Highlights of this issue

Blastomycosis

Blastomycosis is a potentially fatal infection with the dimorphic fungus Blastomyces dermatitidis. It is primarily acquired through inhalation of inoculum from contaminated environmental material, mostly in rural and woodland areas, and is endemic in the Great Lakes region and the Mississippi and Ohio river valleys in the United States. Three case reports, by Robert Lester and colleagues and by John Ross and Douglas Keeling, describe infections apparently acquired outside this area of endemicity, in urban Toronto and in New Brunswick, respectively. They suggest that the area of endemicity may be more extensive than previously assumed and that physicians should be prepared to include blastomycosis in the differential diagnosis of unexplained granulomatous pulmonary or cutaneous disease.

See pages 1303 and 1309

Maternal weight gain and gestational diabetes among the Cree

Gestational diabetes and type 2 diabetes are prevalent in Aboriginal communities. There is evidence that reducing weight gain in obese women during pregnancy may reduce increases in fasting insulin concentrations. Katherine Gray-Donald and colleagues describe an interventional study among the Cree of James Bay in which regular, individual diet counselling and physical activity sessions were used in an attempt to reduce maternal weight gain. However, there were no significant differences between subjects and controls at 6 weeks post partum. The authors reflect on the cultural context that favours plumpness in women and weight gain in pregnancy and considers physical activity during pregnancy undesirable. An accompanying commentary suggests culturally appropriate ways of modifying and extending these interventions and emphasizes the importance of full involvement of the local community.

See pages 1247 and 1273

CME in Mexico

The Mexican Institute of Social Security comprises 1450 family medicine clinics, 240 secondary care hospitals and 10 tertiary care centres. Ricardo Pérez-Cuevas and coauthors describe the development and initial implementation of a continuing medical education program for the Institute's primary care physicians. The program involved developing clinical practice guidelines for acute respiratory infections and type 2 diabetes, training of clinical instructors, an educational intervention and evaluations of physicians' performance and patients' health status. The likelihood of physicians using appropriate strategies to manage the target illnesses increased with the intervention. A commentary by Dave Davis highlights the strengths of this approach, particularly the integration of the education component into the practice setting, the emphasis on action and the study of performance measure of outcome.

See pages 1278 and 1295

Cardiovascular disease

Although lipid-lowering treatment is indicated for people with cardiac disease, primary prevention of cardiovascular disease is more problematic because such disease may never develop in many people with lipid abnormalities. Steven Grover and coworkers evaluate the accuracy of the 1998 Canadian lipid guidelines for predicting people at high risk for coronary artery disease. They found that counting risk factors was less accurate than calculating risk using Framingham risk equations, particularly for women, and that the 1998 guidelines identified high-risk people more accurately than previous guidelines. The authors estimate that 5.9 million Canadians currently free of cardiovascular disease would be eligible for screening and 322 705 (5%) would require lipid therapy.

See page 1263

Total joint replacement

In BC alone 2600 hip replacements and 2100 knee replacements were performed in 1997. Owen Brady and coauthors point out that disorders requiring joint replacement are not restricted to elderly people. Congenital or developmental dislocations of the hip or trauma may cause degenerative joint disease, and total hip arthroplasty may be required for maximum pain relief. Trivial knee injuries in young people may eventually lead to degeneration of the joint and the need for a knee replacement. Thus, most primary care physicians will deal with patients who have undergone or are likely to require joint replacement. When should a patient be referred for total joint replacement? The authors suggest the main indication continues to be pain. They also describe total hip and knee arthroplasty, the postoperative care that is required and potential complications.

See page 1285