONS: In Denmark, the quality of the primary surgical intervention for ovarian cancer is not optimal. In order to enhance survival, compliance with international guidelines and improved registration of the surgical procedures in clinical databases are mandatory.

Fatal injury as a function of rurality-a tale of two Norwegian counties.

BACKGROUND: Many studies indicate rural location as a separate risk for dying from injuries. For decades, Finnmark, the northernmost and most rural county in Norway, has topped the injury mortality statistics in Norway. The present study is an exploration of the impact of rurality, using a point-by-point comparison to another Norwegian county. METHODS: We identified all fatalities following injury occurring in Finnmark between 2000 and 2004, and in Hordaland, a mixed rural/urban county in western Norway between 2003 and 2004 using data from the Norwegian Cause of Death Registry. Intoxications and low-energy trauma in patients aged over 64 years were excluded. To assess the effect of a rural locale, Hordaland was divided into a rural and an urban group for comparison. In addition, data from Statistics Norway were analysed. RESULTS: Finnmark reported 207 deaths and Hordaland 217 deaths. Finnmark had an injury death rate of 33.1 per 100,000 inhabitants. Urban Hordaland had 18.8 deaths per 100,000 and rural Hordaland 23.7 deaths per 100,000. In Finnmark, more victims were male and were younger than in the other areas. Finnmark and rural Hordaland both had more fatal traffic accidents than urban Hordaland, but fewer non-fatal traffic accidents. CONCLUSIONS: This study illustrates the disadvantages of the most rural trauma victims and suggests an urban-rural continuum. Rural victims seem to be younger, die mainly at the site of injury, and from road traffic accident injuries. In addition to injury prevention, the extent and possible impact of lay people's first aid response should be explored.

[Urinary incontinence surgery in Denmark 2001-2003]. / Urininkontinenskirurgi i Danmark 2001-2003.

INTRODUCTION: The centralisation of surgical activity is an important aspect of the ongoing planning of the Danish Healthcare System. Knowledge of the actual status is crucial in the process of decision. In this article incontinence surgery in Denmark, including the frequency of complications, during a three year period is outlined. MATERIAL AND METHODS: This was a retrospective study, where data were extracted from the Danish National Patient Register (LPR) from 2001 to 2003. Data were supported by discharge letters and chart operation descriptions for women readmitted within 30 days after primary operation or if the hospital stays were prolonged. RESULTS: In total 2678 incontinence operations were performed in the period by 51 different departments. Seven departments carried out 51% of all the procedures, while 33 departments carried out 14% of all the procedures. The frequency of postoperative complications was 33.9% after an abdominal procedure, 10.8% after a Tension free Vaginal Tape (TVT) like procedure and 2.3% after urethral injection therapy. For abdominal procedures, "high volume" departments (> 45 operations/3 years) had significantly fewer complications compared to "low volume" departments (<15 operations/3 years), while no difference was found in the TVT-like group. Registration of complications and reoperations was incomplete and incorrect, especially in the TVT-like group. Mortality within 30 days was 0. CONCLUSION: This study shows a decentralised organisation of surgical incontinence activity in Denmark. Many departments carried out very few operations. There is a need for better registration, especially of TVT slings, and there is a need to reliably monitor the quality of incontinence surgery in Denmark. Surgical incontinence activity should be more centralised.

[Organisation and early outcome of restorative proctocolectomy and ileal pouch-anal anastomosis]. / Organisation og tidlige operationsresultater efter ileo-pouch-anal-anastomose.

INTRODUCTION: Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become the operation of choice for patients with ulcerative colitis and familial polyposis. However, the procedure is complex with a long learning curve, and carries a risk of both early and late complications. The purpose of this study was to evaluate the early outcomes (within 30 days after surgery) and organisation of IPAA surgery in Denmark between January 2001 and December 2005. MATERIALS AND METHODS: IPAA patients >18 years old were drawn from the Danish National Patient Registry from 2001 through 2005. Hospital stay and the primary operation were recorded as well as re-operations and readmissions within the first 30 postoperative days. Mortality was recorded from the National Civic Register. RESULTS: 385 patients underwent IPAA surgery during the study period (77/year) in six centres. One centre performed 31% of the operations. The mean postoperative hospital stay (primary - and readmission within 30 days) was 13.5 days. 24% were readmitted within 30 days and 8% were re-operated. The mortality rate was 0.3%. CONCLUSION: Based upon the limited number of operations, the high risk of early readmissions and re-operations, the well-known steep learning curve and the potential improvement with the technically demanding laparoscopic technique, a reorganisation of the procedure to fewer centres is suggested.

[Organisation and early outcome after radical prostatectomy in Denmark 2004-2007]. / Organisation og tidlige operationsresultater efter radikal prostatektomi i Danmark 2004-2007.

BACKGROUND: The organisation, volume and early morbidity after radical prostatectomy has not been researched in Denmark. MATERIALS AND METHODS: The National Hospital Register was searched for all radical prostatectomies in Denmark from 2004-2007, including mortality and readmissions. RESULTS: In total, 1469 radical prostatectomies were performed, initially in 9 departments, decreasing to 6 departments in 2007. From 2004 to 2007 the number of operations increased by approximately 60%. Median hospital stay was 4 days (mean 5.1 days) without any differences between departments. Mortality was 0.2%. CONCLUSION: There is an increasing rate of radical prostatectomies in Denmark. It is proposed that a national database be established to monitor early and long-term outcomes, including the role of surgical technique (nerve sparing, laparoscopic/robotic surgery, etc.) in order to ensure optimal organisation.

[Adrenalectomy in Denmark 2002-2006]. / Adrenalektomi i Danmark 2002-2006.

INTRODUCTION: Laparoscopic adrenalectomy is replacing open adrenalectomy. The advantages are reduced mortality and morbidity, and shorter postoperative hospitalisation. The organization and short-term outcomes of adrenalectomy in Denmark are largely unknown. MATERIAL AND METHODS: Extraction, review, and analysis of data from the National Patient Register and discharge notes from 2002-2006. RESULTS: A total of 297 adrenalectomies, of which 161 were laparoscopic, were identified. Discharge notes were reviewed in 221 of these cases (2002-2005). All except three were performed in a university hospital setting. The laparoscopic to open conversion rate was 7.6%, mortality 1%, and complication rates for open/laparoscopic adrenalectomy 25%/16%. The mean postoperative hospital stays on surgical/urological wards were 6.0/2.9 days for open and laparoscopic procedures, respectively. CONCLUSION: In Denmark, the share of adrenalectomies performed laparoscopically is growing, currently reaching about 65%. Laparoscopic adrenalectomies are only performed at departments with a high frequency of laparoscopic surgery and specialized endocrinological and anaesthesiological support. For educational and research purposes, adrenalectomy should be performed at an even smaller number of departments. Postoperative hospital stay and mortality are at par with internationally reported levels, but the conversion rate of laparoscopic adrenalectomies should be reduced.

[Cystectomy in Denmark 2000-2005]. / Cystektomi i Danmark 2000-2005.

INTRODUCTION: The organization and results after cystectomy in Denmark are unknown. MATERIALS AND METHODS: Based upon the Danish National Hospital Register and discharge notes, postoperative hospitalization, readmission within 30 days, re-operations and mortality after cystectomy in Denmark in the period January 1, 2000-December 31, 2005 were assessed. RESULTS: There were 995 cystectomies with a median postoperative hospital stay of 18.9 days (including readmissions) and hospital mortality of 3.7%. The operations were performed in seven departments without difference in outcome between departments. Morbidity was observed in 58%, 16.8% of which were re-operated for wound or urinary diversion complications. CONCLUSION: It is concluded that cystectomy should be performed in only five departments in Denmark, and the results suggest that an intensified multicenter collaboration should be initiated to improve outcome.

[Surgery of the thoracic aorta in Denmark 1997-2003]. / Operation for torakal aortalidelse i Danmark 1997-2003.

INTRODUCTION: A retrospective review was undertaken to evaluate the results after surgery of the thoracic aorta in Denmark 1997-2003 and to evaluate if the organisation of surgery was in accordance with recommendations from The National Health Service. All operations were performed at one of the five cardiothoracic surgical departments in Denmark according to the recommendations from the National Health Service. However, this review showed that 49 different surgeons performed 542 operations corresponding to 1.7 operation per surgeon per year. MATERIALS AND METHODS: Discharge letters and operative notes on patients operated for aortic aneurysm or aortic dissection were collected from The National Patient Registry. The study comprises 542 patients at a mean age of 59 +/- 12 years of age of whom 366 (68%) were operated on acutely. 369 patients were operated for aortic dissection and 173 were operated for aortic aneurysm. The number of operations increased from 59 in 1997 to 100 in 2003. RESULTS: 30 day mortality was 18% for aneurysms and 30% for dissections. The mean postoperative length of stay was 35 +/- 12 days. When comparing the operating hospitals, there was no difference in mortality or in postoperative length of stay. 345 patients (64%) developed one or more postoperative complications. Severe neurologic complications developed in 20% of the patients operated for aortic dissection and in 10% operated for aortic aneurysm. Reoperation for bleeding occurred in 19% of the patients operated for aortic dissection and in 10% operated for aortic aneurysm. CONCLUSION: This study has shown that mortality and complication rate are higher in Denmark compared with corresponding studies abroad and it should be possible to improve the results in the future.

[The importance of physical activity and body mass index for body satisfaction]. / Betydningen af fysisk aktivitet og body mass index for tilfredshed med kropsbygningen.

INTRODUCTION: Body satisfaction has mostly been investigated among patients with psychiatric diseases. A few studies have found an association between physical activity, obesity and body satisfaction in the healthy population, but the focus has mostly been on the risk of developing diseases. The aim of the present study has been to study the association between body satisfaction, BMI, physical activity and chronic diseases. MATERIALS AND METHODS: A total of 15,252 women and 14,181 men born between 1953 and 1982 (both years included) and registered with The Danish Twin Registry answered a questionnaire which they were sent in 1994. We used the questions on chronic diseases, height and weight, physical activity and body satisfaction. Univariat analysis of body satisfaction and the other variables was carried out using chi2-tests and t-tests. Multivariat analysis was carried out with logistic regression. RESULTS: More men than women are satisfied with their bodies; BMI confers a negative association, while physical activity confers a positive association with body satisfaction. This satisfaction appears to some degree mediated by BMI. The presence of asthma and other lung symptoms and lower-back pain was negatively associated with body satisfaction. DISCUSSION: Thinness tends to be the ideal body image today and this may explain why more obese people are dissatisfied with their body. This ideal is more important for women s perception of their bodies. Physical activity and being healthy adds to body satisfaction.

[Nephrectomy in denmark 2002-2005]. / Nefrektomi i Danmark 2002-2005.

INTRODUCTION: Implementation of principles of fast-track surgery as well as laparoscopy may decrease hospital stay after nephrectomy to about 2-4 days. The aim of this study was to analyse the incidence, use of laparoscopic vs. open nephrectomy, hospital stay, morbidity and mortality in Danish hospitals within the period 2002-2005. METHODS: Extraction of information from the National Patient Register (LPR) and discharge notes from Jan. 1 2002 to Dec. 31 2004. RESULTS: In the 3-year period, 1968 nephrectomies were performed in a total of 45 departments, decreasing to 29 departments in 2004. Five departments performed > 100 operations during the 3 years, 10 departments performed between 50-100 operations and 30 departments <50 operations during the 3 years. The average length of hospital stay (primary and readmission) was 9.1 days. The total mortality rate was 2.2%; lower (1.5%) in departments with high activity vs. departments with low activity (4.3%, p < 0.01). Laparoscopic surgery was performed in 11 departments with a hospital stay of 5.2 vs. 9.5 days and with fewer surgical and medical complications and mortality (0.4% vs. 2.5%), compared with open operation. CONCLUSION: The organisation and results after nephrectomy are not optimal on a nationwide basis. This precludes further optimisation of the early perioperative results, including use of the laparoscopic approach combined with the principles of fast-track surgery. It is suggested that nephrectomy in the future is performed in fewer departments to fulfil these needs.

[Ovarian cancer in Denmark. Status of the surgical intervention]. / Ovariekraeft i Danmark. Status for den kirurgiske indsats.

INTRODUCTION: In Denmark women have not only one of the highest risks of ovarian cancer but also the highest mortality rate. The primary surgery is a key factor in the outcome. MATERIALS AND METHODS: Surgery for the treatment of ovarian cancer in Denmark was evaluated for the period from 1 July 2002 to 31 December 2003 using data from the Danish National Patient Registry (Landspatientregisteret, LPR) as well as the letter with the discharge note. The analysis included all primary surgical procedures during this period where information about number of surgical procedures per department, post-operative hospital stay, complications and mortality were obtained. RESULTS: 765 women, mean age 61 years (range 5-96 years), were operated on for ovarian cancer. The operations were distributed among 52 different hospital departments, and the surgery for advanced stage III patients took place in 32 different departments. The mean postoperative hospital stay was 9.0 days; 28% experienced one or more complications, and 8.1% were reoperated. The mortality rate was 4.2%. CONCLUSION: This first nationwide evaluation of surgery for ovarian cancer in Denmark showed that the surgery took place in far more hospital departments than the five recommended by the Danish National Board of Health. There seems to be room for improvement of quality, and a plan for the next five years is presented.

[Gastric resection for cancer in Denmark, 1999-2004]. / Ventrikelresektion for cancer i Danmark 1999-2004.

INTRODUCTION: We evaluated the organisation, management and outcome for patients operated on with gastric resection for cancer in Denmark in the period 1999-2003. MATERIALS AND METHODS: Nationwide data based on the National Patient Registry and discharge information from hospital departments in the period 1 January 1999 to 31 December 2003 were analysed. RESULTS: Thirty-seven departments performed 537 resections, with an average of 20 departments per year performing such operations. Five departments performed 57.2% of the operations, while 20 departments performed 10.2%. The average postoperative stay was 18 days and the hospital mortality rate was 8.2%, equally distributed with 7.8% for Billroth II resections and 8.5% for total gastrectomy. DISCUSSION: The organization of gastric cancer surgery in Denmark in 1999-2003 was not optimal, with about 20 departments performing about 100 gastric resections annually, and with a mortality rate of slightly over 8% and an average hospital stay of 18 days. We propose that in future, gastric resections for cancer should be performed in a maximum of five departments nationwide.