Highlights of this issue

Head trauma

In Canada about 18 000 people with head injuries are admitted to hospital each year. William Pickett and coauthors studied the blunt head traumas seen at emergency departments in Kingston, Ont., in 1998. The annual rate of potential brain injury was 16 per 10 000 among males and 7 per 10 000 among females, the greatest disparity between the sexes occurring among those aged 10–19 years. The leading causes of potential brain injury were age dependent: they most often resulted from falls from heights among those less than 10 years old, from falls of any kind among those over 65 and from accidents involving motor vehicles or bicyles, sports-related injuries or fights among those 10 to 44 years old.

See page 288

Quality of treatment of congestive heart failure

Current guidelines for the management of congestive heart failure (CHF) emphasize assessment of left ventricular function and treatment with an angiotensin-converting enzyme (ACE) inhibitor. Evette Weil and Jack Tu reviewed the charts of 200 patients with CHF admitted to a teaching hospital in Toronto in 1997. Of these patients, 177 (88.5%) underwent left ventricular function testing before or during their hospital stay; most of those tested (117 [66.1%]) had systolic dysfunction. Of 100 patients considered to be ideal candidates for ACE inhibitor therapy, 89 received the treatment, but only 23 were prescribed doses comparable to those used in clinical trials. Nadia Giannetti comments on current practice, the results of the study and what more can be done.

See pages 284 and 305

Waiting times to diagnosis

Ivo Olivotto and coauthors examine the waiting times to diagnosis among 13 958 women with an abnormal screening result who attended 1 of 7 provincially organized breast cancer screening programs in 1996. The median time from screening to first assessment was 2.6 weeks and from screening to diagnosis 3.7 weeks; 10% of the women waited 11.3 weeks or longer for a diagnosis. Biopsy prolonged the wait (median wait 3.1 weeks without biopsy and 6.9 weeks with biopsy). Among the women who had a biopsy, those found to have cancer had shorter waiting times than women with benign findings; however, 10% of the women with breast cancer waited 12 weeks or longer for the diagnosis. Pasteur Rasuli comments on the benefits of additional diagnostic tests, including the freeing up of scarce surgical resources by removing the large number of women with false-positive screening results from the surgical waiting list.

See pages 277 and 303

Hepatitis A in high-risk groups

In Vancouver recurrent outbreaks of hepatitis A among injection drug users and men who have sex with men have contributed to a hepatitis incidence rate up to 3 times the provincial average. Jan Ochnio and coauthors measured the frequency of past hepatitis A virus (HAV) infection in a sample of 494 Vancouver street youth, injection drug users and men who have sex with men. Anti-HAV antibodies were found in 6.3% of street youth (95% confidence interval [CI] 2.6%–12.6%), 42.6% of injection drug users (95% CI 36.2%–48.9%) and 14.7% of participants who denied injection drug use (95% CI 10.4%–19.1%). Logistic regression analysis revealed that past HAV infection was associated with increased age and birth in a country with high rates of hepatitis infection. Among young adults, injection drug use was a significant risk factor (p = 0.009).

See page 293

Challenges of tPA in stroke

The use of tissue plasminogen activator (tPA) in acute stroke was recently approved in the United States and Canada; however, its benefits and risks are still much debated. David Gladstone and Sandra Black examine protocols and outcomes in the phase III studies that led to the approval of tPA in Canada and then review the postmarketing data accumulated to date. The challenges that remain include improving public awareness of the symptoms of stroke and health care system responsiveness in order to increase the number of patients treated within the first 3 hours after stroke onset and identifying rapidly the patients most likely to benefit from tPA and those at particular risk of tPA-related hemorrhage.

See page 311