Highlights of this issue

Discontinuing benzodiazepine use in elderly patients

Figure. Photo by: Romi Caron

Despite the risks of dependence, benzodiazepines are often prescribed to elderly patients for extended periods to treat insomnia. In such cases, because the abrupt cessation of benzodiazepine use may be fatal, the usual management of benzodiazepine dependence consists of gradual tapering. However, 50%–60% of patients may resume use of the drug afterward. In a study involving older insomniac adults, Baillargeon and colleagues show that, when tapering is combined with cognitive behavioural therapy, 67% of patients remained benzodiazepine free at 3 months, as compared with 34% who had only tapering. This effect was maintained at 12 months of follow-up. The details of the cognitive behavioural therapy are available in an online table accompanying the article (www.cmaj.ca).

See page 1015

Rehabilitation series: dysphagia in stroke patients

In the second part of CMAJ's series on rehabilitation medicine, Finestone and Greene-Finestone outline a practical approach to the management of dysphagia in patients who have had a stroke. They review the clinical signs and symptoms of dysphagia, the diagnostic workup and the dietary strategies for such patients. As well, in online appendices that accompany their article (www.cmaj.ca), the authors describe the nutritional assessment of stroke patients, provide helpful information on enteral (tube) feeding and describe ways to address nutritional and dietary concerns.

See page 1041

Information gaps in the emergency department

Figure. Photo by: comstock.com

Patients who use multiple health care sites often receive fragmented care owing to the inefficient transfer of information between sites. In a clinical setting that demands timeliness, Stiell and colleagues show that these information gaps can hinder patient care. In a study of 1002 visits to an emergency department, they found that one-third of the visits had at least 1 information gap; almost half of the gaps were deemed essential to patient care by the attending physicians. Information gaps were more likely to occur with sicker patients, including those with chronic medical conditions, those arriving by ambulance, patients requiring a monitored bed and older patients. The authors point out that information gaps can give rise to adverse events and poor patient outcomes, longer stays in the emergency department and unnecessary diagnostic testing. In an age when information can travel around the world in a matter of seconds, it is apparent that the technological framework exists for a solution to this problem.

See page 1023

Screening immigrants for TB

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Most cases of tuberculosis (TB) in Canada are found in immigrants from countries with a high incidence of TB. Although chest radiography has been used for over 50 years as the primary screening tool for TB in Canada, the US Institute of Medicine has recommended that tuberculin skin testing be added to the screening of high-risk immigrants to the United States. In a commentary, Menzies explores the reasons why skin testing may be an unpractical solution to identifying individuals with latent TB. The skin test has the potential to yield many false-positive results in patients who have received the BCG (bacille Calmette–Guérin) vaccine or have been infected with nontuberculous mycobacteria. The author argues that, in contrast, chest radiography has the advantage of more accurately identifying people at risk of reactivation of latent disease, who require antimicrobial therapy. The full-text recommendations of the Canadian Tuberculosis Committee and its Immigration Subcommittee for screening immigrants is available in an online appendix to the article (www.cmaj.ca).

See page 1035