Early-stage breast cancer
To investigate whether breast cancer therapy in Quebec varies by hospital caseload, Nicole Hébert-Croteau and colleagues analysed the hospital data on 1259 women with node-negative stage I or II disease. The proportion of women who underwent breast-conserving therapy increased with caseload, from 78% in hospitals admitting fewer than 25 patients per year to 88% in those admitting 100 or more (p < 0.001). Use of systemic adjuvant therapy consistent with guidelines tended to increase with caseload in hospitals participating in multicentre trials and to decrease with caseload in those not participating. FIGURE 1
The Canadian Task Force on Preventive Health Care has reviewed the evidence on the follow-up of women treated for early-stage breast cancer. Randomized controlled trials have shown that routine screening for distant disease does not alter survival or quality of life over routine physical examination. There was insufficient evidence to suggest that mammography or physical examination decreases mortality by detecting ipsilateral recurrence or contralateral disease.
See pages 951 and 1001
Physician shortages
Morris Barer and Greg Stoddart present the facts about physician shortages. The shortages are not the direct consequence of the 10% cut in medical school enrolment in 1993, since these physicians are only now completing their training. The number of physicians who left Canada in 1998 was lower than that in the 2 previous years, and the number returning was greater. Retirement of "baby boomers" is not yet significant. Since physician shortages persist despite a 170% increase in the supply between 1964 and 1993, enrolment increases in medical school in the absence of other initiatives are not likely to solve the problem.
See page 983
Echocardiography and stroke
The Canadian Task Force on Preventive Health Care concludes that there is fair evidence to recommend echocardiography in patients with stroke and clinical evidence of cardiac disease, but insufficient evidence to recommend for or against routine echocardiography in patients without clinical cardiac disease. The task force identifies transesophageal echocardiography (TEE) as the preferred initial screening test. Routine echocardiography is not recommended for patients who have independent indications for or contraindications to anticoagulant therapy. There is fair evidence to recommend anticoagulant therapy in patients with stroke and intracardiac thrombus and insufficient evidence to recommend for or against specific therapy for patent foramen ovale.
In an accompanying editorial Christopher Thompson advises, in the absence of a definitive comparison of the outcomes and costs associated with TEE versus transthoracic echocardiography (TTE) followed by TEE, that TTE is a more prudent and less invasive initial screening test.
See pages 981 and 989
Furby does not interfere
Health Canada has assessed the susceptibility of 13 medical devices to electronic interference from Furby. The electromagnetic fields generated by the toy were about 70 times weaker than those from a digital telephone and did not affect the performance of any of the devices tested.
See page 971
Effective glucose control
David Thompson and colleagues randomly allocated a sample of 46 insulin-dependent patients who were receiving endocrinologist-directed care through a diabetic centre either to continue standard care (n = 23) or to also have regular telephone contact (mean 3 calls per week) with a nurse educator (n = 23). At 6 months the mean glycated hemoglobin level for the intervention group was significantly lower than the level at baseline (0.078 v. 0.096, p < 0.001) and the level for the standard-care group at 6 months (0.078 v. 0.089, p < 0.01). In an accompanying editorial Alun Edwards addresses the feasibility of implementing effective glucose control interventions and considers a new model of interaction. FIGURE 2
See pages 959 and 975
Footnotes
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October 19, 1999