Highlights of this issue
========================


## Insomnia and benzodiazepines

FIGURE 1 Insomnia is a symptom rather than a disease. It is highly prevalent and is often due to common underlying conditions. Benzodiazepines remain a common treatment choice despite uncertainty about the risk-benefit ratio. Anne Holbrook and colleagues present the results of a meta-analysis of 45 randomized controlled trials, all of short duration, comparing benzodiazepines with alternate therapy or placebo. Benzodiazepines were associated with a small improvement in sleep duration (mean 61.8 minutes [95% CI 37.4-86.2]) countered by a propensity for adverse effects, including a decline in cognitive function. How do we weigh extra minutes of sleep against the possibility of cognitive impairment or dependence?

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/2/185/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/162/2/185/F1)

Figure 1. 

**See pages 216 and 225** 

## Telemedicine and ultrasonography

Rajaram Reddy and colleagues have evaluated the efficacy and reliability of teleobstetric ultrasonography services provided from an urban centre to a remote hospital. Forty-nine women underwent 2 second-trimester screening ultrasound examinations. The first was conducted at the local hospital by a technologist and the images were reviewed by a radiologist at the urban centre using 2 personal computers, a modem and a conventional (analog) telephone line. The second required the women to travel 200 km to a regional hospital, where the examination was performed under direct supervision of a radiologist. The quality of the transmitted images was reportedly excellent. There was no significant difference between the 2 groups in the mean gestational age (*r* = 0.979, *p* < 0.001), and 4 abnormalities were detected and reported identically on both examinations.

**See page 206** 

## Who should pay for ACE inhibitor therapy?

FIGURE 2 Angiotensin-converting-enzyme (ACE) inhibitor therapy can significantly delay the progression of diabetic nephropathy to end-stage renal failure. However, the cost of ACE inhibitors often leads to poor compliance. William Clark and colleagues have conducted a decision and cost-utility analysis to assess whether provincial governments should pay for this therapy. By assuming a 34% increase in compliance with the removal of the cost barrier, the authors predict an increase in quality-adjusted life-years of 0.147 coupled with an annual cost savings of $849 per patient.

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/2/185/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/162/2/185/F2)

Figure 2. 

**See page 195** 

## Following up on fenfluramines

Fenfluramines were withdrawn in 1997 because of suspected associations with pulmonary hypertension and valvular heart disease. However, according to Allan Sniderman, careful review of the evidence raises questions about these associations. There were important inconsistencies among the reports of associations with pulmonary hypertension. Also, almost none of the numerous studies since the initial reports of valve disease have identified a significant excess of mitral valve disease. Since patients deserve to know the truth, Sniderman believes regulatory agencies should apply the same thoroughness in following up major adverse drug reactions as they do in their initial evaluation of the drug.

**See page 209** 

## Screening for HAV and HBV

FIGURE 3 People with chronic hepatitis C virus (HCV) infection are at high risk for fulminant liver failure if they acquire hepatitis A. To measure the seroprevalence of hepatitis A virus (HAV) and hepatitis B virus (HBV) in this population, Lori Kiefer and colleagues tested all stored blood samples of 341 people who tested positive for HCV between June and September 1997. The overall prevalence for HAV was 53.1% (95% confidence interval [CI] 47.6%-58.5%) and for HBV 44.3% (95% CI 38.9%-49.7). The authors conclude that most HCV-positive people should be screened for HAV and HBV infection before immunization and that immunization should be offered early since the seroprevalence rate increases with age.

![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/162/2/185/F3.medium.gif)

[Figure3](http://www.cmaj.ca/content/162/2/185/F3)

Figure 3. 

**See page 207** 

## Footnotes

*   January 25, 2000