Highlights of this issue

Managing homelessness and diabetes

Stephen Hwang and Ann Bugeja interviewed 50 homeless people with diabetes in Toronto shelters about barriers to their care. Overall 72% reported experiencing difficulties managing their diabetes. As many as 40% found it hard to obtain the necessities of life, 40% reported a history of mental illness, and 38% displayed signs of alcohol abuse; however, the respondents did not identify these conditions as barriers. The most commonly cited difficulties were related to the quality of the diet in shelters and to the logistics of scheduling and administering medication. The authors recommend that meals in shelters be assessed to determine whether they meet the standards set by Canada's Food Guide to Healthy Living. In an accompanying commentary James Plumb makes the point that effective prevention of disease among homeless people requires effective prevention of homelessness.

See pages 161 and 172

Physician payment for care of homeless people

In a second article related to homelessness Stephen Hwang and colleagues examine the billing records of 3 physicians who provide care at 3 facilities for homeless people in downtown Toronto to document how frequently physicians are paid for the care they provide. Overall the physicians received payment for only 54% of patient encounters. In 46% of the encounters the patients did not have a valid health insurance card. The authors suggest that special arrangements for physician remuneration may need to be considered if health care outreach programs for homeless people are to be sustained.

See page 170

A primer on primary hyperparathyroidism

Our understanding of calcium homeostasis has advanced since the discovery of the calcium receptor. Aliya Khan and John Bilezikian review the pathophysiology of primary hyperparathyroidism and the roles of surgery, hormone replacement therapy, bisphosphonates and calcimimetic agents in its management. The authors conclude that mild, asymptomatic disease can be followed without surgical intervention. In an accompanying commentary Kerry Siminoski disagrees with this conclusion, pointing out that surgical resection of adenomas is safe and effective whereas the costs of monitoring these patients exceeds the expense of surgery after only a few years.

See pages 173 and 184

β-Blockers get in line

James Wright reviews the evidence for the effectiveness of β-blockers in the management of hypertension. Data from comparative trials demonstrate that the reduction in systolic blood pressure is significantly greater with thiazides (2.3 mm Hg) than with β-blockers. The mean rate of treatment withdrawal due to adverse drug reactions was significantly higher among patients given β-blockers than among those given thiazides (10% v. 6.9%, p < 0.001). Even the least expensive β-blockers are much more expensive than the least expensive thiazides. Wright concludes that β-blockers should not be considered first-line drugs for most people with hypertension.

See page 188

Burnout of cancer care workers

Amid growing concern over anecdotal reports of cancer care workers suffering burnout, Eva Grunfeld and colleagues surveyed 1016 physicians, allied health care professionals and support staff in the Ontario cancer care system about job stress. The results are alarming. About one-third of the respondents in each group reported considering leaving their jobs. Emotional exhaustion was reported by 53.3% of the physicians, 37.1% of the allied health care professionals and 30.5% of the support staff. Does this burnout indicate health system overload? And how does it affect patient care?

See page 166