Highlights of this issue
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## Immunization woes

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/168/5/537/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/168/5/537/F1)

Figure. Photo by: Canapress

Immunization against common diseases is heralded as one of the greatest successes in medical history; however, there is evidence that current vaccination patterns are far from optimal. In Canada, signficant variation in immunization practice raises concerns about inadequate coverage, as stated in a commentary by Monika Naus and David Scheifele and reported in a related News article. This, coupled with evidence discussed in our Public Health page that some vaccinations are not as effective as previously believed, can lead to an increased incidence of preventable disease and significant secondary complications, as noted in our News section. An unusual manifestion of a preventable illness, congenital varicella syndrome (CVS), is also reported in this issue. Massimo Mazzella and colleagues describe a case of CVS, most likely resulting from intrauterine reactivation following primary infection, in a male infant delivered by cesarean section at 37 weeks' gestation. The neonate had developed massive hydrocephalus and did not survive.

See pages [561](http://www.cmaj.ca/lookup/volpage/168/561?iss=5), [567](http://www.cmaj.ca/lookup/volpage/168/567?iss=5), [589](http://www.cmaj.ca/lookup/volpage/168/589?iss=5), [598](http://www.cmaj.ca/lookup/volpage/168/598?iss=5) and [599](http://www.cmaj.ca/lookup/volpage/168/599?iss=5) 

## The hype around HOPE

The large Canadian-led Heart Outcomes Prevention Evaluation (HOPE) trial proved the significant beneficial effect of ramipril in the secondary prevention of heart disease. This finding was given considerable attention in the lay and medical media, and prompted heavy marketing by the drug's manufacturer. Karen Tu and colleagues studied the effects of the HOPE trial on prescription rates of ramipril, in particular, and of angiotensin-converting-enzyme inhibitors, in general, and conducted time-series analyses to measure any association with the various stages in the release of the HOPE results. The data showed a striking 400% increase in ramipril prescriptions for elderly patients, including groups that would not have been eligible for the trial. In a related commentary, Louise Pilote discusses the reasons behind the large increase in ramipril prescriptions and whether they were appropriate.

See pages [553](http://www.cmaj.ca/lookup/volpage/168/553?iss=5) and [568](http://www.cmaj.ca/lookup/volpage/168/568?iss=5)

## Drinking, drugs and driving: a student survey

As part of the 2001 Ontario Student Drug Use Survey, students were asked about their pattern of driving in relation to their use of alcohol or cannabis. Alcohol-related motor vehicle collisions are a major source of injury among adolescents, and the risk is great for both passengers and drivers. Although fewer data are available on cannabis and its association with collisions, any intoxication is a concern, particularly in young drivers. Of 1846 students from grades 7 to 13, 32% reported having been a passenger in a car driven by a drunk driver, and of those who had a driver's licence, 15% reported driving while under the influence of alcohol, and 20% after using cannabis. Edward Adlaf and coworkers discuss the implications of these findings.

See page [565](http://www.cmaj.ca/lookup/volpage/168/565?iss=5)

## Graves' disease

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/168/5/537/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/168/5/537/F2)

Figure. Photo by: Chesley Sheppard

The classic presentation of Graves' disease, consisting of thyrotoxicosic symptoms, goitre and ophthalmopathy, is well known even to new medical students. This familiarity belies the complexity of this thyroid disease. Jody Ginsberg discusses the elegant physiology underlying the pathology and the role of the primary care physician in diagnosis and managment.

See page [575](http://www.cmaj.ca/lookup/volpage/168/575?iss=5)