Highlights of this issue

Caregiver burden

Figure. Photo by: Roger LeMoyne. Living Lessons®

The role of family caregivers is crucial in providing support to patients with life-limiting illnesses such as cancer. However, with the attention so firmly placed on the dying patient, the health of the caregiver can easily be overlooked. Grunfeld and colleagues prospectively followed a cohort of 89 caregivers of women with advanced breast cancer for 3 years or until the patient's death. They found that, as the patients moved into the last stages of their illness, a greater proportion of caregivers became depressed and experienced a higher level of burden. A significant proportion of caregivers had to miss work to look after their family member. The mean financial burden borne by families during the patients' illnesses was $8292 for those without and $5765 for those with extended health insurance. The authors raise the point that, with fewer acute care and palliative care beds in the hospital system, family caregivers will be increasingly relied on to provide support for dying cancer patients.

In a related commentary Zarit emphasizes that family caregivers are an essential part of the management team whose needs must be addressed during the course of the patient's illness.

See pages 1795 and 1811

Assessment of chest discomfort in the emergency department

Chest pain is a common presenting symptom in emergency departments. Although acute coronary syndrome (ACS) is a serious potential diagnosis, numerous other causes of chest discomfort may cloud the diagnosis. Christenson and colleagues prospectively examined a cohort of 1819 patients with chest discomfort presenting to the emergency departments of 2 urban tertiary care hospitals. They found that 5.3% of those with an ultimate diagnosis of ACS were inappropriately discharged home without plans for further investigation and that 71.1% of patients without ACS or an adverse event were admitted to hospital or held in the emergency department for more than 3 hours. The authors point out that, although chest pain evaluation units such as those in the United States may improve diagnostic accuracy, the cost-effectiveness of such units has not been tested in Canada. They add that clinical assessment tools are needed to help clinicians identify which patients can safely be discharged after a short period of investigation.

See page 1803

Comparing patient charges in for-profit and not-for-profit hospitals

As proponents of private health care continue to tout the apparent economic benefits of a for-profit system, Devereaux and associates provide a systematic review and meta-analysis of studies comparing payments for care at private for-profit and private not-for-profit hospitals in the United States. The pooled estimate of the 8 studies demonstrates conclusively that private for-profit hospitals are associated with higher payments of care.

In a separate commentary, Woolhandler and Himmelstein discuss the dangers of handing over health care services to private enterprise.

See pages 1814 and 1817

In Synopsis

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Johnston and Baylis review the perilous progress of gene therapy research (see page 1785). Cellucci and associates present a case of intracranial hypertension, or pseudotumour cerebri, in a young woman and discusses the clinical presentation and treatment (see page 1788). Dowlatshahi and colleagues present a case of a diver with bilateral leg weakness (see page 1792); a real-time video of this patient's echocardiogram is available online (www.cmaj.ca). Redelmeier and Van Spall review a study demonstrating that, when passengers in a motor vehicle crash are restrained, they not only improve their own chances for survival but also those of the other occupants (see page 1793).