Highlights

Managing postfracture pain in children

Children with fractures are often not given adequate pain relief. Recent severe adverse effects and deaths from the use of codeine-containing compounds have resulted in a shift to the use of morphine. This trial shows that ibuprofen will result in no less effective pain control and without the usual narcotic adverse effects. See Research, page 1358

Time trends of mental illness symptoms

The prevalence of most symptoms of mental illness in Canadian children and adolescents has remained relatively stable over time, except for hyperactivity, which has increased. This population-based serial cross-sectional study analyzed data on 32 134 participants in eight two-year cycles from 1994/95 to 2008/09 of the National Longitudinal Survey of Children and Youth. Conflicting reports of escalating rates of mental illness in Canada may be explained by differing methodologies between studies, an increase in treatment-seeking behaviour, or changes in diagnostic criteria or practices, say the authors. See Research, page E672

Discussing end-of-life care

The goals of care that are most important to older patients with serious illnesses in hospital are often not addressed by health care providers. This survey of 233 patients and their family members compared guideline recommendations with what care they said they had received and what they preferred. Addressing these gaps could help improve end-of-life care. See Research, page E679

Deprescribing for older patients

More than 50% of older Canadians living in long-term care facilities and 27% living in the community take more than five medications a day. For frail patients approaching the end of life, active removal of medications with minimal proven benefit or with potential for harm may align well with goals of care. Deprescribing may seem daunting, but Frank and Weir offer clear guidance in this review. See Review page 1369

Aprotinin controversy

The early findings of the BART resulted in Bayer withdrawing aprotinin from the market. Following a report by a Health Canada expert advisory panel, which was critical of the findings of the trial, the company was again allowed to market the drug in Canada. It remains unavailable in the United States. The trial’s authors refute Health Canada’s criticisms of their findings and express concern for the safety of patients undergoing cardiac surgery in Canada and the EU. See Analysis page 1379

Imaging in headache

Does a 35-year-old woman with a one-month history of progressive global headaches require imaging? What if the headaches are associated with sex or if she has a relative with cerebral aneurysm? Chakraborty and Miller address these and other questions in this installment of the Choosing Wisely Canada series in CMAJ. See Decisions page 1391

Screening with the Pap test

Who doesn’t require screening with the Pap test? Do women vaccinated against HPV still need to undergo Pap screening? Should a bimanual examination be added to Pap screening? Ponka and Dickinson address these and other questions in this installment of the Choosing Wisely Canada series in CMAJ. See Five things to know about …, page 1394

Brown-Séquard syndrome

A healthy 36-year-old man presented with painless and progressive left footdrop, numbness in the right leg and urinary hesitancy for 10 days. Witiw and Shamji tell us about the syndrome that tied these findings together, and why prompt surgical intervention is usually required. See Clinical images, page 1395

Holiday reading

CMAJ offers some tempting holiday treats this year: a test of the ice-bucket challenge; a look at evidence-based dating; a dissection of journal limitations; and some entertaining typos. Enjoy! See Holiday reading, page 1400