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2005: Year in Review | |
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Aboriginal Health |
Internal Medicine |
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Canadian Medical Directory, 2006 edition 2005: The Year in Review ABORIGINAL HEALTH Aboriginal Canadians at risk for severe trauma Karmali and colleagues performed a population-based study in the Calgary Health Region and analyzed the data on major trauma for a 3-year period. They found that the risk of sustaining severe trauma was nearly 4 times greater in the Aboriginal population than in the general population. The main cause of trauma resulting in severe injuries and death was motor vehicle crashes. As well, Aboriginal Canadians had a 10-fold greater risk of injury secondary to assault and a 3-fold greater risk of traumatic suicide. CMAJ 2005;172(8):1007-11 North American ginseng root and the common cold Predy and colleagues conducted a randomized controlled trial with 323 subjects to see if the immunomodulatory properties of an extract of North American Ginseng root could prevent the common cold or reduce its symptoms. They found that a moderate dose of the extract over 4 months reduced 1) the proportion of subjects who experienced 2 or more colds, 2) the mean number of colds per person, 3) the severity of symptoms and 4) the number of days that symptoms were reported. CMAJ 2005;173(9):1043-8 In a Commentary, Turner assessed the study in light of possible limitations that are unique to clinical trials of “natural” agents. CMAJ 2005;173(9):1051-2 Quebec's Breast Cancer Screening Program Screening mammography volumes vary considerably among health care facilities and radiologists. Théberge and colleagues examined data for over 300,000 women, 275 radiologists and 68 accredited facilities in Quebec to determine if differences in volumes were associated with differences in detection rates of breast cancer and false-positive readings. They found that radiologists who worked in facilities performing a greater number of screenings per year, regardless of the radiologists' volume, had higher detection rates than those who worked in facilities performing fewer screenings. In contrast, the false-positive rates decreased with increasing radiologist caseload, especially if the radiologist worked in a larger facility. CMAJ 2005;172(2):195-9 However, in his Commentary, Urbain cautioned against moving toward a more centralized, high-volume model. CMAJ 2005;172(2):210-1 Updated breast cancer guidelines The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer updated its recommendations for follow-up after breast cancer treatment (guideline 9). The changes were summarized in a Commentary. CMAJ 2005;172(10):1319-20 The revised guidelines and patient guide can be found at: www.cmaj.ca/cgi/content/full/158/3/DC1 Breast cancer and work absence Drolet and colleagues studied the effect on work absenteeism among breast cancer survivors in the 3 years after diagnosis. They found that, although women with breast cancer took time off work in the first year after diagnosis, by the third year they were not absent from work any more than other female workers without cancer, if they did not have any further cancer events. CMAJ 2005;173(7):765-9 Low-grade cervical lesions in young women Cervical infection with oncogenic genotypes of human papillomavirus (HPV) is a necessary early event in cervical carcinogenesis, but not all women with such an infection will go on to have cervical cancer. With HPV testing widely available, clinicians need to understand the natural history of cervical intraepithelial neoplasia to be able to advise women regarding screening. Lau and Franco discussed the natural history and presented an algorithm for the management of low-grade squamous intraepithelial lesions in young women. CMAJ 2005;173(7):771-4 Physician specialty and outcomes for patients with CHF Congestive heart failure has a poor prognosis, and there is conflicting evidence whether physician specialty has an impact on outcomes for CHF outpatients. In a retrospective cohort study of outcomes of patients discharged from 128 acute care hospitals in Alberta with new-onset heart failure, Ezekowitz and colleagues found that patients who were followed by specialists and FPs had significantly lower mortality than those followed by FPs alone. CMAJ 2005;172(2):189-94 Sirolimus-eluting stents
A stent is a wire mesh tube used to prop open an artery and improve blood flow to the heart muscle. In recent years drug-eluting stents have been developed. They are coated with drugs that are slowly released and help keep the artery from reclosing, an occurrence known as restenosis. Yang and Moussa explained the mechanism of action of these types of stents and the clinical and scientific rationale behind their use within a wider context of interventional cardiology. CMAJ 2005;172(3):323-5 Shrive and colleagues evaluated the economic impact of sirolimus-eluting stents given their high cost and widespread use and reported that they are cost-effective when used in patients at increased risk of restenosis or at high risk of death if another revascularization procedure were to be performed. Otherwise, their use is associated with a cost per quality-adjusted life-year that is similar to or higher than that of other accepted medical forms of treatment and carries a high incremental cost. CMAJ 2005;172(3):345-51 Brophy calculated that sirolimus-eluting stents could consume $75 million of our health care budget. Given the inconclusive evidence on efficacy and long-term benefits of sirolimus-eluting stents and the limited budgets, he suggested that increased alternative investments in more basic primary and secondary prevention and treatment programs could be a more prudent approach. CMAJ 2005;172(3):361-2 Controversy: the 2003 dyslipidemia management guidelines In 2003 the Canadian recommendations for the management and treatment of dyslipidemia were revised — but further revisions are in order, argued Manuel and colleagues. The current guidelines may lead to more people who are at low risk of coronary artery disease being screened and prescribed statin therapy, which will increase costs for little overall benefit, they suggested. CMAJ 2005;172(8):1027-31 Genest and colleagues, members of the Working Group on Hypercholesterolemia and Other Dyslipidemias, commented on the data used by Manuel and colleagues and questioned their approach ( CMAJ 2005;172[8]:1033-4), and a rebuttal from the challengers concluded the debate ( CMAJ 2005;172[8]:1037). Insulin resistance syndrome and cardiovascular risk Insulin resistance syndrome carries a risk of ischemic heart disease and may be present in people with a normal body mass index (BMI). St-Pierre and colleagues examined the data for a cohort of men to determine the effect of cumulative features of insulin resistance syndrome on the risk of ischemic heart disease associated with different BMI categories. Among obese men only those who had more than 4 features of the syndrome were at increased risk of ischemic heart disease compared with normal-weight men who had fewer than 3 features of the syndrome. Conversely, normal-weight men with more than 4 features of the syndrome had a 3-fold increase in risk. CMAJ 2005;172(10):1301-5 In his Commentary, Janssen pointed out the clinical importance of identifying high-risk patients with insulin resistance syndrome and the need to treat it aggressively in all patients. CMAJ 2005;172(10):1315-6 Atorvastatin: Is it safe? Hackam commented on a study that examined the efficacy and safety of intensive lipid lowering using atorvastatin in patients with stable coronary disease. CMAJ 2005;172(10):1294-5 Vitamin B12 deficiency as heart risk Robertson and colleagues stated that folic acid fortification has not yet had the expected effect of reducing homocysteine levels, which are associated with carotid plaque area, a strong predictor of cardiovascular events. They measured levels of serum vitamin B12 , homocysteine and carotid plaque in 421 patients referred to vascular disease prevention clinics and found that vitamin B12 deficiency was surprisingly common. In a subset of 224 patients whose creatinine levels were measured, these levels appeared to be as strong a predictor of homocysteine levels as were vitamin B12 levels. CMAJ 2005;172(12):1569-73 Predicting serious cardiac outcome Ischemia-modified albumin appears in the serum within minutes of ischemia, before myocete necrosis, and can be detected 6 hours or more after the onset of symptoms. Worster and colleagues evaluated the prognostic capabilities of high or low levels of ischemia-modified albumin in patients with potential cardiac-ischemia symptoms (within the preceding 6 hours) by recording outcomes such as death, myocardial infarction, heart failure, arrhythmia and refractory pain within 3 days of presentation. CMAJ 2005;172(13):1685-90 Sabatine's Commentary showed that levels of ischemia-modified albumin provided no useful information in predicting which patients would have a serious cardiac outcome in the short term. CMAJ 2005;172(13):1697-8 Cardiac catheterization Cardiac catheterization is done primarily to identify patients with severe coronary artery disease (CAD) for whom revascularization procedures would offer a survival advantage. Graham and colleagues analyzed data for 1995 to 2002 from a registry that captures detailed clinical information for all patients undergoing cardiac catheterization in Alberta to determine whether there is a population rate beyond which the yield of high-risk CAD does not rise. Increased regional rates of catheterization were associated with an increasing yield of high-risk CAD, with no evidence of a plateau in yield when more procedures were performed. These findings suggest that the population rates of cardiac catheterization are suboptimal. CMAJ 2005;173(1):35-9 However, in their Commentary, Natarajan and colleagues pointed out that the problem is not that straightforward and that different contextual factors need to be considered. CMAJ 2005;173(1):49-52 Congestive heart failure When Ducharme and colleagues performed a randomized trial to evaluate the impact of care at a multidisciplinary specialized outpatient heart failure clinic compared with standard care, their results showed that, after 6 months, patients who received care at the specialized clinic were less likely to require readmission to hospital and had shorter hospital stays than patients assigned to standard care. Self-assessed quality of life was also higher among patients in the intervention group. CMAJ 2005;173(1):40-5 A Commentary presented sobering statistics about the prevalence of heart failure in Canada and suggested further directions for the study of optimal care for congestive heart failure patients. CMAJ 2005;173(1):53-4 Decision aids for atrial fibrillation McAlister and colleagues conducted a cluster randomized trial with 434 nonvalvular atrial fibrillation patients from 102 community-based primary care practices to see whether the use of a patient decision aid affected the quality of short- and long-term antithrombotic care. The aid itself included a self-administered audiotape and booklet tailored to the patient's personal stroke risk profile. Antithrombotic care was measured against American College of Chest Physicians recommendations. They found that, although there was short-term improvement in the appropriateness of antithrombotic care when the decision aid was used, the improvement did not persist. CMAJ 2005;173(5):496-501 Canadian Hypertension Education Program: a 6-part series McAlister and colleagues introduced the launch of a 6-part series on hypertension that focused on updated approaches to diagnosis, global atherosclerotic risk, lifestyle modification and therapy. The series was the result of research by experts in the Canadian Hypertension Education Program, a group that generates annual evidence-based hypertension management recommendations. CMAJ 2005;173(5):508-9 In Part 1, Bolli and colleagues presented an algorithm to aid in the timely diagnosis of hypertension ( CMAJ 2005;173[5]:480-3). Part 2 showed how global atherosclerotic risk can be assessed and reduced ( CMAJ 2005;173[6]:593-5). In Part 3, lifestyle modifications were addressed ( CMAJ 2005;173[7]:749-51), and Part 4 examined the management of uncomplicated hypertension ( CMAJ 2005;173[8]:865-7). Part 5 dealt with therapy for patients with hypertension and diabetes mellitus ( CMAJ 2005;173[10]:1154-7), and the final article in this series will appear in 2006. 1. Short QT syndrome There is mounting evidence that a short QT interval is associated with an increased risk of life-threatening arrhythmic events. Short QT syndrome was first described in 2000, but our understanding of the disease has already benefitted from research in genetics, molecular biology and biophysics. Brugada and colleagues reviewed the pathophysiology, clinical presentation and treatment of short QT syndrome. CMAJ 2005;173(11):1349-54
Immediate angioplasty after thrombolysis In a systematic review of whether thrombolysis followed by transfer for immediate percutaneous coronary intervention is safe, feasible and superior to conservative management, Cantor and coauthors found inadequate evidence to recommend routine transfer. Transfer is, however, recommended for patients with cardiogenic shock, hemodynamic instability or persistent ischemic symptoms after thrombolysis. CMAJ 2005;173(12):1473-81 New recommendations for screening for depression The Canadian Task Force on Preventive Health Care presented its updated recommendation statement on screening for depression in the primary care setting. The change in recommendation was based on a body of evidence showing that adults can be screened for depression “in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow-up.” CMAJ 2005;172(1):33-5 Nonspecific back pain Nonspecific back pain is one of the most frequent complaints in the primary care setting and the main cause of work absence and disability in our society. Dionne and colleagues developed a 7-question clinical algorithm to determine the likelihood of patients with nonspecific back pain returning to work with durable good results. Clinicians can use this tool to help decide whether a patient would benefit from conservative management or might require further interventions. Use of the algorithm may help to reduce unnecessary clinical interventions and associated costs. CMAJ 2005;172(12):1559-67 Maher pointed out that Dionne and colleagues' algorithm is much better at predicting a good outcome than a poor outcome and is only somewhat more reliable than some of the guidelines already in use. Maher suggested that more research is needed to assess the use of this tool in determining the best treatment option for patients. CMAJ 2005;172(12):1575-6 Protecting against Clostridium difficile In a Public Health article, Weir and Flegel provided the background, epidemiology, clinical management and prevention of Clostridium difficile infection. CMAJ 2005;172(9):1178 Probiotic therapy for Clostridium difficile infection With the increasing incidence of nosocomial Clostridium difficile-associated diarrhea, probiotics have been suggested for the prevention and treatment of the infection. However, when Dendukuri and colleagues performed a systematic review of randomized controlled trials of the effectiveness of probiotic therapy, they could identify only 4 eligible studies, 2 of which were methodologically flawed. Larger and better quality trials are needed to assess the benefits of probiotic therapy for C. difficile infection. CMAJ 2005;173(2):167-70 Clostridium difficile –associated disease and patient mortality  Since 2002, an epidemic of Clostridium difficile –associated disease (CDAD) caused by a hypervirulent strain has spread to many hospitals in Quebec. Pépin and colleagues studied the effect of the epidemic on mortality and duration of hospital stay among patients admitted to one hospital during 2003 and 2004. They found a high excess mortality among 161 inpatients with nosocomial CDAD compared with 656 matched control subjects. Overall, the CDAD patients spent 10.7 days longer in hospital than the control subjects did. The high attributable mortality represents a dramatic change in the pathogenicity of C. difficile. CMAJ 2005;173(9):1037-41
In a Commentary, Louie looked at the experience in other countries with the same hypervirulent strain. In reviewing factors that might have contributed to the emergence of this strain and steps that can be taken to control outbreaks, he took the position that particular emphasis must be given to controlling the use of antibiotics. CMAJ 2005;173(9):1049-50 Quebec's C. difficile deaths: 409 Eggertson reported that in the year since Quebec began tracking cases of C. difficile , about 8% of those infected, or 409 people, have died. From August 2004 to August 2005 there were 8673 cases of C. difficile recorded. CMAJ 2005;173(11):1308 Sepsis in review Severe sepsis and septic shock account for 3% of hospital admissions and 10% of admissions to the intensive care unit. Almost one-third of patients with severe sepsis die. The review by Rivers and colleagues emphasized the early recognition, diagnosis and treatment of sepsis. The authors considered the importance of the first 6 hours after admission, the transition between sepsis and severe sepsis, and host responses. They also offered practical and up-to-date approaches to treatment and how to identify the high-risk patient. CMAJ 2005;173(9):1054-65 Hyperhidrosis Focal hyperhidrosis, a condition characterized by excessive sweating, occurs as frequently as psoriasis, and it carries a significant psychosocial burden. However, patients rarely seek a physician's help because they are unaware that the disorder is treatable. Haider and Solish reviewed recent findings on the nature of the disorder and described the range of therapies now available, from topical aluminum salts to iontophoresis and botulinum toxin A injections. CMAJ 2005;172(1):69-75 Fungal infection Secko described the exciting implications of the recent discovery of 2 genes that influence the virulence of Cryptococcus neoformans infection. CMAJ 2005;172(9):1174 Oral antihyperglycemic therapy for type 2 diabetes mellitus Orally administered antihyperglycemic agents (OHAs) are often necessary to achieve target glycemic levels. In their comprehensive review, Cheng and Fantus discussed the mechanism of action, efficacy and side effects of 5 OHA drug classes (α-glucosidase inhibitors, biguanides, insulin secretagogues, insulin sensitizers and intestinal lipase inhibitor), as well as the current recommendations for their use. CMAJ 2005;172(2):213-26
Updated screening recommendations The Canadian Task Force on Preventive Health Care provided updated recommendations for screening for type 2 diabetes mellitus to prevent cardiovascular events and death. CMAJ 2005;172(2):177-9 A longer version of the recommendations is available at: www.cmaj.ca/cgi/content/full/172/2/177/DCI Diabetic ketoacidosis and pediatric stroke Ho and colleagues described the case of a 6-year-old patient with type 1 diabetes mellitus in whom ketoacidosis developed, followed by stroke. Although pediatric stroke is not an unknown complication of diabetic ketoacidosis, it is rare, and its treatment is still controversial. CMAJ 2005;172(3):327-8 Multitherapy for patients with diabetes In a randomized controlled trial of multitherapy for poorly controlled type 2 diabetes mellitus, Ménard and colleagues found that, after 12 months, patients given intensive multitherapy, including lifestyle modifications and drug therapy, were more likely than those given usual care to achieve the targets for hemoglobin A1c concentrations, diastolic blood pressure, low-density lipoprotein cholesterol levels and triglyceride levels recommended by the Canadian Diabetes Association. However, 6 months after the intervention ended, the benefits had largely vanished. CMAJ 2005;173(12):1457-63 In a related Commentary, Rothman and Elasy discussed the need for interventions that generate sustained behavioural change in patients. CMAJ 2005;173(12):1467-8 Children who leave the ED without being examined How many children leave emergency departments without being seen by a physician, and why? In a case–control study, Ran Goldman and colleagues reported that 3% (289) of 11,087 children who visited the ED of a Toronto tertiary-care hospital left without being examined. Although one of the main reasons for early departure was resolution of symptoms, 15% of those who left without being examined had been triaged as “urgent.” The authors found that children who left the ED without being seen had a lower illness or injury acuity level, lived closer to the hospital and were more likely to register in the ED between midnight and 4 am. The study also provided data on the clinical and sociodemographic characteristics of patients who leave without being seen. CMAJ 2005;172(1):39-43 Health information security Slaughter and colleagues analyzed the implications of health information security and privacy of provincial electronic patient registries that are being planned to reduce waiting times for specific diagnostic and treatment procedures. CMAJ 2005;172(10):1283-4 Conflict of interest Bernstein discussed ethical requirements about conflict of interest recently imposed by the US federal government on the National Institutes of Health and the implications for Canadian health research. CMAJ 2005;173(4):353-4 Stem cell research and CMA's Code of Ethics Physicians in Canada are able to approach patients with the option of donating cryopreserved embryos for stem cell research. This practice was addressed by the Canadian Assisted Human Reproduction Act and the Human Pluripotent Stem Cell Research Guidelines of the Canadian Institutes of Health Research. Donation of fresh embryos for research, however, is not covered. Using the CMA Code of Ethics , Nisker and White discussed the ethical issues of fresh embryo donation. CMAJ 2005;173(6):621-2 Update of the Declaration of Helsinki The Declaration of Helsinki was first adopted in 1964 and evolved from the Nuremberg Code as a mechanism to protect human research subjects. Since then, it has undergone several revisions. Its most recent changes address the issue of post-study access to treatment. Blackmer and Haddad outlined why these changes were introduced and the controversies that arose as a result, and presented the CMA position on this issue. CMAJ 2005;173(9):1052-3 Evidence-Based Medicine Teaching Tips project This project comprises a series of articles aimed at both learners and teachers of EBM. The tips are offered as “easily digestible bites” or mini-lessons and are presented in tandem with examples of clinical problem-solving. They are constructed to respond to learners' common struggles with understanding the concepts central to EBM, and the teachers' versions, offered online only (www.cmaj.ca), describe the interactive process that unfolds when experienced EBM teachers use these tips. The first 3 articles appeared in 2004 issues of CMAJ. In the 4th article, Hatala and colleagues presented an approach to evaluating potentially important differences, or heterogeneity, in the results of individual studies being considered for a meta-analysis. Readers will learn what heterogeneity is, why it is important, how to assess it and how to use it — and will find systematic reviews and meta-analyses more transparent as a result. CMAJ 2005;172(5):661-5 In the 5th article, Montori and colleagues presented tips and examples of how test performance varies with the spectrum of disease, why disease prevalence does not affect sensitivity, specificity or likelihood ratios, and how the predictive value of a test corresponds with post-test probability of disease. CMAJ 2005;173(4):385-90 Weight loss in elderly people Unintentional weight loss in elderly people is associated with significant adverse health outcomes, increased mortality and progressive disability. Causes of weight loss range from reduced food intake to organic causes to psychological disorders; medications may also contribute to the problem. Alibhai and colleagues reviewed the incidence and prevalence of weight loss in elderly patients, its impact on morbidity and mortality, the common causes of unintentional weight loss and nonpharmacologic and pharmacologic strategies to minimize or reverse weight loss. CMAJ 2005;172(6):773-80 Young blood heals old muscles Between age 30 and 80 over one-third of muscle mass is lost. New research suggests that although older stem cells do retain their inherent reparative ability, the signals that switch this process on fail with age. Seiko reported on the current work by Conboy and colleagues, whose investigations suggest that aging blood can create a repressive environment in which stem cells regenerate tissue poorly. However, the molecular pathways involved in this decline can be reset, offering hope that therapeutic intervention is possible. CMAJ 2005;172(7):869 Coronary artery bypass grafting in elderly patients More and more people 80 years of age and older are being referred for coronary artery bypass grafting (CABG). Baskett and colleagues looked at outcomes of elderly Canadians undergoing this procedure and provided additional evidence for eventual informed policy-making. People in this age group represented 5% of patients undergoing CABG over a 5-year period. These patients had more comorbid conditions and a higher acuity level than younger patients, and a higher overall mortality. The mortality decreased over the study period for both older and younger patients, but the risk of postoperative stroke did not change among the older patients. The authors concluded that advanced patient age should not on its own deter a decision to perform CABG if there is a clinical need for it and that older patients undergoing elective procedures may experience outcomes equivalent to those of younger patients. CMAJ 2005;172(9):1183-6 Class effect of statins in elderly patients Statins are used in the secondary prevention of acute myocardial infarction (AMI). Since all statins belong to the same drug class, they are generally thought to be therapeutically equivalent. However, evidence supporting this assumption has been limited, and prescribing practices suggest that some statins are preferred over others. Zhou and colleagues compared the effectiveness of 5 commonly prescribed statins in a head-to-head retrospective analysis of data for over 18,000 elderly patients who had AMI and who filled a prescription for a statin within 90 days after discharge. They found that the 5 statins were equally effective for secondary prevention after AMI. CMAJ 2005;172(9):1187-94 However, as Wright pointed out in his Commentary, the costs of statins differ, which gives physicians an opportunity to reduce costs to patients and the health care system while still achieving optimal health outcomes for their patients. CMAJ 2005;172(9):1195-6 Leg-ulcer care in the community Leg ulcer is a chronic and relatively common condition present in almost 2 in 1,000 people, most of whom are elderly. Its treatment is long term and costly. A new nurse-led health care protocol providing standardized clinical care according to research-based guidelines might make a difference. When such a program was implemented in a community home care system in Eastern Ontario, Harrison and colleagues compared it with the old model. The results showed that the new protocol's greater involvement of nurses and guideline-driven practice led to an increase in both the use of compression therapy and improved healing rates. This reorganization in health care delivery decreased the cost of treatment significantly, without the need for additional financial investment. CMAJ 2005;172(11):1447-52 Measuring frailty in the elderly
Rockwood and colleagues developed a 7-point, judgment-based Clinical Frailty Scale during the Canadian Study of Health and Aging. They followed a cohort of 2,305 elderly patients for 5 years to determine the scale's ability to predict death and to predict the need for entry into an institutional facility. They presented the correlations between their results and established tools. CMAJ 2005;173(5):489-95
Malaria in Quebec The incidence of malaria in Canada is rising because of increasing immigration from and travel to malaria-endemic regions. When Ndao and colleagues analyzed the performance of the Quebec health care system in the diagnosis and management of a small “epidemic” of malaria among refugees from Tanzania they found that errors of both omission and commission had occurred, despite the presence of a comprehensive system. Of greatest concern was the fact that malaria smears were not requested in almost 20% of symptomatic cases, of which half were children and pregnant women. There is much room for improvement in diagnosis, record-keeping and management of the disease. CMAJ 2005;172(1):46-50 Global climate change and health Canada is experiencing some of the most rapid warming as the temperature of the Earth's land surface slowly rises. Kovats and Haines discussed the health implications of global climate change and the need for effective public health interventions for extreme weather events, as well as for research into strategies that will help populations adapt to climate change. CMAJ 2005;172(4):501-2 New malaria drug Sibbald reported that at least 50 million malaria patients a year could benefit from the first new drug developed by the new Drugs for Neglected Disease initiative (DNDi ). A patent-free, fixed-dose formulation of combined artesunate–amodaq antimalarial will be available in early 2006. CMAJ 2005;172(12):1545 Plague: a continuing threat There was an outbreak of plague in a remote diamond mine in the Democratic Republic of the Congo. In 2003, a total of 9 countries reported 2,118 cases and 182 deaths. Nearly 99% of the cases and deaths were reported from Africa. The US reports about 10–15 cases a year. Weir reviewed the clinical management and prevention of this disease. CMAJ 2005;172(12):1555
Malnutrition and health In their Review article, Müller and Krawinkel described the causes, signs and clinical management of protein–energy malnutrition (marasmus, kwashiorkor) and micronutrient deficiencies. Malnutrition is the direct cause of about 300,000 deaths per year and is indirectly responsible for about half of all deaths in young children. The accompanying increased risk of dehydration, hypothermia, and bacterial and parasitic diseases contributes greatly to the burden of illness in the developing world. These problems can be addressed through the promotion of breast-feeding and food supplementation strategies, but their root cause is poverty. CMAJ 2005;173(3):279-86 Depo-Provera and bone mineral density Medroxyprogesterone acetate is an injectable agent widely used for contraception and the treatment of endometriosis. Health Canada issued a warning that patients taking this drug may experience a significant loss of bone mineral density. CMAJ 2005;172(6):746 Eczema drugs and the risk of cancer Wooltorton reported on a possible association between the use of eczema drugs and an increased risk of cancer. CMAJ 2005;172(9):1179-80 COX-2 inhibitors: What now? Cotter and Wooltorton described the practice implications of the April 2005 restrictions to the use of COX-2 inhibitors. CMAJ 2005;172(10):1299
IV bisphosphonates and invasive dental procedures Wooltorton reviewed the association between intravenous bisphosphonate (Aredia or Zometa) therapy and osteonecrosis of the jaw. CMAJ 2005;172(13):1684 Tuberculin tests CMAJ reported on a Health Canada warning about serious allergic reactions, including anaphylaxis, to tuberculin skin tests. The test should be administered only in settings where trained staff are prepared to deal with anaphylactic reactions and epinephrine (1:1000) is available. CMAJ 2005;173(1):34 Health Canada's adverse reaction database Kondro reported in CMAJ's News section that critics were charging that Health Canada's Canadian Adverse Drug Reaction Information System (CADRIS) was user-unfriendly and downright uninformative, in that it doesn't allow physicians or patients to determine the likely incidence of adverse drug reactions. However, Dr. Joel Lexchin, professor of health policy at York University, stated that, despite its limitations, CADRIS could have some utility. CMAJ 2005;173(2):137
Antipsychotics and the elderly Singh and Wooltorton reported on a warning from Health Canada that atypical antipsychotics, including risperidone and clozapine, may increase the risk of death among elderly patients. CMAJ 2005;173(3):252 Bronchodilator and alcohol Co-ingestion of the long-acting opioid Palladone XL and alcohol can cause rapid release of the opioid and may result in serious side effects, including respiratory depression, coma and death. CMAJ 2005;173(7):756 Asthma and bronchodilators Wooltorton reviewed the safety concerns of long-acting beta 2 -agonists in asthma. CMAJ 2005;173(9):1030-1 Breast implants Eggertson reported that 3 of the 9-member Health Canada advisory panel studying silicone breast implants were paid advisers to one of the two companies seeking to have their medical devices reinstated in Canada or had expenses paid by a company at a seminar or meeting. CMAJ 2005;173(3):241 Eggertson and Murray reported that some MPs were calling on Health Canada to remove members of an expert advisory panel on breast implants, or to suspend the panel's work, because at least 3 members of the panel have ties to manufacturers of the medical devices. CMAJ 2005;173(10):1144 Paroxetine (Paxil) and contgenital malformations See page 8–10 under “Obstetrics” for further information. Nursing home staffing: not-for-profit v. for-profit McGregor and colleagues examined staffing ratios for direct-care and support staff in publicly funded not-for-profit and for-profit nursing homes in British Columbia. They found that not-for-profit facility ownership is associated with higher staffing levels, which suggests that public money purchases fewer direct-care and support-staff hours per resident-day in for-profit long-term care facilities than in not-for-profit facilities. It remains to be seen whether these differences in staffing levels translate into different health outcomes among residents of those facilities. CMAJ 2005;172(5):645-9 Chaoulli v. Quebec
In a June 9, 2005, Early Release News article, Eggertson reported on the Supreme Court's decision that same day in the case of Chaoulli v. Quebec (Attorney General). CMAJ 2005;173(2):139 The Supreme Court's narrow decision was received by some as a long-overdue vindication of the right to timely access to medical treatment, and by others as a body blow to public health care. Flood and Sullivan offered an analysis of the court's decision, which they argued is based on mistaken suppositions about the benefits of a public–private blend of health care provision. CMAJ 2005;173(2):142-3 In the same issue, CMAJ 's editors offered their take on the court's decision and on the tension between individual rights and the public good in Canadian health care policy. CMAJ 2005;173(2):117 Chaoulli v. Quebec — continued In the Aug. 2, 2005, issue CMAJ offered further Commentaries on private and public health care in the wake of the Supreme Court's June 9th decision in the case of Chaoulli v. Quebec (Attorney General). CMAJ 2005;173(3):269-70, 271, 273, 275 and 277. Smart Regulation strategy In late March 2005 the Canadian government declared a major restructuring of its regulatory policy. The Smart Regulation strategy is aimed at streamlining the approval process for new drugs, foods, biotechnology products, veterinary products and pesticides. Graham scrutinized the proposed policy. CMAJ 2005;173(12):1469-70 Sexual risk among gay men: a landmark study Canadian gay men who participated in the world's first test of a vaccine (AIDSVAX) to prevent HIV did not appear to become more risky sexually out of false hope that the vaccine would protect them from infection. A study coauthored by the BC Centre for Excellence in HIV/AIDS in Vancouver and co-investigators in Toronto and Montreal, found that 21% of participants engaged in the riskiest form of sexual encounter during the 6 months before enrolment. The level of risk-taking did not increase during 18 months of follow-up, even among men who at study entry thought the vaccine might provide some protection. The vaccine was ultimately shown to be ineffective. The study data are now being used to answer additional questions concerning the sexual health of gay men. CMAJ 2005;172(4):479-83 New therapeutic approach: Topical microbicides? In Analysis, Balzarini and Van Damme discussed the scientific advances in developing microbicides for intravaginal and intrarectal use in the prevention of HIV infection. CMAJ 2005;172(4):461-4 HIV on holiday
Salit and colleagues surveyed a group of HIV-positive people about their travel patterns and asked what health precautions they took before and during international travel. They found that less than one-fifth sought pre-travel health advice and that many of those taking antiretroviral therapy stopped taking the medications or were poorly compliant with the therapy while travelling. Moreover, only two-thirds of those engaging in casual sexual activities with a new partner while abroad reported always using a condom. Although useful information for the immunocompromised travellers has been available through the US Centers for Disease Control and Prevention, other ways of providing pre-travel advice to this population should also be considered. CMAJ 2005;172(7):884-8 Hepatitis C virus and HIV co-infection Hepatitis C virus (HCV) infection is frequent among people with HIV and contributes to their mortality risk. Braitstein and colleagues investigated the effect of HCV serostatus on the risk of death among HIV-positive patients taking their first regimen of antiretroviral therapy. After adjusting for adherence to treatment, injection drug use and other confounding factors, they found that HCV seropositivity was an independent predictor of death, particularly HIV-related death. CMAJ 2005;173(2):160-4 HIV screening Murray and Weir provided an HIV update, particularly in populations recommended for screening. CMAJ 2005;173(7):752 INFLUENZA PANDEMIC A number of News and Public Health articles on the emerging global threat of an avian influenza (H5N1 virus) pandemic were published in CMAJ during 2005. Here is a sampling of them. H5N1 virus H5N1 virus (i.e. “bird flu”) is the best candidate flu strain for an expected influenza pandemic, but countries around the globe are ill prepared, warned the World Health Organization in a News report by Eggertson. CMAJ 2005;172(1):23-4 In the 2nd of her two reports in the Jan. 4, 2005, issue of CMAJ , Eggertson talked about how unlikely it was that the 6 billion people around the globe could be vaccinated in time for an influenza pandemic. CMAJ 2005;172(1):24 Influenza vaccine Eggertson reported that Vancouver-based ID Biomedical Corporation had begun development of a mock vaccine to protect people against H5N1 influenza. The company was developing a vaccine based on a genetically modified variant of H5N1. Their work will help them prepare for whatever strain does emerge. CMAJ 2005;172(5):623 Avian influenza (bird flu) epidemiology and control worldwide was discussed by Weir. Included was a list of “Prerequisites for the start of a pandemic.” CMAJ 2005;173(8):869-70 Pandemic preparedness: Begin at the source Sibbald reported on the Oct. 24–25, 2005, conference on Global Pandemic Influenza Readiness held in Ottawa. Farm surveillance, along with fair compensation for producers who have to kill infected fowl, is the essential frontline of defence against an avian influenza pandemic, agreed the health ministers from 30 countries and heads of 8 international agencies. CMAJ 2005;173(11):1309-10 Deadly 1918 flu remade Secko reported that there is evidence that the virus responsible for the 1918 pandemic is related to the current avian virus that has scientists fearing a similar worldwide outbreak. However, an understanding of the 1918 virus may lead to treatments that might permit us to avoid a global catastrophe. CMAJ 2005;173(11):1311 Interpreting liver enzyme alterations Routine lab blood tests include the so-called liver function tests. In a Review, Giannini and colleagues provided a guide to interpreting alterations to liver enzyme levels. Using a schematic approach that classifies enzyme alterations as either predominantly hepatocellular or cholestatic, they examined abnormal enzymatic activity within the 2 subgroups, the most common causes of enzyme alteration and then suggested initial investigations. CMAJ 2005;172(3):367-79 Nonalcoholic fatty liver disease (NAFLD) NAFLD, which is emerging as the most common chronic liver condition in the Western world, can lead to cirrhosis. Adams and colleagues reviewed the latest information on NAFLD and discussed its diagnosis and management. The disease is associated with insulin resistance and the metabolic syndrome, but the exact pathophysiology that leads to NAFLD is not well understood. Recommended treatment is limited to weight loss and exercise because randomized clinical trials have not convincingly shown any of the investigated medications to be effective. Because the condition progresses slowly, follow-up, usually done in the primary care setting, should be focused on patients with risk factors for advanced disease. CMAJ 2005;172(7):899-905 See an animated Fig. 1 at www.cmaj.ca/cgi/content/full/172/7/899/DCI Gallstone disease Since the introduction of laparoscopic cholecystectomy in 1991, the use of elective cholecystectomies has increased dramatically. To determine if this increase resulted in a reduction in the incidence of severe gallstone disease, Urbach and Stukel investigated longitudinal trends in the rates of acute cholecystitis, acute biliary pancreatitis and acute cholangitis. They found that the increase in the rate of elective cholecystectomy after 1991 was associated with an overall reduction in the incidence of severe gallstone disease that was entirely attributable to a reduction in the incidence of acute cholecystitis. Since cholecystectomy for severe gallstone disease is associated with a higher cost and risk of operative death than is elective cholecystectomy, the authors concluded that this increase in the use of elective laparoscopic cholecystectomy may have net benefit to the health of Canadians with gallstone disease. CMAJ 2005;172(8):1015-9 CMAJ a Michener finalist CMAJ and Découverte (a Radio-Canada science program) were jointly short-listed for the prestigious Michener Award Promoting Meritorious Public Service in Journalism for coverage of the outbreak of Clostridium difficile in Quebec hospitals. CMAJ reporters Laura Eggertson and Barbara Sibbald, in an Early Release June 4, 2004, report ( CMAJ 2004;171[1]19-21), broke the C. difficile story that at least 79 patients had died of the infection. The Public Health Agency of Canada subsequently launched a surveillance program at 25 major Canadian hospitals. CMAJ 2005;172(10):1281
Contrast media and nephropathy Nephropathy induced by contrast media has become a leading cause of hospital-acquired renal failure owing to the increased use of contrast media in diagnostic and interventional procedures. Patients with pre-existing chronic conditions, such as diabetes mellitus or renal insufficiency, are at highest risk of the condition. Goldenberg and Matetzky reviewed the latest scientific evidence on the causes, pathogenesis and clinical course of contrast-medium nephropathy and described preventive strategies evaluated in clinical trials. CMAJ 2005;172(11):1461-71 Kidney transplant consensus guidelines The Canadian Society of Transplantation has created consensus guidelines on eligibility for kidney transplantation. These guidelines were published as an online supplement to the Nov. 8 issue of CMAJ . Knoll and colleagues presented the key recommendations in a Commentary. CMAJ 2005;173(10):1181-4 Eye deviations in patients with stroke In Analysis, Derakhshan described how one-way callosal traffic theory explains both conjugate eye deviation after stroke and the rare phenomenon of lone abducted eye. CMAJ 2005;172(2):171-3 Animated figures can be seen at www.cmaj.ca/cgi/content/full/172/2/171/DCI
Battling a “brain attack” Lindsay and the members of the Canadian Stroke Quality of Care Study evaluated 51 stroke quality-of-care indicators and settled on 23 that they proposed be used by clinicians, researchers and policy-makers. Using this common set of indicators will facilitate regional comparisons, enable continuous quality improvement and ensure these indicators will become embedded in routine clinical care as a means of ensuring a minimum standard of practice. CMAJ 2005;172(3):363-5 Canadian Alteplase for Stroke Effectiveness Study (CASES) Thrombolytic therapy for acute ischemic stroke has remained controversial primarily because of concerns over whether it can be broadly and safely applied in real practice, given its dependence on time, technology and infrastructure. CASES, a national prospective cohort study, was conducted to determine the safety and effectiveness of thrombolysis with alteplase in the real-world treatment of acute ischemic stroke. The study registry collected data for 1,135 patients enrolled at 60 centres across Canada between 1999 and 2001. More than one-third of the patients had an excellent outcome, and the rates of symptomatic intracranial hemorrhage and orolingual angioedema were low (4.6% and 1.3% respectively). The CASES data indicated that thrombolysis for acute ischemic stroke is a safe and effective therapy in actual practice. CMAJ 2005;172(10):1307-12 Bariatric medicine Bariatric medicine (from the Greek baro , meaning weight) is increasingly being used to describe the field of medicine that deals with obese patients. Sharma described the challenges faced by physicians managing the multitude of health problems encountered in morbidly obese patients. CMAJ 2005;172(1):30-1 Screening for obesity Douketis and colleagues discussed the importance of screening men and women for overweight and obesity and presented a practical approach to using the new Canadian guidelines for body weight classification of adults in clinical practice. CMAJ 2005;172(8):995-8
Chronic systemic inflammation, weight loss and exercise Persistent low-grade inflammation, as indicated by elevated levels of circulating inflammatory markers such as C-reactive protein, interleukin-6 and tumour necrosis factor- a, is a strong risk factor for several chronic diseases, including cardiovascular disease, diabetes and osteoarthritis. As Nicklas and colleagues explained in their Review article, dietary weight loss and increased physical activity may be effective therapies for reducing overall chronic inflammation. Research has shown that levels of circulating inflammatory markers are elevated in people with total and abdominal obesity and that they are decreased after weight loss. The same effect has been observed in association with physical activity. Although the mechanisms by which weight loss and exercise reduce inflammation have yet to be explained, their beneficial effects have been confirmed. CMAJ 2005;172(9):1199-209
Childhood overweight and obesity Increases in childhood overweight and obesity have become a major public health crisis. Veugelers and Fitzgerald surveyed 4,298 children aged 10 and 11 in Nova Scotia to determine the prevalence of overweight and obesity and the contributing impact of parental, family, lifestyle and school factors. Using height and weight measurements, they found that 33% of the children were overweight and 10% were obese. Sedentary children, children purchasing lunch at school and those residing in low-income neighbourhoods were most likely to be affected. The authors called for targeted prevention programs to address this pervasive problem. CMAJ 2005;173(6):607-13 SSRI use during the 3rd trimester In 2004, both the US Food and Drug Administration and Health Canada advised physicians to taper the dosage of antidepressants in pregnant women during the last trimester so that the fetus receives no drug for at least 7–10 days before delivery. The advisories were based on “reports reveal[ing] that some newborns whose mothers took their medications during pregnancy have developed complications at birth.” However, in a May 24, 2005, Commentary, Koren and colleagues stated that, while these complications were seen as consistent with withdrawal symptoms or a direct adverse effect by the antidepressant on the baby, no reports of serious complications or death from poor neonatal adaptation had been published to date. They stated that the balance of evidence suggested that discontinuing clinically needed antidepressants in women near term is unwarranted and may put the mother at an unjustified perinatal risk. Neonatal symptoms occur in a minority of cases and are self-limited. They concluded that, on the basis of available data, regulatory agencies and manufacturers should not perpetuate anxiety among pregnant depressed women. CMAJ 2005;172(11):1457-9 SSRI use during the 1st trimester: possible congenital malformations In the Nov. 22, 2005, issue of CMAJ, in the Health and Drug Alerts section, Williams and Wooltorton discussed the results of an unpublished study by GlaxoSmithKline, which led the US Food and Drug Administration and Health Canada to warn that one SSRI, paroxetine (Paxil), may increase the risk of major congenital malformations when used during the first trimester of pregnancy. They conclude that any woman of childbearing age being treated with paroxetine should be counselled on the absolute and relative risks and that if pregnancy is a real possibility, consideration be given to switching medications. CMAJ 2005;173(11):1320-1 Assessing the ALPHA form A pregnant woman's psychological health is a significant predictor of poor postpartum outcomes such as child abuse, postpartum depression and couple dysfunction. Carroll and colleagues performed a randomized controlled trial to assess the effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial concerns in a total of 227 pregnant women. They found that health care providers who used the ALPHA form were almost twice as likely as providers who did not use the form to detect the psychosocial concerns, and 7 times as likely to detect women who had experienced or witnessed abuse as children. CMAJ 2005;173(3):253-9 In a Commentary, Matthey reviewed a number of similar screening tools and emphasized the value of routinely listening to and assessing the worries and concerns expressed by pregnant women. CMAJ 2005;173(3):267-9 Severe maternal morbidity in Canada Because maternal death is rare in Canada, severe maternal morbidity could be used as a proxy for monitoring the quality of care. Using retrospective data for more than 2 million Canadian women who gave birth between 1991 and 2000, Wen and colleagues estimated the incidence of severe maternal morbidity at about 1 per 250 deliveries and found that the presence of a major pre-existing chronic disease increased the risk almost 6-fold. CMAJ 2005;173(7):759-63
Beta-blockers, thiazides and decreased fracture risk Bhandari and Devereaux reviewed a 2004 study that suggested that beta-blockers and thiazide diuretics may decrease the risk of fracture by theoretically improving bone mineral content. CMAJ 2005;172(1):37
National consumer drug safety network: PharmaWatch The Network hopes to create a bilingual Web-based source of drug information; help Canadians play an active role in developing public policies that reduce the harmful effects associated with prescription drugs, including working for a ban on direct-to-consumer advertising; support equitable access to safe medicines and non-drug therapies; and encourage consumer reporting of adverse drug events. CMAJ 2005;172(9):1168
Medication history errors Vincent Tam and colleagues conducted a systematic review of 22 quantitative studies of the frequency, type and clinical importance of medication history errors at hospital admission and found these types of errors occurred in 67% of the cases cited in these studies. They noted that accurate medication histories at the time of hospital admission are an important element of patient safety. They also stated that, considering the fact that research has suggested that incomplete histories may account for over 25% of hospital prescribing errors, their results indicated a need for a systematic approach to ensure the acquisition of accurate medication histories at the time of hospital admission. CMAJ 2005;173(5):510-5 Middle ear infections: Prescribe antibiotics, or not? Whether to “watch and wait” or prescribe antibiotic treatment when a child presents with middle ear infection is an ongoing debate, and the scientific evidence on which approach is better is inconclusive. Le Saux and colleagues reported on a randomized controlled trial in which 512 children aged 6 months to 5 years in whom a new episode of acute otitis media was diagnosed received either amoxicillin or placebo. The results showed a higher rate of cure after 14 days in the group receiving amoxicillin. However, there was no statistical difference in the number of adverse events or in recurrence rates between the 2 groups. CMAJ 2005;172(3):335-41 Identifying fetal alcohol spectrum disorder Loock and colleagues presented the pivotal role of family physicians in relation to fetal alcohol spectrum disorder (FASD). They highlighted the salient messages for FPs from a comprehensive guideline on FASD diagnosis that was a supplement to the March 1 issue of CMAJ . CMAJ 2005;172(5):628-30 The supplement is available at www.cmaj.ca/content/vol172/5_suppl/index.dtl Vitamin D deficiency in healthy newborns Weiler and colleagues sought to determine whether vitamin D deficiency at birth is associated with bone mineral content of Canadian infants. They measured plasma 25-hydroxyvitamin D as an indicator of vitamin D status in 50 healthy mothers and their newborn term infants and determined the bone mineral content of infants 15 days after delivery. A high rate of vitamin D deficiency was observed among the women and their infants. Among the infants, vitamin D deficiency was associated with greater weight and length but lower bone mass relative to body weight. CMAJ 2005;172(6):757-61 In his Commentary, Ward compared the main findings of Weiler and colleagues' study with other evidence and provided advice on optimal sources of vitamin D. CMAJ 2005;172(6):769-70 Childhood predictors of smoking in adolescence Predictors of teenage smoking that are commonly cited are parental smoking during the teen's childhood, peer pressure during adolescence, and larger lung volumes. Becklake and colleagues investigated these and other possible predictors of teenage cigarette smoking and found that salivary cotinine, a measure of uptake of environmental tobacco smoke, was a significant predictor. It is possible that efficient absorption in childhood of nicotine from second-hand tobacco smoke renders adolescents susceptible to nicotine-seeking behaviour. CMAJ 2005;173(4):377-9 In a related commentary, Anthonisen and Murray wondered whether such findings mean that future anti-smoking interventions will be directed at susceptible subpopulations rather than the population at large. CMAJ 2005;173(4):382-3 Reducing pain in children receiving IV cannulation Taddio and colleagues performed a double-blind randomized controlled trial to evaluate the effectiveness of liposomal lidocaine 4% cream in reducing the pain, procedure time and failure rate of intravenous cannulation in children. Liposomal lidocaine improved the success rate of cannulation, and reduced pain and procedure time. The authors suggested that liposomal lidocaine can be recommended for cutaneous analgesia in children. CMAJ 2005;172(13):1691-5 In a Commentary, Pitetti described recent changes in medical perceptions of how children experience pain and emphasized the importance of decreasing or avoiding the pain experienced by children when undergoing diagnostic or therapeutic procedures. CMAJ 2005;172(13):1699 Asthma Consensus Guidelines for children Although Canadian guidelines for the diagnosis and management of asthma have been published over the last 15 years, little attention has been paid to issues relevant to asthma in childhood. Accompanying the Sept. 13 issue, as a supplement, were updated recommendations for the prevention, assessment and management of asthma in children. www.cmaj.ca/content/vol173/6_suppl/index.dtl Introducing gluten to an infant's diet Belanger and Wooltorton examined the research on the link between when gluten is introduced into an infant's diet and the risk of celiac disease autoimmunity
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Drug approval system questioned in US and Canada Eggertson reported that as the FDA's drug approval process was coming under increasing scrutiny in the US, Health Canada was moving closer to beginning concurrent drug reviews with the US regulator. The joint reviews would take place under the terms of a memorandum of understanding that the two nations signed in April 2004. CMAJ 2005;172(3):317-8 References cited in pharmaceutical ads Cooper and Schriger examined 438 ads published over 1 year in 10 US medical journals. They found that 29% of the ads did not cite any references. Of the references that cited unique source documents, 55% were to journal articles and 19% were to “data on file.” Of the original research cited in the ads, 58% was sponsored by or had authors affiliated with the product's manufacturer. Although the references to journal articles were easily obtainable, other published sources were not, and references to unpublished material were seldom available. Improved accessibility to references and monitoring of their validity are required to help clinicians obtain and evaluate the evidence offered in support of claims made in pharmaceutical ads. CMAJ 2005;172(4):487-91 Effect of prescription drug cost-sharing In a cohort of elderly patients with rheumatoid arthritis, Anis and colleagues found that British Columbia's policy of having elderly patients pay an annual maximum to cover dispensing fees of prescription drugs led to decreased drug use and increased use of free care such as in-hospital drug therapy and physician visits. CMAJ 2005;173(11):1335-9 In a related Commentary, Tamblyn suggested that such policies undermine efforts to shift hospital-centric care to the community. CMAJ 2005;173(11):1343-4 Preventive care and the family doctor The family physician's office is awash in preventive care recommendations and patients who, urged on by reports in the popular media and messages from disease-specific interest groups, demand screening measures that may be inappropriate or even harmful. Pimlott discussed the need for prioritizing even grade A recommendations and for educating the public on how — and which — preventive strategies are best delivered. CMAJ 2005;173(11):1345-6 Epidemic hysteria Mass sociogenic illness, or epidemic hysteria, is a form of somatoform disorder that occurs in the context of a credible threat that provokes great anxiety. Weir listed the 8 symptoms and conditions that indicate its occurrence and suggested appropriate actions to limit its spread. CMAJ 2005;172(1):36 The HAMD-7 Rating Scale and depression McIntyre and colleagues validated a 7-item version of the Hamilton Depression Rating Scale as a brief clinical tool to measure symptom severity in depressed patients. They found that the shortened version is easy to administer and equivalent to the HAMD-17 in assessing remission from major depression after a 2-year treatment period. CMAJ 2005;173(11):1327-31 Modern antipsychotic drugs Modern “atypical” antipsychotic drugs are generally promoted as being clinically superior to older drugs in this class. Gardner and colleagues examined the pharmacology, efficacy, tolerability, adverse effects and cost of the newer, so-called “second-generation” antipsychotics. Modern antipsychotic drugs carry a somewhat lower risk of adverse extrapyramidal symptoms than do older drugs, but they do not present great advances in clinical effectiveness or tolerability, and they are much more expensive. Moreover, some of them present potentially important adverse effects associated with weight gain. Thus, it is reasonable to consider both older and newer antipsychotic drugs for the treatment of psychotic disorders and to inform patients of the relative benefits, risks and costs associated with specific choices. CMAJ 2005;172(13):1703-11 Sushi Weir revisited the public health reasons for the Ontario government's decision that all fish intended to be consumed raw has to be frozen at –20°C and she described the symptoms and treatment of anasakiasis. CMAJ 2005;172(3):329 Malaria Weir advised a systematic investigation of the causes of fever in patients who travel internationally, because malaria may well be the cause. CMAJ 2005;172(4):473 Whooping cough
Pertussis is occurring more frequently among children who are too young to be vaccinated and among adolescents and adults. This is due mainly to waning immunity among vaccinated individuals, who become susceptible to infection in adolescence and adulthood. Since the clinical presentation in adolescents, adults and vaccinated people may be solely a cough of short duration or simply a persistent cough, and because lab and microbiologic tests take time, therapy with erythromycin, azithromycin or clarithromycin should be administered on the basis of a clinical diagnosis. Tozzi and colleagues reviewed recent findings and issues in the diagnosis, treatment and prophylaxis of pertussis. CMAJ 2005;172(4):509-15 Whooping cough among adolescents and adults The recent increase in the incidence of whooping cough among infants despite a high vaccination rate is associated with an increased infection rate among adolescents and adults, who have become a reservoir of the pathogen Bordetella pertussis . This implies that immunity to pertussis, whether infection- or vaccine-induced, wanes over time. Preston reviewed the findings of the Bordetella genome project and examined how new knowledge of the molecular basis of B. pertussis pathogenesis can be used in the development of strategies for the eradication of the disease. CMAJ 2005;173(1):55-62 MRSA — Staphylococcus aureus Dhaliwal and McGeer reviewed and commented on a 2005 study on the effectiveness of isolation measures in preventing the spread of methicillin-resistant Staphylococcus aureus (MRSA). CMAJ 2005;172(7):875 Safer playgrounds, fewer injuries
When changes to the CSA standards for playground equipment prompted the removal of unsafe equipment from 136 elementary schools in Toronto, Howard and colleagues determined the impact on the number of playground injuries among school children. They found that the injury rate decreased in the 86 schools where the playground equipment was replaced, such that a total of 550 injuries were avoided during the 10-month study period after safe equipment was installed. CMAJ 2005;172(11):1443-6 Well water contamination The safety precautions that all users of private wells should take to keep their water safe from contamination were reviewed by Weir. In most jurisdictions water from private wells is not protected by drinking-water regulations and it's up to owners to regularly test water quality. Good times to test are during spring run-off, after a heavy rain, after work has been done on the well, or after there have been changes in nearby land use or changes in the colour or smell of the water. CMAJ 2005;172(11):1438 Shingles Weir commented on a potent new vaccine against varicella zoster virus and how it might affect the incidence of shingles. CMAJ 2005;173(3):249 Does socioeconomic status affect rates of diagnostic imaging? Although the use of health care services in a publicly funded system should be equal among all members of society, this is not always the case in practice. After analyzing population-based data, Demeter and colleagues found a pattern of increased use of diagnostic imaging in patient groups with higher incomes. CMAJ 2005;173(10):1173-7 Support groups for single mothers Lipman and Boyle assessed the effect of a community-based program of support and education groups on maternal well-being and parenting. Compared with single mothers who received a standard list of community resources, those in the intervention group had improved scores for depressed mood and self-esteem in the short term, but not for social support and parenting. However, the positive effects did not last over the longer term. CMAJ 2005;173(12):1451-6 Genomics and public health Knowledge about the human genome will lead to tools for clinical diagnosis at all levels of health care. Scientists are currently trying to identify numerous common genetic variants that increase or decrease individual risk for disease. However, current consent and privacy mechanisms may limit the use of the genome databases used as gene or “biobanks” in this research. Knoppers discussed these issues and the concept of “public” or “common” goods to provide ethical and legal principles to these research endeavours. CMAJ 2005;173(10):1185-6 Consequences of acute bacterial gastroenteritis: Walkerton fallout To determine the long-term health effects of acute bacterial gastroenteritis, Garg and colleagues followed 1,958 residents of Walkerton, Ont., for nearly 4 years after an outbreak of acute gastroenteritis due to contamination of the regional drinking water supply with Escherichia coli O157:H7 and Campylobacter species. Newly diagnosed hypertension was detected in 27% of participants who had been asymptomatic during the outbreak and in 32% and 36% of those who had had moderate and severe symptoms of gastroenteritis respectively. These increased rates of hypertension were accompanied by evidence of reduced kidney function. These findings suggest that acute bacterial gastroenteritis is an important risk factor for long-term health effects such as hypertension and renal impairment. CMAJ 2005;173(3):261-6 Homelessness and pregnancy Homelessness during pregnancy exposes women to poor nutrition, violence and substance use. How this affects the health of their newborn infants has not been systematically researched. When Little and colleagues studied a cohort of 3,756 women they found that homeless or inadequately housed women delivered earlier and had smaller babies than women in their control group. These effects were exacerbated when substance use was also involved. CMAJ 2005;173(6):615-8 Meningococcal disease Invasive meningococcal disease is endemic in Canada, with 2 cases per 100,000 population per year. Murray reminded readers of the diagnosis, clinical management and requirements for public health reporting of meningococcal disease. CMAJ 2005;173(12):1443-4
Asthma Stanbrook reviewed a 2005 multicentre, randomized, double-blind trial that studied whether daily or “as-needed” inhaled steroid use provided the most benefit for patients with mild persistent asthma. They concluded that an as-needed treatment strategy may be acceptable, provided it is accompanied by education and an action plan with clear instructions about how and when to increase medication use. CMAJ 2005;172(11):1439 Addressing the shortage of rural physicians A Society of Rural Physicians of Canada Task Force presented recommendations on how Canada may tackle shortages of rural physicians by encouraging more students of rural origin to pursue medical training. Strategies centred on educational initiatives, funding support, and changes to the admissions process. The Task Force believe their recommendations could lead to an increase in the number of students from rural backgrounds admitted to medical school, which could “ultimately produce more graduates who choose a career in rural practice.” CMAJ 2005;172(1):62-5 Preferred formats for abridged scientific articles Several scientific and general medical journals now publish full-length articles on their Web sites, with abridged versions in their print journals. When readers and authors of the BMJ were asked which of 3 formats of abridged articles they preferred, a conventional format was selected over a version using an enhanced abstract and another using newspaper-style headings. A significant percentage of respondents said that they would not submit their papers to the journal if the enhanced-abstract or journalistic format was used. CMAJ 2005;172(2):203-5 New copyright proposals Geist analyzed new copyright proposals that may restrict access to online information otherwise publicly available and looked at the potential impact on research, medical education and practice in Canada. CMAJ 2005;172(8):989-90 Clinical trial registration On May 23, 2005, the members of the International Committee of Medical Journal Editors (ICMJE), which includes CMAJ, published a joint statement announcing that, for the next 2 years, only clinical trials fully registered in a publicly available and searchable registry will be considered for publication. The ICMJE journals will apply this policy to all trials beginning after July 1, 2005, and to ongoing trials, which should be registered by Sept. 13, 2005. CMAJ 2005;172(13):1700-2 Balance training to prevent sports-related injuries Among adolescents, sport is the leading cause of injury requiring medical attention. Proprioceptive balance training is used in sports-related injury rehab. It is also becoming recognized as an important element in injury prevention. Over a 6-month period Emery and colleagues measured the effectiveness of proprioceptive balance training in improving balance in adolescents and in reducing sports-related injury. After 6 weeks of progressive daily balance training using a wobble board, static and dynamic balance had improved in the intervention group. For the remainder of the 6 months the adolescents in the intervention group maintained their improved balance by training weekly. During that observation period, fewer adolescents in the intervention group than in the control group reported sports-related injuries. CMAJ 2005;172(6):749-54 Perioperative cardiac events in noncardiac surgery Increasing numbers of patients worldwide are undergoing noncardiac surgery because of substantial advances in the surgical treatment of diseases and improvement of patients' quality of life. However, such surgery is associated with significant cardiac morbidity and mortality and consequent costs. In the first of 2 Review articles on the topic, Devereaux and colleagues examined the magnitude of the problem of perioperative cardiac events in noncardiac surgery, the pathophysiology, approaches to cardiac risk assessment and how physicians should communicate this risk to patients. CMAJ 2005;173(6):627-34 Up to 50% of perioperative myocardial infarctions (MIs) may go unrecognized if physicians depend only on clinical signs and symptoms. In the second of 2 Review articles on major perioperative cardiac events in patients undergoing noncardiac surgery, Devereaux and colleagues reviewed the evidence regarding monitoring strategies for perioperative MIs in such patients and proposed diagnostic criteria that reflect the unique features of these events. In addition, they examined the evidence supporting perioperative prophylactic interventions. CMAJ 2005;173(7):779-88 Nonsurgical management of small-bowel obstructions Most cases of partial small-bowel obstruction are managed conservatively, with patients receiving nothing by mouth. Long hospital stays are often required, and surgery may be necessary because of complications. Chen and colleagues, in a randomized controlled trial, found that enhancing standard conservative management with the oral administration of a laxative, a digestant and a defoaming agent was effective in reducing the length of hospital stay and the subsequent need for surgery. CMAJ 2005;173(10):1165-9 Repeat induced abortion and a history of sexual abuse Fisher and colleagues used a 65-item self-report questionnaire to survey a consecutive series of women presenting for induced abortion. They found that women undergoing repeat induced abortion were more likely to have a history of sexual abuse or sexual violence compared with women presenting for a first abortion. Other frequent characteristics for this group were increased age, oral contraceptive use, and having given birth. These findings raise the question of whether to screen women presenting for an induced abortion for a history of abuse. CMAJ 2005;172(5):637-41 In her Commentary, Phillips considered the link between victimization and unplanned pregnancy. Pointing out that a paradoxical effect of the demise of abortion committees may be a reduced awareness of the circumstances of women who seek abortion, she recommended that all women patients be screened for exposure to violence. CMAJ 2005;172(5):653-4 Emergency contraception: Plan B
Soon and colleagues analyzed the data generated by a public health policy initiative in BC that has allowed trained pharmacists to provide emergency contraceptives without a prescription. They found that in the first 2 years after the policy initiative the use of emergency contraceptives more than doubled. The authors estimated that, in the same period, about 550 pregnancies in 13,717 women were prevented by pharmacist-provided emergency contraception. CMAJ 2005;172(7):878-83 A News article by Sibbald looked at pros and cons of women having to consult with a pharmacist before being allowed to purchase Plan B ( CMAJ 2005;172[7]:861-2), and CMAJ 's Editorial welcomed improved access to levonorgestrel but questioned the requirement for pharmacist consultation ( CMAJ 2005;172[7]:845). Plan B: The controversy heated up Eggertson and Sibbald delved further into the privacy issues that were raised over Plan B. Several provincial privacy commissioners and the Women's Health Network are concerned over pharmacists collecting personal data from women in the name of “counselling” before dispensing Plan B. CMAJ 2005;173(12):1435-6 In a Dec. 21, 2005, Early Release online News story, Eggertson reported that Ontario pharmacists had dropped the controversial screening form their pharmacists were using before dispensing Plan B ( CMAJ 2005;doi:10.1503/cmaj.051681). Letters to the Editor and all articles on this topic are available online: cmaj.ca Women's sexual dysfunction Definitions of women's sexual dysfunction have changed substantially in the last several years as a result of new research and clinical experience. Unlike previous definitions, these new ones acknowledge the highly contextual and complex nature of women's sexuality and take into account its subjective aspects. In addition to describing the characteristics of women's normal sexual motivation, interest, arousability and response, Basson summarized female sexual dysfunctions and offered a general approach to diagnosis and treatment. CMAJ 2005;172(10):1327-33 Trafficking in women The authors analyzed the extent of trafficking in women worldwide and in Canada and the health problems these women experience. CMAJ 2005;173(1):25-6 Older women's health priorities and perceptions of care Tannenbaum and colleagues surveyed women aged 55–95 years from across Canada about their health priorities and their perceptions about the degree to which their priorities are being addressed by their health care providers. The priorities identified most frequently were preventing memory loss, learning about medication side effects and correcting vision impairment. According to the women's perceptions about care delivery, health care providers are addressing many, but not all, of their health concerns. CMAJ 2005;173(2):153-9 In their Commentary, Phelan and LoGerfo pointed out the apparent mismatch between what older women's health concerns are and what health care providers focus on, and the need for clinicians to discuss the benefits of interventions within the context of their patients' goals and values. CMAJ 2005;173(2):165-6 ** | |
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