Highlights

A rule to rule out coronary artery disease in primary care

Five simple pieces of clinical information can be used to diagnose or rule out coronary artery disease in patients in primary care. This clinical prediction rule was derived from a cohort of 1199 patients in Germany and validated in 762 patients in Switzerland. The rule is not meant to replace clinical judgment for assessing acute coronary syndromes but can help exclude coronary artery disease in patients with less acute symptoms, say the authors. See Research, page 1295

A decision rule developed and validated in two large cohorts shows remarkable promise in improving the diagnosis of coronary artery disease in primary care. See Commentary, page 1281

Evaluating a quality-improvement strategy in surgery

A quality-improvement strategy to change surgical practices did not reduce hospital rates of permanent colostomy or local recurrence of cancer among patients receiving surgery for rectal cancer. Simunovic and colleagues report this finding from their cluster-randomized trial using the Quality Initiative in Rectal Cancer strategy. See Research, page 1301

The cost-effectiveness of screening for colorectal cancer

Annual testing with a high-sensitivity fecal occult blood test or colonoscopy every 10 years offers the best value for money in screening for colorectal cancer in Canada. This is the finding of Telford and colleagues, who used an economic analysis based on a Markov model of 10 screening strategies. They compared costs and effects and recommend the most promising strategies. Implementation will depend on local resources and patient preferences. See Research, page 1307

Mathematical modelling provides an approach to compare screening programs, but the underlying assumptions require careful scrutiny, cautions Robert Smith. If the estimates of comparative cost-effectiveness reported in the research by Telford and colleagues are to be seen in practice, then policy-makers must pay careful attention to implementation so as to meet the model’s assumptions about such things as screening intervals, costs of treatment and test performance. See Commentary, page 1283

Vitamin D in adult health and disease

Osteoporosis Canada emphasizes that, for most Canadians, vitamin D supplementation is necessary to achieve an optimal serum level of vitamin D and thus to reduce the risk of osteoporosis. The recommended daily intake of vitamin D is 400–1000 IU for those at low risk for osteoporosis, but doses up to 2000 IU are safe and do not require monitoring. See Review, page 1315

Reconsidering the lifetime ban on blood donation by men who have sex with men

In 1983, Canada and many other countries deferred indefinitely blood donation from any man who has had sex with another man, even once since 1977. This approach was justified, given the prevalence of HIV among this population and that there was no blood test to screen donors for HIV infection. Now, the availability of highly sensitive methods to screen for HIV-positive samples argues against maintaining a lifetime ban for all men who have had sex with men. See Analysis, page 1321

Bullous eruption in a five-month-old girl

A five-month-old girl presented with many urticarial papules on the trunk and vesicles and tense bullae on the abdomen, limbs, hands and feet. She did not have fever and was growing normally. What is your call?See Practice, page 1325

Allergic-type reactions to radiographic contrast media

Allergic-type reactions after administration of radiographic contrast media can be immediate or delayed. In patients who have a history of moderate to severe allergic-type reactions to contrast media, alternative imaging tests may provide similar information without the risks. See Practice, page 1328