Toilet training children
Toilet training should be started when both the child and parent are willing and able to participate. Moreover, a positive, consistent approach to toilet training is unlikely to cause long-term harm. See Commentary, page 511
What coroners decide
When coroners have the freedom to decide, they are more likely to conduct an inquest into the death of a child than that of an elderly person and to investigate deaths following complications of medical care. They are least likely to investigate suicides. These findings come from an analysis of coroners’ inquests in five Australian jurisdictions over seven and one-half years. The processes of coroners’ decisions are invisible but have an important influence on our understanding of death, say Walter and colleagues. See Research, page 521
High-sensitivity troponin T assay
A high-sensitivity troponin T assay performed well at diagnosing myocardial infarction (MI) in patients with chest pain but without ST-segment elevation on electrocardiogram, especially those presenting four to six hours after onset of symptoms. This diagnostic cohort study involving 939 people with chest pain compared routine use of a troponin I assay with early measurement (at presentation and two hours later) with a high-sensitivity troponin T assay and examined prognosis over one year. The findings need to be confirmed, but suggest that the new test could rule out MI for some patients as early as two hours after presentation, say Aldous and colleagues. See Research, page E260
Why patients might not want dialysis
Patients approaching end-stage kidney disease are willing to forgo considerable life expectancy to avoid dialysis. This result is based on a discrete choice experiment using questionnaire responses from 105 patients with renal disease that measured their preferences. Information about patients’ preferences for the type and location of dialysis is important for the planning of future renal services, say Morton and colleagues. See Research, page E277
Appropriate nephrology referrals
The number of appropriate referrals to nephrology increased in the year after routine reporting of the estimated glomerular filtration rate (eGFR) by laboratories was introduced. However, the proportion of referrals that were deemed appropriate did not change significantly because inappropriate referrals also increased. These findings come from a study involving 2672 patients referred to the nephrology service at a tertiary care hospital in the year before and the year after automatic reporting of the eGFR began. An increase in appropriate referrals will potentially improve patient care, say Akbari and colleagues. See Research, page E269
Pharmaceutical intellectual property
Laws governing pharmaceutical intellectual property in Canada cost over $100 million annually in litigation and keep consumer prices high. According to Grootendorst and colleagues, the problem stems from legal uncertainty created by the complex sets of regulations and rights over the period of market exclusivity. They propose several options for reform, including offering fixed periods of market exclusivity for innovative drugs. See Analysis, page 543
Subarachnoid hemorrhage
About 1 in 14 patients presenting to an emergency department with a severe acute headache will have experienced a sub-arachnoid hemorrhage from an aneurysm. Do all patients with this presentation require computed tomography imaging and a lumbar puncture? Fine and colleagues discuss the latest literature that may change how clinicians assess these patients. See Practice, page 555
Treating community-acquired pneumonia
Although community-acquired pneumonia is uncommon, it can be life threatening. Leis and Gold emphasize that validated scoring systems can help triage patients into those who can receive treatment at home, those who require admission to hospital and those who should be referred promptly to intensive care. See Practice, page 559