Unique metabolic clinic treats youth for side effects of anti-psychotic drugs

In January 2010, BC Mental Health & Addiction Services opened the Provincial Mental Health Metabolic Clinic at BC Children’s Hospital. The first of its kind in Canada, the clinic was established in response to local research highlighting health concerns among youth who use a certain class of anti-psychotic medications.

Atypical anti-psychotic drugs treat a range of serious mental and behavioural disorders among youth, including schizophrenia, ADHD, autism spectrum disorders and substance abuse. Prescriptions for these medications in youth are increasing, and it’s estimated that up to 5,500 BC youth currently use these drugs.

“There isn’t a clinic similar to what we have here anywhere else in the world.”

Dr. Jana Davidson

However, atypical anti-psychotics are also associated with an increased risk for metabolic disorders such as obesity and type 2 diabetes among adult patients. This knowledge prompted researcher Dr. Dina Panagiotopoulos to look at whether youth faced similar risks.

A chart review of patients admitted to the hospital’s Child and Adolescent Psychiatry Unit revealed that youth treated with atypical medications had three times the risk of developing abnormally high blood sugars (pre-diabetes) or type 2 diabetes and twice the risk of becoming overweight or obese.

Although the long term impacts haven’t been studied, “The concern is that if we don’t intervene early on, these children could develop serious health issues,” says Dr. Jana Davidson, medical director of Child and Adolescent Mental Health Programs at BC Children’s Hospital. “In each child, we need to look at whether the potential risk for side effects outweighs the potential benefits.”

For those whose mental health and quality of life depend on these medications, the new clinic offers the support of a healthy living coach, nutritionist, endocrinologist, nurse and consulting psychiatrist to assess, treat and monitor metabolic issues. The program also offers toolkits and educational resources for health professionals and families, and a provincial database for physicians to monitor their patients’ metabolic health.

Dr. Jana Davidson is medical director of Child and Adolescent Mental Health Programs at BC Children’s Hospital and a clinical associate professor and head of the Child & Adolescent Psychiatry Program at UBC.

Dr. Dina Panagiotopoulos is a clinician scientist and a pediatric endocrinologist at BC Children’s Hospital and assistant professor of endocrinology in UBC’s department of pediatrics.

Study confirms benefit of counselling for patients with sudden kidney failure

Most patients with kidney disease experience a gradual loss of kidney function over many months or years before they need to begin dialysis. However, for about 40 percent of kidney patients the need for dialysis occurs much more quickly, over a few months or weeks, and sometimes literally overnight.

These “parachute patients” don’t have time for the normal process of becoming prepared for dialysis and informed about their dialysis options, which include conventional hemodialysis as well as such independent options as home hemodialysis and peritoneal dialysis (PD) in which the patient manages their own dialysis care.

“There is evidence that independent dialysis modalities can be associated with better clinical outcomes and improved quality of life for patients in comparison with conventional hemodialysis,” says nephrologist Dr. Nadia Zalunardo.

To provide better information about dialysis to parachute patients and ensure more informed dialysis decisions by this patient group, in 2007 pilot project funding was provided by the BC Renal Agency for a dedicated renal triage nurse (RTN) at Vancouver General Hospital.

“Independent dialysis may not only offer better health outcomes for some patients, it’s also a more cost effective approach to dialysis care.”

Dr. Nadia Zalunardo

The effectiveness of the RTN pilot project was evaluated in a recent retrospective study supported by the BC Renal Agency and led by Zalunardo. The study involved 73 parachute patients on conventional hemodialysis, about half of whom received dedicated counselling about their dialysis options from a renal triage nurse (RTN). The other half did not have access to an RTN and received information about their dialysis options through clinic visits or from their doctors.

The study found that 34 percent of the patients who received RTN counselling eventually switched to independent dialysis – either PD or home hemodialysis. By comparison, only 15 percent of parachute patients who did not receive RTN counselling made this switch.

“These results provide strong support for continuing our renal triage counselling program for parachute patients,” says Zalunardo. “Independent dialysis may not only offer better health outcomes for some patients, it’s also a more cost effective approach to dialysis care.”

Dr. Nadia Zalunardo is a nephrologist at Vancouver General Hospital

Childrens’ use of vitamins should be discussed with doctors

When parents bring their sick child in to see a doctor, they expect to be asked about their child’s symptoms, medical history and medication use. But they may be surprised to find their doctor is also concerned about whether their child takes vitamins.

While vitamins are generally safe, the potential effects of their use in children shouldn’t be ignored, according to Dr. Ran Goldman, a clinician scientist at BC Children’s Hospital.

“We know that vitamins have active components that can interact with other over-the-counter or prescribed medications in a way that can create toxicities or present as symptoms of illness,” he explains. “These symptoms could include abdominal pain, fatigue, or unexplained general weakness.”

For example, vitamin C can interact with acetaminophen, which is commonly given to children to reduce fever or manage pain. Acetaminophen remains in the system longer in the presence of vitamin C, which could result in elevated and potentially harmful drug levels.

In interviews with 1,800 patients visiting a pediatric emergency department, Goldman and his colleagues found one-third reported using vitamins and only two-thirds of these patients mentioned it to their doctors. Further, the research team found that among vitamin users, one-third had a potential risk of interactions between the vitamins they used and other medications they were taking. Children with chronic illnesses who regularly take a variety of medications were identified as having the greatest potential risk.

“We know that vitamins have active components that can interact with other medications in a way that can create toxicities or present as symptoms of illness.”

Dr. Ran Goldman

This research has led to more physicians asking their pediatric patients about the use of vitamins and other supplements. The key now, Goldman says, is communicating this information broadly so that more people are aware of the potential risks. “We need to change the perception that because vitamins are natural products, they can have no ill effects.”

Dr. Ran Goldman is research director, head of the division of pediatric emergency medicine and a senior associate clinician scientist at BC Children’s Hospital, and an associate professor in the department of pediatrics at UBC.

Research shows potential danger for babies of nursing mothers who take Tylenol No.3

The most frequently used analgesic for women in Canada and the US following childbirth is Tylenol No.3, which contains codeine. The drug is routinely prescribed to women who receive an episiotomy during delivery or who deliver by caesarean section, and is used by more than half of all women after giving birth.

However, following a mysterious infant death in Ontario in 2006, researchers in Toronto aided by clinical pharmacologist Dr. Bruce Carleton and geneticist Dr. Michael Hayden at the BC Children's Hospital uncovered evidence that Tylenol No.3 is not safe for all breastfeeding mothers.

Asked by the Ontario coroner’s office to explain the death of the infant, the researchers found that the mother’s breast milk contained high levels of morphine. Morphine is produced naturally in the body from codeine through a process of biochemical conversion. Normally, over time the body metabolizes this morphine into a harmless salt that is excreted through the kidneys.
 

Tylenol No. 3 Risk - Up to 19,000 babies born every year in Canada could be at risk from breastfeeding if their mothers use Tylenol No.3 to manage post-delivery pain.

Through genetic analysis of the infant’s and mother’s DNA, the BC Children's Hospital research team found that the infant’s mother had a genetic variation that caused her body to convert codeine into at least twice the normal amount of morphine. A second abnormality furthered the problem by interfering with her body’s ability to metabolize the morphine and render it inactive.

Although the genetic variants responsible in this case are relatively rare, affecting approximately five percent of the population, Carleton points out that Canada – with an annual birth rate of 340,000 babies – could have up to 19,000 babies born every year to mothers with these genetic variations and exposed to risk if their mothers used Tylenol No.3 while breastfeeding.

As a result of these findings, physicians across North America have been warned regarding codeine use among breastfeeding mothers and all prescription drug labelling for Tylenol No.3 has been changed to include mention of the risk.

Dr. Bruce Carleton is senior clinician scientist and director of the Pharmaceutical Outcomes Programme at BC Children's Hospital, and a professor in the department of pediatrics at UBC.

Dr. Michael Hayden is director of the Centre for Molecular Medicine and Therapeutics at BC Children's Hospital, Canada Research Chair in Human Genetics and Molecular Medicine, and a professor of medical genetics at UBC.

New standard for HBV testing reduces cost and improves patient care

Kidney patients on dialysis are regularly tested to make sure they are fully immunized against hepatitis B virus (HBV), a blood-borne virus associated with liver failure. Even after becoming immunized however, patients can lose their immunity and require booster shots.

In a recent study, a research team led by BC Renal Agency nephrologist Dr. Monica Beaulieu looked at how often dialysis patients around the province were tested and immunized for HBV and found only 50 percent of dialysis patients were tested at the recommended frequency, while13 percent were tested less and 37 percent more than called for by clinical guidelines.

Cutting costs - The new HBV testing protocol is estimated to save the provincial health system hundreds of thousands of dollars a year in lab, vaccine and clinician costs.

In response to these findings, the BC Renal Agency developed an online HBV testing protocol for use by dialysis clinics across BC. The new protocol simplifies the process for tracking patient vaccination records and minimizes the potential for human error.

By eliminating unnecessary HBV testing for dialysis patients, Beaulieu estimates the new protocol saves the provincial health system hundreds of thousands of dollars a year in lab, vaccine and clinician costs. The protocol also ensures that dialysis patients in every region of the province are tested consistently and according to clinical guidelines.

Dr. Monica Beaulieu is a nephrologist and medical lead for special projects for the BC Renal Agency.

BC-led network delivers fast answers on influenza vaccine effectiveness

The world of seasonal influenza prevention proceeds at a breakneck speed. “Every year we’re in this intense rush to get vaccine out the door and into people’s arms before the influenza season hits us in November,” says Dr. Danuta Skowronski at the BC Centre for Disease Control.

To evaluate the effectiveness of the seasonal influenza vaccine each year – and respond quickly to issues if they arise – the BCCDC received national funding in 2007 to lead a surveillance network across BC, Alberta, Ontario and Quebec. Physicians in the network provide BCCDC with swab test results and vaccination information from patients who present with influenza symptoms during the flu season. “This allows us to compare the vaccine rates between those who test positive and those who test negative for influenza,” explains Skowronski.

This observational method has proven to be a cost-effective and reliable alternative to yearly randomized controlled trials of seasonal vaccines. Importantly, it also provides the infrastructure to rapidly evaluate new vaccines during a pandemic situation.

“Having our provincial laboratory and epidemiologists in one centre makes the BCCDC unique in Canada. Because of this long-standing collaborative environment, it’s natural that the national vaccine surveillance network first evolved in BC.”

Dr. Danuta Skowronski

This occurred in 2009, as Canada braced to respond to H1N1 virus (human swine flu), declared a pandemic by the World Health Organization. A small BC-based study led by Skowronski raised the initial flag that people who had received the seasonal flu vaccine may be at greater risk of catching H1N1. To test this finding on a much larger scale, she turned to data gathered by the four provinces through the surveillance network. “Lo and behold, we found the same thing,” she says, citing a doubling of H1N1 infection risk for those who’d had the seasonal flu vaccine.

Over the summer of 2009, Skowronski and her team notified agencies around the world, conducted further studies and presented their results to help inform vaccination policy for the coming fall influenza season. This work prompted most provinces to delay their seasonal flu vaccine programs until after the H1N1 vaccine was rolled out.

Dr. Danuta Skowronski is the epidemiologist lead for influenza and other emerging respiratory-borne pathogens at the BC Centre for Disease Control, and a clinical professor at UBC’s School of Population & Public Health.

About 20 percent of pregnant women carry the herpes simplex virus (HSV or genital herpes) and risk transmitting infection to their newborn baby during delivery. Although transmission to newborns is relatively rare, herpes simplex infection is serious and potentially life-threatening to infants.

Historically, when a woman with a history of genital herpes showed any signs of outbreak close to her delivery date, she would automatically be scheduled for a Caesarean section to prevent transmission. This is no longer the case, thanks to important research by Dr. Deborah Money at BC Women’s Hospital & Health Centre.

Money proved that using a common antiviral drug was a safe and effective way to reduce the chance of HSV transmission, eliminating the need for C-sections for women with the virus. In addition to being better for the health of mother and infant, using the antiviral drug also makes sense from an economic point of view – antiviral drug costs are virtually pennies per patient versus hundreds of dollars for C-section surgery.

Money’s research has resulted in changes to Canadian clinical guidelines for managing herpes simplex virus during pregnancy, improving care for an estimated 2,000 pregnant BC women with HSV every year.

Dr. Deborah Money is executive director of the Women's Health Research Institute and an associate professor of obstetrics & gynaecology at the University of British Columbia.

Sophisticated new medical technologies are regularly introduced into the marketplace, promising better and faster results. But are they worth the health care investment?

Not necessarily, according to Dr. Deborah Money, a world-renowned infectious disease expert at BC Women’s Hospital & Health Centre. She investigated whether there was any benefit in testing pregnant women for Group B streptococcal disease using a cutting-edge DNA-based test that yields results in hours, rather than days. Pregnant women who test positive for this very common bacterium are given antibiotics during labour to prevent bacterial infection in their newborns.

Money’s findings concluded that the current clinical practice in BC – to send a vaginal swab to the lab for testing about a month prior to delivery – is just as effective as the real time, high-tech test in screening for Group B streptococcal. It’s also much less expensive, at about one-tenth the cost of the new technology.

Dr. Deborah Money is executive director of the Women's Health Research Institute and an associate professor of obstetrics & gynaecology at the University of British Columbia.

"What are my odds of surviving?” It’s a question that Vancouver cardiac surgeon Dr. Jaap Hamburger hears from every patient he treats. It’s also the key consideration for heart specialists in choosing the safest treatment for patients with blocked coronary arteries.

For many years heart surgeons have used an online calculator to determine a patient’s risk of death following open heart surgery. But no such calculator existed for an alternative procedure called percutaneous coronary intervention, or PCI (commonly called angioplasty). For PCI, a catheter is inserted into a leg artery and threaded up to the heart, where the blockage is opened with a small balloon, and often held open with the insertion of a tiny stent.

Unique Cardiac Research 

"Our ability to capture outcomes for every single cardiac patient within a large, diverse population means we’re able to do research in BC that simply can’t be done in other places.”

Dr. Karin Humphries, Cardiac Services BC

“We couldn’t objectively compare a person’s risk between having surgery or PCI,” explains Hamburger. To address this issue Hamburger turned to BC’s Provincial Cardiac Registry, which contains information about every heart procedure done in the province. Provincial director Dr. Karin Humphries says the registry is a unique resource: “We’re able to do research that simply can’t be done in other places.”

By analyzing the records from 35,000 BC cardiac patients, Hamburger and his research team discovered 10 risk variables for PCI, including patient age, extent of vessel disease, blood flow, and the presence of other diseases. Using this information, the team has created an online calculator for use by doctors anywhere in the world, to quickly and accurately assess PCI risk for their cardiac patients.

Comparing PCI and coronary bypass surgery

• In 2008/09, there were 7,164 PCIs performed in British Columbia, and 1,887 isolated coronary artery bypass grafts (bypass surgeries). 
• PCI is usually an outpatient procedure, the patient returning home the same day. 
• The average hospital stay for bypass surgery patients is four days. 
• The average system cost for a PCI procedure is about $3,000
• The average system cost for a bypass surgery is about $15,000.

Dr. Karin Humphries is an associate professor in the division of cardiology in UBC’s department of medicine, and provincial director of data services, research & evaluation for Cardiac Services BC.

Assessing these risks and making predictions is a challenging task. Traditionally, forensic risk assessment tools focused only on violence to others. They also took a long-term approach. “We’d say, ‘based on the historical factors in this person’s file, they should be considered a high risk for violence for the rest of their life’,” says Brink.

A new approach developed by Brink and his colleagues is changing all of that. START (Short Term Assessment of Risk and Treatability) is a tool that helps mental health teams assess, monitor and manage risk among psychiatric patients.

In addition to identifying a patient’s specific challenges and “red flags” for problematic behaviours, the tool helps pinpoint their strengths – factors useful for managing and reducing the risk of violence. This knowledge helps care teams develop targeted treatment strategies that build upon a patient’s existing positive attributes.

Although START was developed for psychiatric patients within the justice system, Brink is enthusiastic about its usefulness in other hospital and community settings.

Dr. Johann Brink is a clinical professor in the department of psychiatry at UBC and scientific director of the Forensic Psychiatric Services Commission.

In 2008, a vaccine for the human papillomavirus (HPV) was introduced into the province’s vaccination program for school-aged children. Offered to girls in grades six and nine, the vaccine provides almost 100 percent protection against the subtypes of HPV that cause 70 percent of all cases of cervical cancer.

Implementing this important vaccine into BC’s health system took the efforts of a PHSA-wide team of health professionals led by the BC Centre for Disease Control and including epidemiologists, mathematical modellers, pharmacists, lab scientists, geneticists, nurses and physician specialists. The team analyzed provincial-level data toward determining the most efficient and cost-effective vaccination strategy. The team’s evidence-based recommendations guided the BC Ministry of Health Services and the regional health authorities in rolling out the vaccine program, contributing directly to health policy on a significant preventive health measure for girls and women in BC.

Related to the current vaccination program, researchers at the Vaccine Evaluation Centre at BC Children’s Hospital and the BC Centre for Disease Control are leading nationwide clinical trials comparing the effectiveness of a two-dose HPV vaccine versus the currently-recommended three-dose regime. If the two-dose method is proven equally effective at providing immunity, it would cut total vaccine costs by a third, or about $100 per person. 

Vaccine Adoption 

Approximately 65 percent of eligible BC girls (in grades six and nine) received their first dose of the HPV vaccine in the first year of the program

Anemia is a common complication of kidney disease and is generally treated with an expensive category of drugs called erythropoiesis-stimulating agents (ESAs). Of the $29 million the BC Renal Agency spends each year on medications for patients with kidney disease, $22 million is spent on ESAs.

To gain better control over the use of these costly drugs the agency, in collaboration with the regional health authority renal programs, decided to trial a best practice approach to anemia management. The pilot study involved establishing hemoglobin targets for all BC renal patients and using ESAs at the minimum dosage required to achieve those targets. Data gathered from the pilot showed that patients achieved their hemoglobin targets more quickly and sustained them longer than prior to the pilot study. In addition, reducing ESA dosages has resulted in a saving of $3.9 million in drug costs over the past two years. This saving was achieved in spite of a 13 percent increase in the total number of renal patients in the province.

Best practices approach to drug use helps cut costs

"Based on the results we’ve seen, there is no question that a standardized, best practices approach to anemia management is not only helping us save money on drugs, it’s also improving outcomes for our patients.”