Pulsatile luteinizing hormone secretion in the ovariectomized, thyroidectomized red deer hind following treatment with dopaminergic and opioidergic agonists and antagonists

Two experiments were conducted to determine whether dopaminergic or opioidergic pathways are modulated by thyroid gland secretions for seasonal suppression of LH secretion in red deer hinds. Ovariectomized (n = 5) or ovariectomized and thyroidectomized (n = 4) hinds, treated with estradiol implants, received the dopamine agonist bromocriptine or the antagonist sulpiride during pulse bleeds in July (breeding season) and October (nonbreeding season). Comparison of July and October mean plasma LH concentration (3.5 +/- 1.3, 0.7 +/- 0.1 ng/ml, respectively), pulse frequency (1.9 +/- 0.4, 0.7 +/- 0.2 pulses/4 h), and pulse amplitude (1.3 +/- 0.5, 0.7 +/- 0. 02 ng/ml) showed lower (p < 0.05) levels in October, and these levels were not significantly affected by thyroidectomy or drug treatment. In the absence of estradiol implants, the hinds received bromocriptine or morphine during the breeding season (July) and their antagonists, sulpiride or naloxone, respectively, in the nonbreeding season (November). In euthyroid hinds there was a seasonal decrease (p < 0.05) in mean plasma LH concentration, pulse frequency, and pulse amplitude, which did not occur in thyroidectomized hinds. There were no effects of drug treatment on LH concentration except for a small increase following sulpiride in November. Plasma prolactin concentration was significantly increased by antagonists and decreased by agonists on most occasions. We conclude that in red deer hinds, seasonal regulation of LH secretion does not involve dopamine or endogenous opioids and the thyroid gland is required specifically for LH suppression in the absence of estradiol.

Hospitalizations for back and neck problems: a comparison between the Province of Ontario and Washington State

OBJECTIVE

To examine back and neck hospitalizations in the Province of Ontario and Washington State. Because of their different organization and financing, there has been considerable interest in comparing healthcare systems in Canada and the United States. Features of healthcare systems might be expected to result in greater variations in care for elective than urgent conditions.

DATA SOURCE

Automated hospital discharge databases.

STUDY DESIGN

Previously developed algorithms were used to identify surgical and nonsurgical hospitalizations for back and neck problems in the administrative databases. We compared overall rates of hospitalization and lengths of hospital stay in Ontario and Washington as well as small area variations within the province and state.

PRINCIPAL FINDINGS

Surgical back and neck hospitalizations were three times as common in Washington, but medical hospitalizations were twice as common in Ontario. Provincial lengths of stay were longer for both surgical and nonsurgical hospitalizations. Admission rates varied substantially and significantly among small areas in both Washington and Ontario. Variations in hospital length of stay were greater in Ontario, particularly for nonsurgical back and neck hospitalizations.

CONCLUSION

The two jurisdictions had very different patterns of hospital utilization for one of the most common health problems seen by physicians. Our results suggest that the global controls on hospital budgets and access to technology in Ontario were associated with lower rates of surgery, higher rates of hospital-based medical care, and longer lengths of stay. They also indicate that the utilization review process in Washington was associated with lower small area variation rates for medical back care.

Peripheral serotonin measures in prepubertal psychiatric inpatients and normal children: associations with suicidal behavior and its risk factors

BACKGROUND

This study reports relationships between suicidal behavior and its risk factors in prepubertal children and whole blood and platelet serotonin-related measures.

METHODS

Seventy-five prepubertal psychiatric inpatients including 23 (30.7%) nonsuicidal, 32 (42.7%) with suicidal ideation, and 20 (26.6%) with a suicide attempt were compared to 35 normal prepubertal controls with regard to platelet serotonin content, serotonin-amplified platelet aggregation, and whole blood tryptophan.

RESULTS

Mean whole blood tryptophan content was significantly lower among inpatient children with a recent suicide attempt than among normal controls or inpatients with suicidal ideation (F = 3.94, df = 3.54, p < or = .01). Inpatient children with a mood disorder had significantly higher platelet serotonin content than inpatients without a mood disorder (F = 3.86, df = 2.80, p < or = .03). Racial/ethnic differences were also observed for inpatients and normal controls, with whites having significantly lower levels of platelet serotonin (expressed as ng/mL blood or ng/10(9) platelets) than blacks or Latinos. Blacks had significantly higher levels of whole blood tryptophan than other racial/ethnic groups.

CONCLUSIONS

The results suggest that whole blood tryptophan and platelet serotonin content should be studied for their predictive validity as risk factors for suicidal behavior in youth while controlling for racial/ethnic differences.

A double-blind, placebo-controlled, crossover trial of an antiandrogen in the treatment of Tourette's syndrome

The objective of this study was to document the effects of androgen receptor blockade on tic and obsessive-compulsive symptoms in Tourette's syndrome (TS) patients. Thirteen adult TS subjects, 10 men and 3 women, completed 3 weeks of each phase of a double-blind, placebo-controlled, crossover trial of flutamide, a selective androgen receptor antagonist. Symptom severity ratings and hormone levels were obtained at each of the trial's six clinic visits. Flutamide was well-tolerated and produced a significant reduction in motor but not phonic tic symptom severity. It modestly improved symptoms of obsessive-compulsive disorder in the men who had this disorder. Changes in hormone levels during flutamide administration provided evidence for the existence of physiologic mechanisms that compensate for the blocking of the androgen receptor. The therapeutic effects of flutamide are modest in magnitude and they seem to be short-lived, possibly because of physiologic compensation for androgen receptor blockade. Given the potentially serious side effects of flutamide, the use of this agent in the treatment of tics should be reserved for patients who have relatively debilitating symptoms. The therapeutic and endocrine findings may have implications for understanding the sex differences in TS prevalence and the sex-specific variability in the phenotypic expression of the putative TS vulnerability genes.

Effects of thyroidectomy and thyroxine replacement on seasonal reproduction in the red deer hind

Two experiments were conducted to test whether thyroid hormones are required for the cessation of the breeding season in female red deer. In Expt 1, 16 mature hinds were allocated early in the breeding season (May) to the following groups: thyroidectomized (THX), thyroidectomized and treated with subcutaneous thyroxine implants which increased plasma tri-iodothyronine to physiological concentrations (THX + T4), or euthyroid controls. Plasma progesterone concentrations consistent with oestrous cyclicity were evident in all hinds during the breeding season (May-September) but after 23 September plasma progesterone concentrations became generally low (< 2.0 nmol l-1) in control and THX + T4 hinds. In contrast, thyroidectomized hinds not receiving thyroxine continued to exhibit circulating progesterone comparable with breeding season concentrations until the end of the experiment (late December). Nine hinds were ovariectomized or ovariectomized and thyroidectomized in May and treated with subcutaneous oestradiol-impregnated capsules, which were removed for periods of about 1 months during August, November and January, to test whether thyroid hormones are involved in the seasonal decline of LH secretion (Expt 2). In the presence of oestradiol, basal LH concentrations and episodic LH secretion were low during the non-breeding season (September-March) (P < 0.05). During this season, basal and GnRH-induced LH concentrations and LH pulse frequency remained similar for both groups except in the absence of oestradiol, when basal LH (3.1 +/- 0.8 versus 1.3 +/- 0.5 ng ml-1, P < 0.05 and GnRH-induced LH (25.9 +/- 3.6 versus 4.7 +/- 0.4 ng ml-1, P < 0.001) concentrations were higher in thyroidectomized hinds than in euthyroid hinds, respectively. Twenty-five hinds were ovariectomized and thyroidectomized during the breeding season and treated with subcutaneous thyroxine implants at different times to identify when thyroid hormones are required to be present to suppress LH concentrations during the non-breeding season in the absence of oestradiol. Thyroxine treatment at the beginning of or during the non-breeding season was effective in suppressing plasma LH concentration, but this action of thyroid hormones did not occur during the breeding season. These results indicate that, in red deer hinds thyroxine is required for termination of the breeding season and that thyroid gland secretions specifically block steroid-independent inhibition of reproductive activity during the non-breeding season. This inhibitory mechanism requires thyroid hormones to be present only from around the time of the end of the breeding season for their normal expression, and they remain responsive to thyroid hormones after this period.

Effects of diagnosis, race, and puberty on platelet serotonin levels in autism and mental retardation

OBJECTIVE

To reevaluate platelet serotonin (5-HT) levels in autism, measuring and controlling for effects of race and puberty. The specificity of hyperserotonemia for autism versus cognitive impairment is also assessed.

METHOD

Platelet 5-HT levels were measured in 77 individuals, aged 2 through 37 years, with autistic disorder; 65 normal controls; and 22 mentally retarded or otherwise cognitively impaired (MR/CI) prepubertal children. Effects of diagnosis, race, and pubertal status were evaluated by analysis of variance in separate pre- and postpubertal groups. 5-HT levels were expressed as ng/mL blood and ng/microL platelet volume.

RESULTS

Among prepubertal children, significant effects of diagnosis (ng/mL; F2,109 = 5.9, p = .004) and race (F2,109 = 14.7, p < .0005) were found. Autistic youngsters had significantly higher 5-HT concentrations than controls, although the elevation (25%) was less than typically reported; MR/CI children had levels very similar to those of controls. White children had significantly lower 5-HT levels than black or Latino youngsters, regardless of diagnosis. Diagnosis and race effects were nonsignificant in the postpubertal group. Postpubertal subjects had lower 5-HT concentrations than prepubertal subjects (ng/mL; F1,114 = 28.5, p < .0005).

CONCLUSIONS

The data underscore the importance of matching for race and pubertal status in neuropsychiatric research and suggest that the prevalence of hyperserotonemia in autistic individuals may have been overestimated because of a failure to control for both variables. Hyperserotonemia was not found in MR/CI youngsters without autistic features.

Tryptophan depletion during continuous CSF sampling in healthy human subjects

The tryptophan (TRP) depletion paradigm has been employed to investigate mood and behavioral effects of acutely lowering plasma TRP, and presumably brain serotonin (5-hydroxytryptamine [5-HT]) levels through administration of a special diet and/or amino acid drink. Our goal was to test the assumption that a corresponding fall in central levels of TRP and 5-HT (measured by its major metabolite, 5-hydroxyindoleacetic acid [5-HIAA]) occurs during the standard execution of this method in healthy adult subjects. Three males and two females completed the protocol, which included a one-day low-TRP diet and a TRP-free amino acid drink. Lumbar puncture was performed, with placement of an indwelling catheter connected to a peristaltic pump and fraction collector. Cerebrospinal fluid (CSF) was sampled continuously for a 13.5-hour period (before, during, and after the drink), with fractions removed every 15 minutes. Plasma samples were simultaneously obtained. CSF TRP levels and plasma TRP levels were highly correlated, falling a mean of 92% and 85% from baseline, respectively. CSF nadirs were reached several hours after plasma nadirs. CSF 5-HIAA decreased modestly (24% to 40%, mean 31% change from baseline), with lowest concentrations observed 8-12 hours after the amino acid drink. These data suggest that TRP depletion results in substantial declines in central 5-HT turnover.

Dopamine beta-hydroxylase: two polymorphisms in linkage disequilibrium at the structural gene DBH associate with biochemical phenotypic variation

Levels of the enzyme dopamine beta-hydroxylase (DbetaH) in the plasma and cerebrospinal fluid (CSF) are closely related biochemical phenotypes. Both are under strong genetic control. Linkage and association studies suggest the structural gene encoding DbetaH (locus name, DBH) is a major locus influencing plasma activity of DbetaH. This study examined relationships of DBH genotype determined at two polymorphic sites (a previously described GT repeat, referred to as the DBH STR and a single-base substitution at the 3' end of DBH exon 2, named DBH*444 g/a), to CSF levels of DbetaH protein in European-American schizophrenic patients, and to plasma DbetaH activity in European-American patients with mood or anxiety disorders. We also investigated linkage disequilibrium (LD) between the polymorphisms in the pooled samples from those European-American subjects (n=104). Alleles of DBH*444 g/a were associated with differences in mean values of CSF DbetaH levels. Alleles at both polymorphisms were associated with plasma DbetaH activity. Significant LD was observed between respective alleles with similar apparent influence on biochemical phenotype. Thus, allele A3 of the DBH STR was in positive LD with DBH*444a, and both alleles were associated with lower plasma DbetaH activity. DBH STR allele A4 was in positive LD with DBH*444 g, and both alleles were associated with higher plasma DbetaH activity. The results confirm that DBH is a major quantitative trait locus for plasma DbetaH activity, and provide the first direct evidence that DBH also influences CSF DbetaH levels. Both polymorphisms examined in this study appear to be in LD with one or more functional polymorphisms that mediate the influence of allelic variation at DBH on DbetaH biochemical phenotypic variation

Fee code creep among general practitioners and family physicians in Ontario: why does the ratio of intermediate to minor assessments keep climbing?

BACKGROUND

"Fee code creep" is the increasing tendency of primary care physicians in Ontario to bill for more intermediate than minor assessments over time. The authors examine the extent and nature of fee code creep and describe physician characteristics associated with the changes.

METHODS

A cross-sectional and longitudinal analysis of Ontario Health Insurance Plan billing and physician characteristic data was conducted for fee-for-service general practitioners and family physicians (GP/FPs) in Ontario. The ratio of intermediate to minor assessments (I-M ratio) was determined for the period 1978-79 to 1994-95, and the relation of various physician characteristics to high ratios was tested with bivariate and multivariate analysis.

RESULTS

The I-M ratio rose 10-fold, from 0.3 in 1978-79 to 2.9 in 1994-95. Although the I-M ratio was higher for older patients and young children, changes in population age profile over time did not account for any of the increase. The median ratio varied widely among groups of physicians: urban physicians had higher ratios than rural ones (3.9 v. 3.0, p < 0.05), and recent graduates had higher ratios than physicians 60 years of age or older (5.1 v. 2.9, p < 0.05). The I-M ratio was inversely related to number of visits; physicians billing for fewer than 5000 visits had a median ratio of 4.2, whereas those billing for 20,000 visits or more had a median ratio of 1.6.

INTERPRETATION

Fee code creep has contributed to expenditure growth in Ontario. This phenomenon was related to both an increase in I-M ratio over time among physicians practising throughout the study period and an influx of new physicians billing at a higher ratio. Creep was not the result of aging of the population.

High-billing general practitioners and family physicians in Ontario: how do they do it? An analysis of practice patterns of GP/FPs with annual billings over $400,000

BACKGROUND

To better understand the reasons why some fee-for-service physicians have high billing levels, the authors compared the practice and demographic characteristics of general practitioners and family physicians (GP/FPs) who submitted over $400,000 in annual Ontario Health Insurance Plan (OHIP) fee-for-service claims in 1994-95 with those of GP/FPs who billed between $35,000 and $400,000.

METHODS

The authors describe the OHIP billing and physician characteristic data for fiscal year 1994-95. They used multivariate logistic regression to determine factors independently associated with high billing status.

RESULTS

A total of 219 GP/FPs (2.5% of the GP/FPs in Ontario) billed over $400,000 in 1994-95. Of these, 14 had billing patterns similar to those of specialists, and 27 billed predominantly for diagnostic and therapeutic procedures (particularly physiotherapy). The remaining 178 (81.3%) billed for a mix of services similar to that of other GP/FPs but on average had 2.6 times the volume of patient assessments and a greater share of their total billings derived from diagnostic and therapeutic procedures (9.1% v. 5.6%). Multivariate analysis indicated that these high-volume GP/FPs were less likely than GP/FPs who billed between $35,000 and $400,000 to be 60 years of age or older (odds ratio [OR] 0.09, p < 0.05) and female (OR 0.21) and were more likely to be foreign graduates (OR 1.85) and practising in a region with low physician supply (OR 0.45 for each increase of 1 physician per 1000 population). Metropolitan Toronto was an outlier to the latter relation and was more likely to have high-volume GP/FPs (OR 16.89).

INTERPRETATION

High-billing GP/FPs attained their high billing levels by maintaining large numbers of patient visits and by performing procedures. Further research is needed to determine the time spent per patient and the quality of care delivered by these physicians as well as the appropriateness of the procedures that they perform.

Free-standing health care facilities: financial arrangements, quality assurance and a pilot study

Free-standing health care facilities now deliver many diagnostic and therapeutic services formerly provided only in hospitals. The financial arrangements available to these facilities differ according to whether the services are uninsured or insured. For an uninsured service, such as cosmetic surgery, the patient pays a fee directly to the service provider. For an insured service, such as cataract surgery, the provincial government uses tax revenues to fund the facility by paying it a facility fee and remunerates the physician who provided the service with a professional fee. No comprehensive, proactive quality assurance efforts have been implemented for either these facilities or the clinical practice provided within them. A pilot study involving therapeutic facilities in Ontario has suggested that a large-scale quality improvement effort could be undertaken in these facilities and rigorously evaluated.

Trends in hospital use for mechanical neck and back problems in Ontario and the United States: discretionary care in different health care systems

OBJECTIVE

To describe and compare trends in hospital admission rates for mechanical neck and back problems between 1982 and 1992 in Ontario and the United States.

DESIGN

A descriptive analysis of hospital admissions, with data for Ontario extracted from the Canadian Institute for Health Information database and data for the US extracted from the National Hospital Discharge Survey.

SETTING

All acute care hospitals in Ontario and a probability sample of acute care hospitals in the US.

PATIENTS

Adults aged 20 years or more who were admitted to an acute care hospital for mechanical neck or back problems in 1982, 1987 or 1992. Mechanical neck and back problems were defined using an algorithm developed by the study team.

OUTCOME MEASURE

Hospital admission rate per 100,000 adults.

RESULTS

Between 1982 and 1992 the hospital admission rate for medically treated cases decreased by 52% in Ontario and by 75% in the US. Over the same period the admission rate for surgically treated cases increased by 14% and by 35% respectively. By 1992 the admission rate for medically treated cases in the US was 23% higher than that in Ontario, whereas the rate for surgically treated cases was 164% higher.

CONCLUSIONS

The hospital-based medical or surgical treatment of mechanical neck and back problems provides an example of discretionary care. The higher admission rates for surgery in the US may reflect a larger supply of surgical specialists and imaging units. Further work is needed to confirm these findings for other types of discretionary care and to compare the appropriateness of care and clinical outcomes for discretionary care in these 2 jurisdictions.

Celestial marriage and earthly rents: interests and the prohibition of polygamy

Just prior to the Civil War, the US government set out on a relentless campaign to eliminate polygamy within the Mormon Church. This paper offers evidence that the political restrictions on the practice of polygamy were the result of rent seeking by potential beneficiaries of such laws (the Edmonds Act of 1882). Polygamy created benefits for women, but reduced the welfare of most men, in a time period when only adult males had the franchise.

Auditing prescription practice using explicit criteria and computerized drug benefit claims data

Bringing information on patterns of existing practice together with information on appropriate practice is an essential component of efforts to improve health care. In this study, computerized claims from a universal and comprehensive drug benefit plan for the elderly were brought together with explicit criteria for appropriate prescribing in the elderly in order to provide an estimate of the extent of potentially inappropriate prescribing in the covered population and the degree to which inappropriate prescribing was associated with defined physician characteristics. The analysis showed that 38% of elderly people who received antidepressants, 19% of those who received oral hypoglycemics, 18% of those who received sedative hypnotics and 13% of those who received non-steroidal anti-inflammatory drugs were defined as having received a potentially inappropriate drug. Older physicians and physicians without speciality certification were more likely to prescribe potentially inappropriate drugs. This analysis shows that criteria-based audits of drug claims databases can be used to provide an overview of prescribing problems at a population level and can reveal physician characteristics that may predict poor prescription practice. However, since neither explicit criteria nor claims databases can accurately capture the clinical details that ultimately define the appropriateness of care, audits of claims data should be linked to a more definitive measure of appropriateness and strategies designed to improve care.

Carbonyl histochemistry in rat reperfusion nerve injury

Free radical mediated, site-specific lipid and protein oxidation has been implicated in the pathophysiology of an ischaemic/reperfusion injury. The aim of the present study was to determine whether carbonyl formation could be detected histochemically in reperfused rat sciatic nerves. We also examined the effects of preischaemic alpha-tocopherol supplementation on carbonyl formation in reperfused nerves. Seven hours of near-complete ischaemia was induced in rat right hindlimb by occlusion of major arteries using microvascular clips. Histochemical detection of carbonyl compounds, applying naphthoic acid hydrazide (NAH) and Fast Blue B (FBB), was undertaken at thigh, knee and calf levels of sciatic, tibial and peroneal nerves. NAH-FBB reactivity was confined to vessels in reperfused nerves. Positively stained epi-, peri- and endoneurial vessels were invariably observed after 2 h of reperfusion at all levels examined. After 24 and 48 h and 7 days of reperfusion, NAH-FBB-positive vessels were more frequently found at knee and calf levels than at the thigh level. Following preischaemic alpha-tocopherol supplementation, no vessels were stained positively with NAH-FBB, except for some epineurial vessels at knee and calf levels after 2 h of reperfusion. Morphometry in endoneurial vessels at the knee level revealed that endothelial cell area in alpha-tocopherol-treated reperfused nerves was significantly less when compared with those in reperfused nerves without alpha-tocopherol. In conclusion, we have demonstrated histochemical evidence of carbonyl formation in vessels, but not with nerve fibres, in ischaemic/reperfused rat sciatic nerves. These abnormalities were prevented with preischaemic supplementation of alpha-tocopherol.

Hospital restructuring and the epidemiology of hospital utilization: recent experience in Ontario

OBJECTIVES

The author highlights changes in hospital utilization that have occurred in association with restructuring of Ontario hospitals. The basic features of the epidemiology of hospital utilization described link the analysis of the organizational and structural components of hospitals with a more comprehensive evaluation of the impacts of their restructuring and have implications for international comparative studies.

METHODS

Data from the Canadian Institute for Health Information and the Canadian census were analyzed to provide a population-based description of hospital utilization and care. These hospital data provided information on changes in the patterns of care that occurred during restructuring, based on hospital separations for the fiscal years 1991-1992 through 1995-1996.

RESULTS

Analysis of hospital utilization patterns revealed a 30% decrease in the days of care provided per 1,000 population during the period, the result of declines in both the age-adjusted inpatient separation rates and average length of hospital stay. The shift of surgical treatment to outpatient settings contributed to the reduction in inpatient days of care. The decline in utilization was experienced unevenly across age groups, with the elderly experiencing less of the decline than did younger age groups. Individuals living in the poorest areas used more inpatient care than did those living in the richest areas, although the gap in utilization narrowed over the period.

CONCLUSIONS

International comparisons of the epidemiology of hospital utilization and the impact of hospital restructuring will require the use of multiple data sources and the development of shared evaluative frameworks. Health data systems in Canada support the assessment of the broader impacts of hospital restructuring and offer a framework for developing research projects that can provide useful information on these important changes in health-care policy.

Plasma beta-endorphin, adrenocorticotropin hormone, and cortisol in autism

Plasma levels of the hypothalamo-pituitary-adrenal axis hormones beta-endorphin (BE), adrenocorticotropin hormone (ACTH), and cortisol were measured in autistic (N = 48), mentally retarded/cognitively impaired (MR/CI, N = 16), and normal control (N = 26) individuals. Comparison of log transformed data from the three groups revealed that levels of BE and ACTH were significantly higher (p < .05) in the autistic individuals than in normal controls. The higher means in the autistic group were due to significantly higher plasma levels of BE and ACTH, indices of acute stress response, in the more severely affected individuals. The data support the idea that individuals with severe autism have a heightened response to acute stressors rather than chronic hyperarousal or elevated basal stress response system functioning.

Epithelial antibiotic induced in states of disease

Epithelial defensins provide an active defense against the external microbial environment. We investigated the distribution and expression of this class of antimicrobial peptides in normal cattle and in animals in varying states of disease. beta-defensin mRNA was found to be widely expressed in numerous exposed epithelia but was found at higher levels in tissues that are constantly exposed to and colonized by microorganisms. We observed induction in ileal mucosa during chronic infection with Mycobacterium paratuberculosis and in bronchial epithelium after acute infection with Pasteurella haemolytica. It has been proposed that expression of antimicrobial peptides is an integral component of the inflammatory response. The results reported here support this hypothesis and suggest that epithelial defensins provide a rapidly mobilized local defense against infectious organisms.

Risperidone treatment of children and adolescents with pervasive developmental disorders: a prospective open-label study

OBJECTIVE

To investigate the short-term safety and efficacy of risperidone in the treatment of children and adolescents with pervasive developmental disorders.

METHOD

This was a 12-week, prospective, systematic, open-label trial that included 18 subjects (15 boys and 3 girls) with a mean age of 10.2 +/- 3.7 years. The sample included 11 subjects with autistic disorder, 3 with Asperger's disorder, 1 with childhood disintegrative disorder, and 3 with pervasive developmental disorder not otherwise specified. Fourteen subjects had comorbid mental retardation. Behavioral ratings were obtained during two baseline visits and again after 12 weeks of risperidone treatment.

RESULTS

The optimal dose of risperidone for the 18 subjects was 1.8 +/- 1.0 mg/day. On the basis of the global improvement item of the Clinical Global Impression Scale, 12 of 18 subjects were considered responders. Significant improvement was seen in measures of interfering repetitive behavior, aggression and impulsivity, and some elements of impaired social relatedness. The most common side effect was weight gain (range 10 to 35 lb).

CONCLUSIONS

These preliminary results suggest that risperidone may be effective for improving interfering behavioral symptoms in some children and adolescents with pervasive developmental disorders. Double-blind, placebo-controlled studies are needed before definitive statements of safety and efficacy can be made.

Neonatal ACTH administration elicits long-term changes in forebrain monoamine innervation. Subsequent disruptions in hypothalamic-pituitary-adrenal and gonadal function

The findings from this study demonstrated that the manipulation of the HPA system resulting from ACTH administration during neonatal development produces long-term, differential effects, not only on adrenocortical activity, but also on the activity and integrity of the forebrain monoamine systems. Increased concentrations of the monoamines within the forebrain regions studied at days 7 and 15, suggest a hastened maturation of these neural systems in animals neonatally treated with ACTH. The observed neurochemical alterations in these animals at one year are suggestive of an accelerated aging in the monoamine systems. A further consequence of these disturbances during development is an altered functioning of the HPG axis, as demonstrated by a delayed onset of puberty as previously reported, as well as significantly decreased proestrus plasma estradiol. Although deficits in sexual behavior also existed, it seems probable that these behavioral changes are a manifestation of altered neural systems regulating the ability to cope with a novel stimulus or situation, rather than a disruption of the "feminization" of the brain during sexual differentiation. This is in contrast to the male rat which exhibits permanent deficits in male typical sexual behavior following developmental ACTH treatment. The clinical relevance of these findings may be extensive. Perinatal exposure to events or agents that markedly increase ACTH and the corticosteroids may cause significant immediate and long-term changes in central monoamine functioning. These changes may constitute some of the most deleterious effects of stress exposure in infants and children. The alterations may be especially devastating in individuals with predispositions to stress-sensitive disorders such as anxiety, depression, and Tourette's syndrome. Finally, the use of ACTH in the treatment of infantile spasms may need to be reassessed in light of the possible long-term effects of ACTH on central monoamine functioning.

On becoming 65 in Ontario. Effects of drug plan eligibility on use of prescription medicines

OBJECTIVES

The authors assess (1) the effects of first-dollar prescription drug insurance coverage provided by the Ontario Drug Benefit plan at age 65 on prescription drug use by seniors, and (2) the differential effects of this coverage on prescription drug use by seniors with varying levels of health status.

METHODS

The authors modeled self-reported prescription drug use contained in the 1990 Ontario Health Survey as a function of eligibility for coverage, controlling for health status and other factors. The two-part model was used and was estimated by maximum likelihood.

RESULTS

The provision of first-dollar prescription drug insurance coverage at age 65 is associated with an increase in drug use. Increases in drug use are, however, concentrated primarily among individuals with lower levels of health status. Most of the increased use occurs among individuals already under physician supervision, ie, an increase in the level of use among drug users rather than an increase in the probability of use.

CONCLUSIONS

As Ontarians turn age 65 and become eligible for publicly subsidized prescription drugs, their use increases but the effect appears to be restricted mainly to persons with lower levels of health status. Given a growing trend toward reduction of public subsidy and increased reliance on patient cost sharing, more research is needed to quantify the use and health effects of such initiatives.

Case selection and appropriateness of coronary angiography and coronary artery bypass graft surgery in British Columbia and Ontario

OBJECTIVES

To compare the types of patients selected for coronary angiography (CA) and coronary artery bypass graft (CABG) surgery, and the appropriateness of the procedures performed on these patients in a random sample of cases in British Columbia and Ontario.

DESIGN

Retrospective randomized medical record review.

SETTING

All hospitals performing CA and/or CABG in British Columbia and Ontario in fiscal year 1989/90.

PATIENTS

For CA, 395 randomly selected patients in Ontario and 139 randomly selected patients in British Columbia; for CABG, 431 randomly selected patients in Ontario and 125 randomly selected patients in British Columbia.

MAIN OUTCOME MEASURES

Case selection was measured in terms of the demographic and clinical characteristics of patients undergoing the procedures. Appropriateness was measured by comparing the clinical characteristics of patients undergoing the procedures with explicit criteria established by a panel of Canadian physicians. The yield from CA was measured as the proportion of patients who were found to have insignificant anatomical disease.

RESULTS

Analysis of patients selected for CA showed that sample patients from Ontario were less likely than those from British Columbia to be female (25% versus 37%, respectively, P = 0.012) and less likely to have undergone a previous revascularization (12% versus 24%, respectively, P = 0.005). The distribution of main indications for CA differed between the two provinces (P = 0.002), with Ontario patients more likely to have chronic stable angina (45% versus 24%) and less likely to have unstable angina (16% versus 26%). For CABG, sample patients from Ontario were less likely to be 65 years of age or older (32% versus 45%, P = 0.016) and more likely to have an ejection fraction less than 35% (14% versus 5%, P = 0.006). The distribution of the main indications for CABG differed (P < 0.001), with Ontario patients more likely to have chronic stable angina (68% versus 38%) and less likely to have unstable angina (20% versus 43%). There was no statistically significant difference in CA cases rated as inappropriate (8.4% in Ontario versus 10.8% in British Columbia, P = 0.396) or CABG cases rated as inappropriate (3.9% in Ontario versus 2.4% in British Columbia, P = 0.393). There were no statistically significant differences in the proportion of CA that yielded insignificant anatomical disease (17.5% in Ontario versus 18.4% in British Columbia, P = 0.355).

CONCLUSIONS

There were differences between Ontario and British Columbia in the demographic and clinical characteristics of patients selected for CA and CABG. This may indicate differences in the referral process in the two provinces. Despite these differences the rates of inappropriate procedures and the yield from CA were similar.