Highlights

Driving while pregnant may be risky

During the second trimester of pregnancy, women who drive are more likely to have a car crash than they were before pregnancy or later in their pregnancy. Based on routine data from 507 262 women who gave birth and 6922 car crashes, Redelmeier and colleagues detected a 42% relative increase in the risk of being involved in a crash for women who were drivers. The authors suggest that prenatal care should include instruction on safe driving. See Research, page 742

Normal physiologic changes during pregnancy may increase sleep deprivation and stress, which may increase the likelihood of human error. An increased risk of motor vehicle crashes among pregnant women is biologically plausible but we lack sufficient data for clear establishment of a link. See Commentary, page 733

Prone positioning in acute respiratory distress syndrome

Prone positioning reduces mortality among patients with acute respiratory distress syndrome as long as protective lung ventilation is used. This systematic review included evidence from 11 randomized controlled trials, of which 6 used protective ventilation. Perceived difficulties in using the prone position may prevent implementation in some centres, and future research should address this need. See Research, page E381

New treatments for metastatic melanoma

The survival of patients with metastatic melanoma has dramatically improved with the use of kinase inhibitors and immunotherapeutic antibodies. Gedye and colleagues explain how these novel agents differ from traditional chemotherapeutics and discuss their unique adverse effects. See Review, page 754

Resident duty hours in Canada: past, present and future

How many consecutive hours should residents in Canada be expected to work and still deliver high-quality, safe care? The National Steering Committee on Resident Duty Hours has acknowledged that reducing hours doesn’t necessarily improve patient safety. Pattani and colleagues consider the evidence to support various strategies. See Analysis, page 761

Impaired awareness of hypoglycemia

A 32-year-old man with type 1 diabetes mellitus presented to a diabetes clinic after a loss of consciousness. Although he recovered following glucagon injected at home, he reported having no warning signs or symptoms before the event. Plourde and colleagues discuss the issue of impaired awareness of hypoglycemia in patients with type 1 or insulin-treated type 2 diabetes and propose ways to restore awareness among these patients. See Practice, page 770

Chikungunya

Cases of imported chikungunya fever are being seen in Canada. The virus is spread by mosquitoes, and infection can cause a constellation of symptoms including fever, weakness and rash. However, the hallmark is severe, chronic and debilitating arthritis or arthralgia that may persist for years, say Schwartz and colleagues. At this time, treatment is mainly supportive. See Practice, page 772

Local spread of chikungunya in the Americas has recently been identified. Travellers visiting the Caribbean are at risk for this infection. MacFadden and Bogoch tell us more. See Practice, page 775

Atrophying pityriasis versicolour

A 47-year-old man with a long history of psoriasis presented with areas of skin atrophy and scaling on his back. Examination of skin scrapings from these areas showed thick fungal hyphae and spores consistent with Malassezia yeast. Why does skin atrophy occur in conjunction with yeast infection? Cullingham and Hull explain. See Practice, page 776