Highlights of this issue
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## Nutritional support in the intensive care unit

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/2/169/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/170/2/169/F1)

Figure. Photo by: Eric Field

Optimal nutritional support for critically ill patients decreases morbidity and mortality. How patients are fed is also a key factor: enteral feeding can decrease the incidence of sepsis, whereas parenteral feeding may increase mortality. Martin and colleagues report the results of a cluster-randomized clinical trial of an algorithm that stresses early enteral nutritional support in the critical care setting. Compared with patients who received nonstructured nutritional support, those who received nutritional support according to the algorithm had improved hospital mortality rates and significantly shorter mean hospital stays. Although the treatment of critically ill patients is complex, this study adds clarity to one important factor.

See page [197](http://www.cmaj.ca/lookup/volpage/170/197?iss=2)

## Global health

Continuing with our commitment to report on global health, we follow the progress of a federal bill that would ease patent restrictions to allow the export of generic medications from Canada to developing countries. A new prime minister at the helm and an anticipated federal election in the coming months may be distraction enough to stall the bill indefinitely. In a commentary, Orbinski calls for action on this issue and points out that Canada has an opportunity to set a strong international precedent.

See page [224](http://www.cmaj.ca/lookup/volpage/170/224?iss=2)

## Adverse effects of antiretroviral therapy

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/2/169/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/170/2/169/F2)

Figure. 

Highly active antiretroviral therapy (HAART) significantly reduces AIDS-related morbidity and mortality. However, adverse effects limit the use of HAART for many patients. Montessori and colleagues review these adverse effects, which include lactic acidosis, hepatic toxicity, hyperglycemia, lipodystrophy, hyperlipidemia and osteoporosis. They also explain the various mechanisms of toxicity associated with HAART and offer recommendations on how to monitor patients receiving this therapy.

See page [229](http://www.cmaj.ca/lookup/volpage/170/229?iss=2)

## Universal health insurance

Some argue that universal health insurance encourages wasteful use of health care services. Proposed cost-saving strategies to discourage such use include user fees and medical savings accounts. Using Manitoba physician billing and hospital expenditure data and Canadian census data, Roos and colleagues examined annual spending on health care in Winnipeg. They report that it was highest among residents of neighbourhoods with the lowest average incomes but that high-cost users came from every socioeconomic group. The authors conclude that, because health care costs are largely driven by poor health and hospital expenditures, user-fee strategies would not help to achieve cost savings.

See page [209](http://www.cmaj.ca/lookup/volpage/170/209?iss=2)

## Surgical treatment of reflux disease

![Figure3](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/170/2/169/F3.medium.gif)

[Figure3](http://www.cmaj.ca/content/170/2/169/F3)

Figure. Photo by: Marisa Bonofiglio

Gastroesophageal reflux disease (GERD) is very common, causes painful symptoms and is a risk factor for esophageal cancer. Although medical therapies are effective, symptoms recur once they are stopped. In a commentary, Urbach and colleagues attempt to clarify the role of surgery in the management of GERD and describe the laparoscopic technique of Nissen fundoplication, a procedure that wraps the gastric fundus around the lower esophagus to create a one-way valve. Because the indications for surgery remain controversial, the authors recommend that it be reserved for a select group of patients and performed by surgeons with expertise in the procedure.

See page [219](http://www.cmaj.ca/lookup/volpage/170/219?iss=2)