Highlights of this issue
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## Transient ischemic attacks and stroke

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/7/1073/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/170/7/1073/F1)

Figure. Photo by: Christine Kenney


![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/7/1073/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/170/7/1073/F2)

Figure. 


![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/7/1073/F3.medium.gif)

[Figure3](http://www.cmaj.ca/content/170/7/1073/F3)

Figure. Photo by: GCa/Science Photo Library

It has long been known that patients who present with a transient ischemic attack (TIA) are at high risk of stroke. In this issue, 2 studies attempt to quantify this risk. Gladstone and colleagues, using data from the Ontario Stroke Registry, show that the 30-day risk of stroke or death was 9% among the TIA patients with a speech deficit and 12% among those with a motor deficit. They also reveal that diagnostic tests are underused: 58% of patients underwent CT scanning, 44% carotid Doppler ultrasonography and 19% echocardiography. Furthermore, more than one-third of patients did not receive antithrombotic therapy at discharge. Eliasziw and colleagues, using data from the North American Symptomatic Carotid Endarterectomy Trial, report a 90-day risk of ipsilateral stroke of 20.1% following a first-recorded hemispheric TIA.

In a related commentary, Verro points out that similar risks of stroke after TIA have been reported over the past 50 years. He reminds us that the attributable risk from factors such as hypertension decline with age and that the contribution of age should be the focus of future research. 

See pages [1099](http://www.cmaj.ca/lookup/volpage/170/1099?iss=7), [1105](http://www.cmaj.ca/lookup/volpage/170/1105?iss=7) and [1113](http://www.cmaj.ca/lookup/volpage/170/1113?iss=7)

The management of patients who present with a TIA can be complicated. Johnston and Hill review the diagnostic workup of such patients. They outline key clinical features that clinicians should look for, as well as laboratory and imaging studies that should be performed. The authors stress the importance of timely investigations and hospital admission for patients who present with hemispheric TIA.

See page [1134](http://www.cmaj.ca/lookup/volpage/170/1134?iss=7)

A variety of treatments have been advocated for the prevention of stroke. O'Rourke and colleagues review the evidence for treatments currently available for stroke prevention: antiplatelet agents, anticoagulants, antihypertensive drugs, lipid-lowering drugs and carotid endarterectomy. They also review the current understanding of the pathophysiology of atherosclerotic disease and how it pertains to stroke.

See page [1123](http://www.cmaj.ca/lookup/volpage/170/1123?iss=7)

## Physician kickbacks

In health care, a kickback is defined as financial compensation of physicians for patient referrals. Payments may come from diagnostic laboratories, physiotherapy clinics or specialists. Choudhry and colleagues argue that, although compensation for referrals can be acceptable in the business world, it creates a conflict of interest when applied to health care services. Specifically, incentives may cause unnecessary referrals and result in inefficiency and increased costs. More contentious are referrals to services owned by the referring physician. The authors present their review of existing provincial laws.

In a related commentary, Litman outlines the legalities of fiduciary relationships. Physicians are considered fiduciaries (“obligatory altruists”) in view of their power and influence and the relative vulnerability of patients. He points out that fiduciary duty mandates exemplary relational behaviour, including the avoidance of conflicts of interest, and is not concerned with standard-of-care issues.

See pages [1115](http://www.cmaj.ca/lookup/volpage/170/1115?iss=7) and [1119](http://www.cmaj.ca/lookup/volpage/170/1119?iss=7)