A retrospective cohort study of prescription drug use among youth with intellectual/developmental disabilities in British Columbia.

BACKGROUND: People with intellectual/developmental disabilities (IDD) are known to have high rates of prescription drug use, particularly for psychotropic medications. This is of concern due to the many side effects associated with these medications and because of the risks of polypharmacy. In this paper we compare the most commonly dispensed drugs and all psychotropic medications for youth with IDD compared with youth without IDD. METHODS: Using population-level administrative health data over a 10-year period, this study examined medications dispensed to youth with an IDD aged 15-24 years compared with youth without an IDD. The most common medications dispensed and the number of youth they were dispensed to were determined. As well a wide variety of psychotropic medications were examined. RESULTS: There were a total of 20 591 youth with IDD and 1 293 791 youth without IDD identified. Youth with IDD had higher odds of being dispensed pain medications, amoxicillin, salbutamol, levothyroxine and all the psychotropic medications (antidepressants, antipsychotics, anxiolytics, anti-adrenergic agents, mood stabilisers and stimulants). For youth with IDD, 6558 (31.85%) were dispensed two or more different psychotropic medications within a year, compared with 75 963 (5.87%) of youth without IDD. DISCUSSION: Compared to youth without IDD, youth with IDD had significantly higher odds of being dispensed most of the prescription medications studied, including all of the psychotropic medications. They were also twice as likely to be dispensed two or more medications from different classes of psychotropic drugs within the same year. These findings have important implications for the health of people with IDD and for their health care providers.

Population Data BC: Supporting population data science in British Columbia.

BACKGROUND: Population Data BC (PopData) was established as a multi-university data and education resource to support training and education, data linkage, and access to individual level, de-identified data for research in a wide variety of areas including human and community development and well-being. APPROACH: A combination of deterministic and probabilistic linkage is conducted based on the quality and availability of identifiers for data linkage. PopData utilizes a harmonized data request and approval process for data stewards and researchers to increase efficiency and ease of access to linked data. Researchers access linked data through a secure research environment (SRE) that is equipped with a wide variety of tools for analysis. The SRE also allows for ongoing management and control of data. PopData continues to expand its data holdings and to evolve its services as well as governance and data access process. DISCUSSION: PopData has provided efficient and cost-effective access to linked data sets for research. After two decades of learning, future planned developments for the organization include, but are not limited to, policies to facilitate programs of research, access to reusable datasets, evaluation and use of new data linkage techniques such as privacy preserving record linkage (PPRL). CONCLUSION: PopData continues to maintain and grow the number and type of data holdings available for research. Its existing models support a number of large-scale research projects and demonstrate the benefits of having a third-party data linkage and provisioning center for research purposes. Building further connections with existing data holders and governing bodies will be important to ensure ongoing access to data and changes in policy exist to facilitate access for researchers.

The quick and the dead: "managing" inpatient care in British Columbia hospitals, 1969-1995/96.

OBJECTIVE: To examine changes in hospital use in British Columbia during a decade of capacity reductions. DATA SOURCES/STUDY SETTING: The data used are all separation records for British Columbia hospitals for the years 1969, 1978, 1985/86, 1993/94, and 1995/96. Separation records include acute care, rehabilitation, extended care, and surgical day care hospital encounters in British Columbia that were concluded during the years of interest. STUDY DESIGN: Analyses were based on per capita use of services for five-year age groups of the population to ages 90+; the emphasis was on looking at changes in the use of specific types of hospital services over the 26 years of study, with a particular focus on the most recent decade. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from hospital separations files owned by the British Columbia Ministry of Health and housed at the Centre for Health Services and Policy Research. All separation records for the years of interest were included in the study. PRINCIPAL FINDINGS: Acute care use continued to fall over the last decade. The rate of decline increased during the last time period of study and affected seniors to the same degree as younger patients. At the same time, use of extended care decreased, compared to steady increases in earlier years. The result was that by 1995/96 nearly 40 percent of inpatient days were used by people who died in hospital, compared to 9 percent in 1969. These people, however, still represent a small proportion of separations. CONCLUSIONS: The "bed blocker" problem common to many hospital systems appears to have been largely alleviated in British Columbia over the decade 1985-95. The concurrent decrease in extended care use, however, makes it difficult to say where and how these people are now being cared for. Care for the dying has become a bigger issue for hospitals, but whether this is because of heroic interventions at the end of life is not clear. A "top-down," capacity-driven management approach to hospital use in British Columbia has produced effects that may seem familiar to those involved in more "bottom-up" managed care approaches in the United States.

Prescription of methylphenidate to children and youth, 1990-1996.

BACKGROUND: There are concerns about the frequency and appropriateness of psychostimulant drug prescription to children. In order to identify unusual or unexpected patterns of use or prescribing, we reviewed prescription of methylphenidate (Ritalin) to children and adolescents aged 19 years or less in British Columbia between 1990 and 1996. METHODS: We obtained information about patients, physicians and prescriptions from British Columbia's Triplicate Prescription Program database for controlled drugs. Prescription data were available for the period Jan. 1, 1990, to Dec. 31, 1996. Linkage with the BC Linked Health Dataset provided additional demographic and health information. RESULTS: In 1990, 1715 children received at least 1 prescription for methylphenidate (1.9 per 1000 children). By 1996, the number had increased to 10,881 children (11.0 per 1000). Because some children were prescribed methylphenidate in more than 1 year, we also calculated the frequency with which the drug was prescribed to children who had never received it before. This rate increased from 1.0 per 1000 children in 1990 to 4.7 per 1000 in 1995; the rate fell in 1996 to 3.5 per 1000. The number of children receiving methylphenidate varied across health regions of the province, from 12.0 to 35.4 per 1000. Use also varied by socioeconomic status quintile: in the 2 lowest (least privileged) quintiles, 21.6 per 1000 children received methylphenidate, compared with 18.4 per 1000 in the 3 highest quintiles (relative risk 1.2, 95% confidence interval 1.1-1.2). Pediatricians and psychiatrists wrote 23% and 21% of all prescriptions respectively. General practitioners accounted for 56% of all prescriptions and 41% of initial methylphenidate prescriptions. A claim for prior specialist consultation was found in 30% of such cases. Many of the children who received more than 10 prescriptions had seen 4 or more physicians. The average daily dosage prescribed differed little among general practitioners, pediatricians and psychiatrists, unlike the mean interval between successive prescriptions: 89.9 (standard deviation [SD] 68.2), 99.8 (SD 64.1) and 75.9 (SD 70.2) days respectively. Persistence with therapy was more likely when a psychiatrist provided the initial prescription, or with involvement of more than one specialty. INTERPRETATION: Many trends and practices in the prescription of methylphenidate to children in British Columbia are consistent with other settings and accepted standards. Some aspects warrant closer investigation, including regional and socio-economic discrepancies in the distribution of patients, the relative involvement of primary and specialist care providers, continuity of care issues and time intervals between prescriptions.

Hospital downsizing and trends in health care use among elderly people in British Columbia.

BACKGROUND: There has been considerable downsizing of acute care services in British Columbia over the past 2 decades. In this population-based study we examined changes in the proportion of elderly people who used acute care, long-term care and home care services between 1986-1988 and 1993-1995 to explore whether the downsizing has influenced use. Changes in death rates were also examined. METHODS: The British Columbia Linked Health Database was used to select all British Columbia residents aged 65 years, 75-76 years, 85-87 years or 90-93 years as of Jan. 1, 1986 (cohort 1), and Jan. 1, 1993 (cohort 2). Each person was assigned to 1 of 6 mutually exclusive categories of health care use reflecting different intensities of use (i.e., hospital, long-term or home care). The proportions of people within each category were compared between the 2 periods, as were the age-standardized death rates. RESULTS: There were 79,175 people in cohort 1 and 92,320 in cohort 2. Overall, the relative proportion of people in each use category was similar between the 2 study periods. The most substantial changes were an increase of 2 percentage points in the proportion of people who received no facility or home care services and a decrease of 2 to 3 percentage points in the proportion who received some acute care but no facility-based continuing care. The age-adjusted all-cause death rates for the earlier and later cohorts were virtually identical (15.7% and 15.8% respectively), although the rate increased from 63.6% to 70.1% among those in the "full-time facility with acute care" group. INTERPRETATION: Overall changes in health care use were small, which suggests that the repercussions of the decline in acute care services for elderly people have been minimal. The higher age-adjusted death rates in the later cohort in full-time care suggests that long-term stays are becoming reserved for a sicker group of elderly people than in the past.

Mortality rates after cataract extraction.

Senile cataract may be a marker of generalized tissue aging. We examined this hypothesis using population-based linked health data. We hypothesized that any such association would diminish with increased use of cataract surgery. Mortality rates of those 50-95 years of age undergoing cataract surgery in British Columbia during either 1985 or 1989 were compared with the provincial population of comparable age who did not undergo cataract surgery during the study period. The 1985 cohort included 8,262 patients undergoing surgery and a comparison population of 804,303, and the 1989 cohort included 11,952 patients and a comparison population of 839,393. Using Cox regression, for the 1985 cohort, the hazard ratios for dying during follow-up were 3.2 for males 50-54.9 years of age [95% confidence limits (CL) = 2.0, 5.0] and 3.3 for females (95% CL = 1.9, 5.7). Hazard ratios for older age groups decreased with age. We also fit an additive risk model that produced excess mortalities that were less age dependent. In the 1985 analysis, these ranged from +7.1 per 1,000 (95% CL = +0.44, +13.76) to +20.3 (95% CL = +13.24, +27.36) for males and -17.5 (95% CL = -28.28, -6.72) to +2.0 (95% CL = -2.12, +6.12) for females. Findings for the 1989 analyses were similar, indicating that the association between cataracts and generalized aging remained constant despite a large increase in the use of cataract surgery.

Lung carcinoma presenting as metastasis to intracranial meningioma: case report and review of the literature.

Tumor-to-tumor metastasis is rare. The authors report a case of a 52-year-old man with a 1-year history of a right parasaggital meningioma, whose clinical signs were consistent with enlarging meningioma. In preparation for surgery, the routine preoperative chest radiograph revealed a lung mass. Fine-needle aspiration of the mass revealed adenocarcinoma. The patient underwent surgical excision of the intracranial mass, which was thought to be a meningioma. However, pathologic examination revealed a transitional meningioma extensively infiltrated with deposits of metastatic carcinoma from the patient's primary lung tumor. Metastasis to meningioma was therefore responsible for the rapid enlargement of the long-standing meningioma, and caused the first clinical manifestation of primary lung carcinoma. Recurrent metastasis developed at the surgical site 5 weeks later, requiring surgical excision and postoperative radiation to prevent further recurrence. This is a highly unusual presentation for lung carcinoma and, to the authors' best knowledge, is the first such case reported. A review of the published literature revealed 20 other cases of lung carcinoma metastatic to meningioma, which were incidentally discovered on surgery or autopsy.

Saphenous vein interposition graft for recurrent carotid stenosis after prior endarterectomy and stent placement. Case report.

Although the use of carotid artery stents is increasing, the management of recurrent stenosis after their placement is undefined. The authors report on a patient who underwent two left carotid endarterectomies followed by left carotid angioplasty and stent placement for recurrent stenosis. A third symptomatic recurrence was subsequently managed by placement of a saphenous vein interposition graft from the common carotid artery to the distal cervical internal carotid artery. The patient remained without hemispheric or retinal ischemia at his 5-month follow-up visit. Interposition grafting should be considered as a treatment option for carotid restenosis after initial endarterectomy and stent placement.

Intraoperative use of electroencephalography as an assessment of cerebral blood flow.

The electroencephalogram (EEG) is exquisitely sensitive to decreases in cerebral blood flow (CBF). The EEG can detect cerebral ischemia in the awake and generally anesthetized patient. EEG monitoring of CBF during carotid endarterectomy alerts the surgeon to the need for a shunt. In the surgery of intracranial aneurysms, it can detect cerebral ischemia secondary to temporary vessel occlusion or determine the optimal anesthetic doses for brain protection.

The surgical management of benign intracranial meningiomas and acoustic neuromas in patients 70 years of age and older.

Over a 22-year-period (1967-1989) 80 patients 70 years of age and older underwent surgery for resection of a benign intracranial tumor. This group included 56 meningiomas and 24 acoustic neuromas. Forty-five of the tumors were completely excised, whereas 35 were partially removed. Tumor regrowth was documented in seven patients during the follow-up period, five of whom underwent additional surgery for resection of recurrent tumor. Thirty-six (64.3%) of the patients with meningiomas had only a minimal or no preoperative neurologic deficit, whereas twenty (35.7%) had a major deficit. Fifty-three (94.6%) patients who underwent surgery for resection of their meningioma made a good recovery (48 were improved or unchanged and five had minimal nonincapacitating worsening), one (1.8%) was worse, and two (3.6%) died. Fourteen (58.3%) of the patients with acoustic neuromas had only a minimal or no preoperative neurologic deficit, whereas 10 (41.7%) had a major deficit. Twenty-two (91.7%) of the patients who underwent surgery for resection of their acoustic neuroma made a good recovery (18 were improved or unchanged and four had minimal nonincapacitating worsening), two (8.3%) were worse, and none died. We conclude that, when indicated, surgery for intracranial meningiomas and schwannomas can be offered to patients 70 years of age and older with acceptable morbidity and mortality.

Intracranial dissection of the distal middle cerebral artery as an uncommon cause of distal cerebral artery aneurysm. Case report.

An aneurysmal dissection of a right middle cerebral artery (MCA) branch is described in a 56-year-old woman. The abnormality was an incidental finding on computerized tomography and subsequently appeared on magnetic resonance imaging performed to evaluate the patient for subjective pulsatile tinnitus. The intracranial aneurysm was documented to have enlarged on serial angiography over a 6-week interval. Treatment was believed to be necessary because of the unknown etiology of the aneurysm, with the differential diagnosis including mycotic or neoplastic aneurysm with a risk of hemorrhage. The lesion was excised and flow to the distal MCA branch was preserved with an anastomosis of the superficial temporal artery to the MCA. The aneurysm, which developed at the level of the sylvian fissure, proved on pathological study to be related to a focal dissection of the MCA branch. The radiographic appearance and pathological findings are presented. Focal dissection must henceforth be included in the differential diagnosis of peripheral cerebral artery aneurysms.

Ventriculoatrial shunt distal catheter placement using transesophageal echocardiography: technical note.

Accurate placement of the distal end of a ventriculoatrial shunt at the cavo-atrial junction is important for long-term shunt function as well as for avoiding cardiac arrhythmias, thrombus formation, and damage to myocardial tissue. Standard methods of intraoperative localization, including chest x-ray, pressure measurements, and electrocardiogram recording, can be inaccurate. By using intraoperative transesophageal echocardiography, the distal end of the catheter can be localized to the cavo-atrial junction.

Discoordinate regulation of isoforms of Na,K-ATPase and myosin heavy chain in the hypothyroid postnatal rat heart and skeletal muscle.

During postnatal life, many contractile and electrophysiological properties of the rat heart undergo changes. Among the changes is a switch in the expression of Na,K-ATPase catalytic subunit isoforms. Thyroid hormone has been postulated to play an important role in the postnatal transformation of the heart, and its effect on myosin heavy chain isoform gene transcription is well documented. To test whether it controls Na,K-ATPase gene switching in vivo, we made neonatal rats hypothyroid by maternal treatment with methimazole. The expression of Na,K-ATPase catalytic subunit isoforms in cardiac and skeletal muscle membranes was measured with specific antibodies at time points from birth to 4 weeks of age. Postnatal changes in Na,K-ATPase isoform expression in cardiac ventricle and hind limb skeletal muscle were similar in control and hypothyroid animals. In the same hypothyroid animals, the postnatal switch from the V3 (beta) isoform of myosin heavy chain to the V1 (alpha) isoform was blocked. The conclusion is that thyroid hormone may have a modulatory role in Na,K-ATPase gene expression, but it is not the developmental signal that dominates gene switching.

Immunofluorescent localization of three Na,K-ATPase isozymes in the rat central nervous system: both neurons and glia can express more than one Na,K-ATPase.

In the CNS, there are multiple isozymes of the sodium and potassium ion-stimulated adenosine triphosphatase (Na,K-ATPase) that have differences in affinity for Na+, ATP, and cardiac glycosides. Three forms of the catalytic subunit (designated alpha 1, alpha 2, and alpha 3) are known to be derived from different genes, but little is known of the cellular distributions of the proteins or their physiological roles. Isozyme-specific monoclonal antibodies permitted the immunofluorescent localization of the 3 Na,K-ATPases in the rat CNS, and markedly different patterns of staining were seen. All 3 isozymes were detected, singly or in combination, in 1 or more neuronal structures, while both alpha 1 and alpha 2 were detected in glia. Many different neuroanatomic structures or cell types stained for more than 1 isozyme. Even when a structure or region stained for more than 1 isozyme, the pattern of staining was frequently dissimilar, suggesting complex differences in gene expression and cellular localization.

Lymphocytic adenohypophysitis of pregnancy with complete recovery.

A case of lymphocytic adenohypophysitis in a postpartum woman who became symptomatic during her 8th month of pregnancy is presented. The clinical presentation, endocrine findings, pathological findings, and operative management are discussed. Transient hypopituitarism is documented. Unlike most previously published cases, this woman had complete recovery of anterior pituitary function.

Aneurysm of the ICA petrous segment treated by balloon entrapment after EC-IC bypass. Case report.

A 44-year-old man experienced the sudden onset of horizontal diplopia and hemifacial numbness. Arteriography demonstrated a left intrapetrous carotid artery aneurysm. The patient was successfully treated with a left superficial temporal artery to middle cerebral artery bypass followed by balloon entrapment of the aneurysm. There have been at least 40 previously reported cases of aneurysms of the petrous portion of the carotid artery. These aneurysms can be mycotic, traumatic, or developmental in origin. They can present with massive otorrhagia or epistaxis from acute rupture or with decreased hearing and paresis of the fifth through eighth cranial nerves and, less frequently, of the ninth, 10th, and 12th cranial nerves caused by direct pressure. They can also produce pulsatile tinnitus, and sometimes they are discovered as a retrotympanic vascular mass during otological examination. The treatment of choice is carotid artery occlusion. Trapping of the aneurysm by detachable balloons eliminates immediately the risk of hemorrhage, offers the possibility of test occlusion of the internal carotid artery with the patient awake prior to permanent occlusion, and should also reduce the risk of thromboembolism. It should be preceded by a bypass procedure when preliminary evaluation indicates that the patient will not tolerate internal carotid artery occlusion.